Perio 1 Final (1st half) Flashcards by A G

A functional system of different tissues that invest & support teeth

Periodontium

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What is included in the periodontium?

Cementum
PDL
Alveolar bone
Gingiva

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Soft tissue that covers the alveolar process & cervical portions of teeth; firmly attached to teeth & surrounding bone

Gingiva

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Gingival unit consists of

gingival margin
marginal/free gingiva
gingival sulcus
attached gingiva
interdental gingiva
col
free gingival groove
mucogingival jx

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What describes the following clinical presentation?

Free gingival margin (scalloped, coral pink, keratinized), attached gingiva (keratinized & stippled), alveolar mucosa (loose, darker red, NONkeratinized), bleeding <10% total probing sites; pocket depth 1-3 mm, can occur on intact or reduced periodontium

Healthy gingiva

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Pigmentation results from synthesis of melanin by melanocytes, located in

The basal layer of the epithelium

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Unattached/free gingiva, border that surrounds the teeth, can be separated from tooth by a perio probe

Marginal gingiva

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Shallow crevice between the marginal gingiva & enamel/cementum, can be also be called a pocket

Gingival sulcus

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Transudate or exudate; contains a wide array of biochemical factors and is used as a marker for health & disease

Gingival (crevicular) fluid

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In a healthy sulcus, the amount of gingival fluid is _______ ________. During inflammation, the gingival fluid flow ________.

very small; increases

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Gingival fluid functions (4)

Cleanse materials from sulcus.
Contains plasma proteins to improve adhesion of epithelium to tooth
Antimicrobial properties
Antibody activity to defend gingiva

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Firm, dense, stippled, tightly bound to periosteum/tooth/bone; coral pink color; immobile; keratinized

Attached gingiva

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Attachment of gingiva on anterior vs. posterior teeth

Great on anterior teeth (maxilla more than mandible); narrowest on posterior teeth

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Contour of gingiva

More scalloped anteriorly, becomes a straighter line posteriorly

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A shallow, V-shaped groove that’s closely associated with the apical free gingiva; runs parallel to margin of gingiva; seldom present

Free gingival groove

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Shape determined by interproximal relationship of teeth; pyramidal in anterior regions, flattened in BL direction in molar regions

Interdental gingiva (papilla)

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Relationship of interdental gingiva to labial and lingual gingiva; conforms to shape of interproximal contact

Col

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In areas of diastemas, is there a col?

No, because there is no interproximal contact

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Junction of gingiva & alveolar mucosa

Mucogingival junction

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Covers basal part of alveolar process, continues into vestibular area on buccal aspect of teeth & floor of the mouth on the lingual aspect; loosely attached to periosteum (movable)

Alveolar mucosa

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Gingival epithelium consists of _________ __________ epithelium. What are the 3 types?

Stratified squameous

Outer/oral epithelium
Sulcular epithelium
Junctional epithelium

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Continuous lining of stratifed squameous epithelium; covers marginal gingiva & attached gingiva; keratinized/parakeratinized; 4 layers (stratum basale, spinosum, granulosum, & corneum)

Oral epithelium

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Lines gingival sulcus; thin, NONkeratinized, stratified squamous epithelium (without rete pegs); from coronal limit of JE to crest of gingival margin; semipermiable membrane (bacteria can pass thru); lacks stratum granulosum & corneum; no merkel cells

has the potentail to keratinize if exposed to the oral cavity

Sulcular epithelium

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Stratified squamous, NONkeratinized epithelium; attached to tooth surface by internal basal lamina (no type IV collagen)

Junctional Epithelium

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Gingival fiber group that attaches gingiva to tooth

Gingivodental fibers

Gingival fiber group that attaches the tooth to the periosteum

Dentoperiosteal fibers

Gingival fibers consist of

Type 1 collagen

Gingival fiber functions (3)

1. Brace marginal gingiva 2. Withstand forces of mastication 3. Unite marginal gingiva to cementum and attached gingiva

3 groups of gingival fibers

1. gingivodental (tooth to gingiva) 2. circular (around tooth) 3. transseptal (between 2 teeth)

Gingival fibers extend from:

1. the tooth to the crest of the gingiva (pulls sulcus towards tooth) 2. the tooth to the outer surface of attached gingiva 3. the tooth to the external periosteum

Cellular elements of gingiva (6)

1. fibroblasts 2. mast cells 3. macrophages 4. histocytes 5. adipose 6. eosinophils

Gingival blood supply is primarily from?

