PERIO Flashcards
What can perio be classed into?
Health and Disease
HISTOLOGICALLY, what does gingival HEALTH look like?
There is still evidence of the presence of inflammatory cells (neutrophils) in the gingival connective tissue, even after seconds of brushing, plaque starts to accumulate causing VASODILATION - there may not be a clinical sign of inflammation, but histologically there is.
What are the CLINICAL signs of clinical gingival health
Pink/Pale gingiva
Stippling (orange peel effect) - this is caused by the arrangement of the connective tissue underlying gingivae - tight epithelium (lots of collagen)
Knife edge margins
No BOP/inflammation present
What are the CLINICAL signs of a gingivitis (5)
Red
Swollen
Rolled margins
BOP
Loss of stippling
Describe the aetiology of gingivitis (how is it caused)
all to do with the QUANTITY of plaque
the plaque will initiate an inflammatory response
over more than 7 days, we will have mature plaque meaning greater thickness, gram -ve anaerobic bacteria (facultative) start to appear - microbial succession causing GINGIVITIS
Describe the stages we can get from gingivitis (3)
can either:
- stay the same
- regress
- progress onto periodontitis
What are the clinical signs and symptoms of PERIODONTITIS (9)
- increased probing depth
- bleeding
- mobility
- furcations
- shrinkage
- halitosis
- plaque
- calculus
- pre-existing gingivitis
Describe the AETIOLOGY of periodontitis (how is it caused?)
bacteria (PLAQUE), Poor OH
RISK factors Local and Systemic
Describe some SYSTEMIC risk factors that can increase the risk of periodontal disease
immunocompromised (medical conditions) , diabetes, smoking, genetics, age
Describe some LOCAL risk factors that can increase the risk of periodontal disease(5)
Overhangs, restoration deficiencies, calculus, tooth anomalies, appliances - orthodontic or dentures that are ill fitting.
Describe how smoking can effect the periodontium HISTOLOGICALLY (on a cellular level)
Smoking causes VASOCONSTRICTION in the gingival tissues, this in turn restricts the number of host cells entering the gingival tissues through the blood, therefore, there are less neutrophils (PMNL’S) and macrophages (monocytes when OUTWITH tissue in bloodstream). Due to the lack of neutrophils rushing into the site due to the vasoconstriction, we get less fibroblast production and therefore no laying down of collagen
Describe what we can see CLINICALLY in a smokers periodontium (9)
smokers have:
- more calculus
- plaque
- spend less time brushing teeth
- more alveolar bone loss
- deeper pockets
- more vertical defects
- hyperkeratinised tissue
- REFRACTORY response is impaired to NSPT
- Healing is impaired
Describe how Diabetes can affect the periodontium
an increase in glucose molecules within the blood can impair the host response and increase the levels of disease/healing process post NSPT - THIS IS ONLY IN POORLY CONTROLLED DIABETES!
Diabetes increases the risk and severity of periodontal disease. Factors that contribute to this include slowed circulation, which can render gum tissue susceptible to infection, and lowered body resistance to infection, which increases the probability of gums becoming infected. Individuals with Type II diabetes face a higher risk of developing gum disease because their immune response does not develop antibodies to pathogens associated with periodontitis.
List the different types of Acute Periodontal Conditions (5)
Necrotizing Gingivitis
Necrotizing Periodontitis
Pericoronitis
Periodontal Abscess
Acute Herpetic Gingivostomatitis
Describe the AETIOLOGY of Necrotizing Gingivitis (how is it caused)
This is a fuso-spirochetal infection, caused mainly by TREPONEMA VINCETIL along with Fuso Nucleatum, Prevotella Inter, treponema denticola - all GNABs
Describe the RISK FACTORS that may make us succeptible to NG (4)
- immunocompriomised
- Poor OH
- Smoking
- Stress
Describe the clinical signs/symptoms of NG (12)
- grey pseudomembranous slough
- foetor oris
- Red, angry, severely inflamed gingivae
- SPONTAENEOUS bleeding
- ‘punched out’ papillae
-ulceration - pain
- general malaise
- fever (sometimes)
- lymphadenopathy
-metallic taste - in extreme cases, if left untreated, we can get facial necrosis
What is the MANAGEMENT OF NG(4)
- OHI/smoking cessation
- Prescription of metronidazole for 3-5 days (400/500mg 3 times a day)
- USS (1st reason for the CAVITATIONAL effect to kill anaerobic bacteria, 2nd reason for a cooling effect on gingivae - pts like this sensation)M
- Review condition in 7 DAYS - further PMPR/advice
Describe the AETIOLOGY OF Necrotizing Perio
- ALWAYS preceded by NG
- all else is the same
- Histopathology is slightly different in that it is bone loss and PDL loss
- clinically, we can often see exposed bone (v nasty disease)
Describe what pericoronitis is
Usually occurs on PE teeth, operculum causes plaque to get trapped under resulting in inflammation and infection
What is the AETIOLOGY of a perio abscess
Bacteria not being able to exit the blocked pocket, this blocked pocket may be from calculus, food, a scaling in which there has been a bit of dislodged calc that has gotten stuck.