PDL Alveolar process Supraperiosteum

Gingival blood supply is secondarily from?

Vascular plexus adjacent to JE & oral epithelium

Palatal mucosa does NOT have

Mucogingival junction

Hard CT that covers root; main function is to attach PDL fibers to tooth; non-vascularized; more resistant to resorption; light yellow color (lighter than dentin); not as hard as dentin

Cementum

Cementum chemical composition

45-50% inoraganic substances (Ca & P hydroxyapatite, trace elements) 50-55% organic material & H2O Type I collagen & proteoglycans

Types of cementum

Cellular Acellular

Forms 1st (before teeth are in occlusion); covers cervical 1/3 or 1/2; no cells; calcified Sharpey's fibers (Type I collagen); collagen fibers are parallel to roots

Acellular cementum

Formed after teeth are in occlusion; irregular; contains cementocytes; less calcified; resembles bone

Cellular cementum

Cementum thickness

Continuous deposition, especially at apex (due to occlusal wear)

What is hypercementosis due to?

Physiological or pathologic conditions (ex= bruxing)

Cementum functions (3)

1. Attachment of collagen fibers from tooth to alveolar bone 2. Protects dentin 3. Passive eruption

Form the bone that supports the teeth within the sockets; only develops during the eruption of teeth

Alveolar process

Chemical composition of alveolar bone

1/3 organic = 90% type I collagen 2/3 inorganic = hydroxyapatite, Na, Mg, & Fl

Alveolar process components (3)

Cortical plate Alverolar bone proper Trabaculae

Where is the alveolar crest located?

1.5-2 mm below CEJ

Fenestration vs. dehiscence

Fenestration = hole Dehiscence = complete opening *Cause is not clear and may complicate periodontal surgery

CT that surrounds the root & connects it to the bone; continuously adapting to support teeth; highly cellular & vascular

PDL

PDL fiber composition

Principle fibers = Sharpey's fibers Type 1 collagen

Anastamosing network between tooth & bone

PDL fibers

Principle fibers of the PDL (6)

1. Transseptal group 2. Alveolar crest group 3. Horizontal group 4. Oblique group 5. Apical group 6. Interradicular group

Extend over the alveolar crest between teeth; imbedded in cementum at both ends; always present

Transseptal fibers

Extend obliquely from alveolar crest to cementum below JE; prevents extrusion; resists lateral movements

Alveolar crest fibers

Extend at right angles to tooth; anchored in cementum at one end and in alveolar bone at the other

Horizontal fibers

Largest group of PDL fibers; extend from bone to cementum in an apically oblique direction; withstand vertical forces

Oblique fibers

Fibers extend from apex to base of socket; not present on incomplete roots

Apical fibers

Fibers extend from cementum to bone in furcations

Interradicular fibers

PDL functions (5)

1. soft-tissue casing to protect vessels/nerves from injury by mechanical forces 2. transmission of occlusal forces to bone 3. attachment of teeth to bone 4. maintains gingival tissues in proper relationship to teeth 5. resists impact of occlusal forces

PDL blood supply sources

Branches from the alveolar A Branches from the interradicular AA Gingival vessels

PDL blood supply is very well ______________

vascularized

PDL nerve supply

Sensory = penetrates ligament thru apical foramina, foramina in alveolar wall, terminates as free endings Autonomics = from superior cerivcal ganglion

4 types of nerve endings in PDL

1. free nerve endings (pain) 2. Ruffini-like mechanoreceptors 3. Meissner corpuscles (mechanoreceptors) 4. pressure & vibration endings

Fusion of the cementum & alveolar bone, obliteration of PDL; results in root resorption, PDL replaced by bone

Ankylosis

Principal fibers are comprised of collagen ______, reticular fibers of collagen ______, and basal lamina collagen ______.

Type I; Type III; Type IV

The expression of collagen type XII occurs during...

Tooth development & timed with alignment and organization of periodontal fibers

The expression of collagen type XII is limited to...

Tooth development to cells within PDL

Type VI collagen immunolocalized to

PDL and gingiva

Gingival epithelium cell types

Primary= Keratinocytes Secondary= Langerhans cells, Merkel cells, & Melanocytes

Proliferates in basal & suprabasal layers; progressively flattens; increases tonofilaments & desmosomes; produces keratohyaline granules; nucleus disappears

Keratinocytes

basal layer; cuboidal cells; forms BM; site of cell replication; full complement of organelles

Stratum basale

prickle cell layer; prominent peripheral cytoplasmic processes (appear spiny); rich in tonofilaments that end in attachment plaques of desmosomes

Stratum spinosum

Keratohyalin granules; flattened cells with diminished oragnelles; pyknotic nuclei; degenerative mitochondria; desmosomal changes in upper regions

Stratum granulosum

flattened, pyknotic cells; tightly packed tonofilaments; no organelles; continued degredation of desmosomal attachment

Keratinized layer

2 dense attachment plaques; tonofibrils insert into plaques & extend into cytoplasm

Desmosomes

1/2 desmosomes; attachment of epithelial cells to BM and tooth surface; cell junctions

Hemidesmosomes

Cell communication channels; lost in areas of inflammation

Gap junctions

Zona occludens & macula occludens; fusion of cell membranes that function in ion exchange, compartmentalization & adhesion

Tight junctions

Length of the JE ranges from ______ in health. The JE attaches to afibrillar cementum, which lacks what type of collagen?

0.25-1.35 mm Type IV

Name the disease: Associated with dental biofilm; color change to blue/red; no attachment loss; inflammation causes shiny appearance, loss of stippling, soft tissue, loss of knife edge; confined to the gingiva; dental plaque can exacerbate; reversible; bleeding on probing > 10% of sites

Gingivitis

Name the disease: Not associated with dental biofilm; attachment loss; usually only seen in patients 40+

Gingival disease

What is a normal gingival sulcus? A periodontal pocket?

Normal= 1-3 mm Perio= 4+mm

What types of organisms predominate in healthy gingiva & gingivitis?

Facultative organisms

What types of organisms predominate in periodontitis?

Anaerobic organisms

Can the inflammatory process of gingivitis be reversed?

Yes! Can reverse within 1 week with oral hygiene practice.

Localized vs Generalized gingivits

Localized= < 30% sites BOP (canines and back) Generalized= > 30% sites BOP (canine forward)

Effects of smoking on BOP?

Significantly reduces BOP due to vasoconstriction

Are there stages to CLINICAL gingivitis?

Are there stages to HISTOPATHOLOGICAL gingivitis?

Yes! Inital (no plasma cells) Early (few plasma cells) Established (10-30% plasma cells) Advanced (>50% plasma cells)

Increased migration of leukocytes (mainly neutrophils) into the JE and gingival sulcus; alteration to most coronal aspect of JE; loss of perivascular collagen (5-10%)

Initial lesion (histopatholgical gingivitis)

Accumulation of lymphoid cells (T lymphocytes) subjacent to JE; further loss of collagen fibers (60-70%) that support marginal gingiva

Early lesion (histopatholgical gingivitis)

Predominance of plasma cells w/out appreciable bone loss; presence of immunoglobulins in CT and JE; proliferation, apical migration & lateral extension of the JE

Established lesion (histopatholgical gingivitis)

Cytopathically altered plasma cells; formation of periodontal pockets

Advanced Lesion (histopatholgical gingivitis)

Types of soft deposits that can produce disease

1. Acquired pellicle 2. Bacterial plaque 3. Materia alba 4. Food debris

How does the oral cavity support microbial growth?

Warmth Moisture Available nutrients pH O2 Metabolic inhibitors

How are nutrients provided for Supragingival bacteria?

-dietary patterns & types of food (prefer carbs) -stickiness of foods & frequency -dietary effects on Strep. Mutans & dental carries are well documented -interbacterial feeding mechanism

V. alkalescens metabolizes lactic acid produced by streptococci (cannot metabolize glucose) This raises the pH of the environment, which facilitates the carbohydrate metabolism by streptococci

Interbacterial feeding mechanism

How are nutrients provided for subgingival bacteria?

-do NOT use dietary nutrients -metabolize peptides & amino acids (from the breakdown of tissue, crevicular fluid and interbacterial feeding) *inflammation increases crevicular fluid flow & tissue breakdown*

Environment for disease (primary factors)

Microbial plaque Plaque by-products Host response.

What determines predominance of anaerobic or facultative bacteria?

pH & O2

Early colonizers

Streptococci & actinomyces (aerobic) *utilize O2, which then favors the growth of anaerobic species

Environment of the gingival crevice has limited nutrition. What are the 3 sources?