EXISTING PERIODONTITIS IS A RISK FACTOR OF TIS TYPE OF ABSCESS
What is the MANAGEMENT of a perio abscess
- sometimes a course of antibiotics
- scaling/PMPR carried out to flush away debris
- Review
What are the clinical signs and symptoms of a perio abscess
- swelling of face
- pain
Describe the Aetiology of Acute Herpetic Gingivostomatitis
Caused by herpes simplex 1 virus (hsv-1)
What are the clinical signs and symptoms of AHG (8)
- generalised erythema (redness)
- pain
- all over mouth
- around vermillion border
- ulceration (yellow hue)
- lymphadenopathy
- fever
- general malaise
What is the management of AHG
Due to it being a viral infection, ABs are not involved - therefore, we would treat this with analgesia and control temperature
Describe the complication of of AHG
due to it being a virus, it lies DORMANT to the trigeminal ganglion
How can AHG be reactivated ?
can be reactivated by:
- immunosuppresion
- stress
- exposure to UV light (sunlight)
What is the clinical sign of reactivated AHG
Herpes Labialis (coldosre)
What are the two main areas of management within perio
PREVENTION (plaque control)
NSPT (instrumentation)
Describe 3 main mechanical plaque control methods for prevention in perio
OHI - TBing techniques (what types), ID cleaning (what types)- MECHANICAL PLAQUE CONTROL ALWAYS TAILORED TO INDIVIDUAL, PMPR (removal of calculus removing retentive for plaque to adhere to) (explain each of these further)
What is important to consider when providing OHI to a patient
Need to consider pt motivation, and effects of non-compliance. We should always concentrate on the positives! keeps pt morale high
Describe some methods of chemical plaque control for prevention of perio
- toothpaste - fluoride and triclosan
- mouthwashes - chlorohexadine, phenol, oxidising mouthwashes
Describe some adv and dis of using chlorohexadine mouthwash
Adv - is that is has bisbiguanide in it which is a plaque inhibitor
Dis - can cause gross staining, can alter the function of taste buds, associated with calculus formation, can effect the efficacy of salivary glands
Describe the adv and dis of using phenolic mouthwashes
adv - is that it has a slight antibacterial function - very short lasting
Dis - use after brushing which washes fluoride away, increase in alcohol content increasing the risk of OC (cosmetic mouthwash like Listerine)
Describe the adv and dis of oxidising mouthwashes
Adv is that it contains hydrogen peroxide which can act as a cavitational effect and kill bacteria which can be effective for conditions such as NG
why do we carry out NSPT (non-surgical perio treatment)
TO RENDER THE ROOT SURFACE BIOLOGICALLY COMPATIBLE WITH HEALING or DISRUPT THE BIOFILM
HOW do we carry out NSPT
By instrumenting the root surface by using :
USS, hand scalers
Describe the sequence of treatment carried out in NSPT and why are we doing it
- pre USS in order to: disrupt the plaque biofilm and break up large calculus deposits
- hand scale - for fine tuning
- post USS - flush out any remaining debris
What is the sequence planning for RSD / why
- OHI
- 6 ppc (why? - because it gives us a more DETAILED view of disease present in mouth, and also provides pts with motivation as it is almost like a visual aid
- supra and sub PMPR (professional mechanical plaque removal) - NSPT
- review ppds in 3/12.
Describe 3 states a patient will either be post rsd treatment at the 3/12 review
STABLE, NON RESPONSIVE, PARTLY RESPONSIVE
What action do we take if a patient is in a stable state post rsd/treatment?