1. Diet 2. Host 3. Gingival crevicular fluid (not rich in nutrients)

What are the components of biofilm?

-pellicle -bacterial plaque -materia Alba -food debris

Associates w/tooth surface; microbes bind together in a polysaccharide matrix; protects bacteria from antimicrobial agents; must be mechanically removed

Biofilm

Thin, unstructured glycoprotein film that covers the tooth surface (including restorations & calculus) within minutes of dental cleaning

Pellicle

Pros and cons of the pellicle

Pros = protects against acid; lubricates Cons = participates in plaque formation

What are the initial colonizers of the pellicle?

Actinomyces Viscosus Streptococcus Sanguis

What is one of the most important 2nd colonizers of the pellicle?

Porphyromonas gingivalis

Bacterial plaque is visible after _____ if oral hygiene isn't effective. Why does plaque accumulate easily on the gingival 1/3?

1-2 days -mastication & movement cause mechanical removal of the coronal 2/3rds only

Soft accumulation of bacteria; lacks organized structure of plaque; easily displaced with H2O spray

Materia alba

Hard deposit; mineralized plaque; covered by unmineralized plaque layer

Calculus

Soft, nonmineralized microbial accumulation that forms biofilm; firmly adheres to tooth/restorations/prosthetics; organized (filamentous forms dominate); organic matrix; CANNOT be removed by rinsing/water spray

Bacterial plaque

What are the 3 types of interbacterial relationships?

1. coaggregation (interbacterial adherence) 2. adhesins 3. inhibitors

What is coaggregation (interbacterial adherence) responsible for?

Secondary colonization (interaction between Gram + and Gram - species)

Allow microorganisms to attach to 1+ surfaces

Adhesins

Antibodies (Secretory IgA)

Inhibitors

What are the stages of plaque formation?

1. Formation of pellicle 2. Intial colonization of bacteria 3. Secondary colonization, which leads to plaque maturation

How long does primary colonization take during plaque maturation?

1-2 days

How do gram negative organisms attach to plaque?

They attach to surface receptors on gram + cocci/rods *Otherwise, they would have a poor ability to attach.

During plaque maturation, when do we see an increase in gram negative species?

Days 4-7

As a result of the ______ surface of calculus, it can become a ________ _______ for pathogenic bacteria. (becomes a microbial niche)

rough; retentive site

What are the 3 steps of calculus formation?

1. Pellicle formation 2. Plaque formation 3. Mineralization (occurs within 24-72 hours)

What are the primary sites of calculus formation?

Facial aspect of max. molars Lingual aspect of man. incisors (develops in areas that are difficult to access)

What are the effects of calculus on plaque?

Amplifies the plaques effect by keeping it in close contact with the tissue surface

Supragingival calculus is ____ and is made of _____ crystalline form(s). It is influenced by ___________ secretions

heterogenous; 4; salivary

Subgingival calculus is ____ and is made of _____ crystalline form(s). As tissue receeds, subgingival calculus can appear _______________

homogenous; 1; supragingivally

Supragingival calculus is composed of ______ inorganic salts, mainly ________ _________.

70-90%; calcium phosphate

Supragingival calculus also contains varying amounts of ________ ___________ and __________ __________

calcium carbonate; magnesium phosphate

What are the 4 crystals of calcium phosphate that are in calculus?

1. Brushite (B) 2. Octacalcium phophate (OCP) 3. Hydroxyapatite (HP) 4. Whitlockite (W)

What is the first inorganic crystal of supragingival calculus to appear? The 2nd? What is the major form?

1st= Brushite 2nd= Octacalcium phosphate Major= Hydroxyapatite

What is the average mineral content of supragingival calculus?

37%

What is the predominant crystal in subgingival calculus?

Whitlokite

What are the modes of attachment for calculus?

1. Pellicle 2. Penetration of calculus bacteria into cementum 3. Mechanical locking into surface irregularities 4. Close adaptation of calculus to unaltered cementum

T/F It is possible to remove all calculus on the root without sacrificing some hard tissues of the root

FALSE

Non-specific plaque hypothesis

Overgrowth of plaque causes perio disease More plaque= greater extent of disease Tx= get rid of all plaque

Specific plaque hypothesis

Only certain plaques are pathogenic Pathogenicity dependent on presence/increase in specific microorganism

What are the 3 types of gingival pockets? What are they associated with?

1. Relative 2. False 3. Pseudopocket Associated with gingivitis - caused by gingival enlargement WITHOUT destruction to underlying perio tissues

What are the 2 types of periodontal pockets?

1. Absolute 2. True Associated with destruction of perio tissues and attachment loss

2 types of true pockets

1. Suprabony (pocket above alveolar bone) 2. Infrabony (pocket at/below alveolar bone)

How are bacteria associated with periodontitis able to evade the host defense mechanisms?

1. Breakdown of the periodontal tissues 2. Production of leukotoxins (kill neutrophils) 3. Production of proteolytic enzymes that kill antiboides 4. Production of factors that suppress the immune response

What are the direct effects of bacteria to periodontia?

1. Gingipains (produced by P. gingivalis) 2. Leukotoxins (produced by Aa) 3. Lipopolysacharides (capable of inducing bone resorption) 4. Metabolic byproducts (H2S, NH3, fatty acids) that are toxic to surrounding cells

Measured pocket (probe depth) + visible recession below CEJ

CAL

If the CEJ of adjoining teeth are not at the same level and the alveolar crest appears horizontal, is this indicative of alveolar bone loss?

3 types of bone loss

1. Horizontal 2. Vertical 3. Complex lesion (moat/troughlike appearance)

Develops between teeth; bone of outer B or L plate resorbed, but the outer plates of bone remain intact; can be difficult to see radiographically unless heights of B and L plates are different

Crater

Interpretation of bone loss complicated by anatomic structures; found on max & man molars; found on proximal surfaces of max premolars

Furcation

T/F The absence of calculus on a root on a radiograph indicates that there is no calculus present on the root

False, can be undetectable on a radiograph

Crown to root ratio for: 1. Normal Periodontium 2. Slight horizontal resorption 3. Moderate periodontitis 4. Advanced horizontal resorption

1. 1:2 (very favorable) 2. 1:1.5 (favorable) 3. 1.2: 1 (unfavorable) 4. 2:1 (very unfavorable)

Glickman Grade I (furcation classifications)

1. Incipient 2. Pocket formation into flute, intact interradicular bone. 3. Minimal bone loss. 4. Suprabony pocket.

Glickman Grade II (furcation classifications)

1. "Cul-de-sac" 2. Loss of interradicular bone & pocket formation, not extended to opposite side. 3. Bone destroyed on 1+ aspect of furcation, but a portion of the alveolar bone & PDL remain.

Glickman Grade III (furcation classifications)

1. Through-and-through 2. Tunnel like bone loss that's occluded by gingival tissue (clinically not visible)

Glickman Grade IV (furcation classifications)

1. Grade III furcation with severe gingival recession, which exposes the furcation entrance

The study of distribution & determinants of health-related states/events; application of this study to control of disease

Epidemiology

ALL cases of a disease present within a designated population at a specific time (new & pre-existing)

Prevalence

NEW cases of a disease CONTRACTED in a population w/in a specified time

Incidence

Number of diseased patients who are correctly IDd as having disease

Sensitivity

Number of healthy persons correctly determined NOT to have the disease

Specificity

What is the marker of gingivitis/periodontal disease?

bleeding upon probing (high specificity, low sensitivity)

What are the determinants of disease?

1. Risk factor 2. Risk indicator 3. Odds Ratio

A characteristic that places an individual at an increased risk of contracting a disease

Risk factor

A probable risk factor that is IDd in cross-section correlation studies, but not in longitudinal studies

Risk indicator

Probability that exposure to certain risk factors will result in disease <1 = more protected >1= more risk

Odds ratio

How do you decrease a type I error (false positive)?

decrease p-value (significance criterion); ideally p < 0.5

How do you decrease a type II error (false negative)?

increase power (ideally > 0.8)

What is the prevalance of gingivitis in schoolchildren in the US?

40-60%

Is BOP more likely to be found in males or females?

Males

What % of adults were found to have gingivitis on at least 3-4 teeth?

50%

Effects of smoking of periodontal health

Increases alveolar bone loss, even with the same amount of oral hygiene. Can restrict vasculature and make BOP less likely, even in the presence of disease.

What is the primary etiology of periodontitis?

Bacterial plaque

Periodontitis is possibly modified by or associated with _____ and ______.

diabetes; smoking