Maintenance Therapy (or also called supportive periodontal therapy - SPT) - THIS IS ONLY FOR PTS WHO HAVE A STABLE PERIODONTIUM and is tailored to the individual
Describe the PATHOGENESIS?HISTOPATHOLOGY of the progression to perio disease/how does plaque develop on a tooth (4)
- Within seconds of brushing - plaque bacteria sticks to tooth by the acquired pellicle (aerobic, gram positive eg streptococci) - NOT MUCH DAMAGE TO PERIODONTIUM HERE
- Within hours: Bacteria will multiply causing layers of plaque to develop however, it is still simple anaerobic bacteria here along with rods, lactobacilli and actinyomyces
- After 7 days (or more), we not have mature plaque on surface of tooth, therefore the thickness is increased. In the deeper layers we will now get gram -ve anaerobic (facultative) bacteria start to appear eg tanarella forsythia, treponema denticola. THIS RESULTS IN GINGIVITIS
- PERIODONTITIS develops
What 3 paths can gingivitis take?
can either stay the same, regress, or progress onto periodontitis
What are the 4 lesions called from the page and schroeder (1976) study?
- initial lesion
- early lesion - 1/2 both EARLY stages of gingivitis
- established lesion - clinically obvious gingivitis
- advanced lesion - periodontitis
Describe the INITIAL LESION (4)
- 24-48 hours plaque accumulation
- vasodilation of blood vessels, increase in neutrophils, increase in GCF - THIS IS ALL BELOW THE JE
Describe the EARLY LESION
- After 1 week
- fibroblasts are destructed, therefore a decrease in collagen - THIS IS VERY MINIMAL
- cytokines rush into site and immunoglobulins are produced (pro-inflammatory) released.
- more inflammatory infiltrate so neutrophils and lymphocytes
- increase in GCF
- inflammatory swelling of gingiva results in deeper gingival crevice
- favour the growth of -ve bacteria
Describe the ESTABLISHED lesion
- 2-3 weeks
- gingivitis is CLINICALLY diagnosed/ESTABLISHED
- gingival connective tissue largely replaced by inflammatory infiltrate
- JE replaced by ulcerated leaky pocket epithelium - no longer attached to tooth
- increased neutrophils in pocket
- increase in immunglobulins
- bacteria and host cells BATTLE causing damage
- decrease in collagen
What do neutrophils do in host response
provide host defence mechanisms such as phagocytosis of pathogens
Describe/list some of the bacteria found in a perio pocket
Pg, Td, Tf (RED COMPLEX)
fn, Pi, Aa (ORANGE)
Describe what the bacteria do within the deep perio pocket (3)
They cause DESTRUCTION by:
-producing toxic material
- instigating the inflammatory/immune response
- they evade the host response
Describe some features of Porphyromonas Gingivalis
it has a capsule around it giving it a protective barrier called fimbrae
has gingipains -these are proteases which degrade cytokines thereby downregulating the host response
contains enzymes, toxins and acids
Describe the host response within periodontal disease
we can have either an inflammatory response or an immune response
inflammatory is fairly straight forward initiates the innate response
immune can be either innate (natural) or acquired
what does the inflammatory response involve within the host response
firstly VASODILATION (in response to plaque on tooth surface) of blood vessels occurs, meaning there is an influx of neutrophils (PMNL’S) and increased gingival crevicular fluid. The initial inflammation in the periodontal tissues should be considered a physiologic defence mechanism against the microbial challenge, rather than pathology (no immune cells involved here). The clinical findings of the disease at this stage include supragingival and subgingival plaque formation, which are usually accompanied by calculus formation and gingival inflammation. If plaque is removed, there is resolution with return to homeostasis; if the lesion persists, it becomes pathology. (PERIO - WHERE THE IMMUNE RESPONSE INS INVOLVED)
describe innate immunity within the host response
Innate immunity is the body’s first line of defence (is initiated by the inflammatory response - so is the specific/acquired) against pathogens and foreign invaders, including bacteria, viruses, and fungi. It provides immediate, NON-SPECIFIC protection against a wide range of potential threats.
Components of innate immunity include physical barriers (such as the skin), chemical barriers (such as saliva), and cellular components (such as neutrophils, macrophages, dendritic cells, and natural killer cells).
describe acquired immunity within the host response
this involves the release of ig’s, t cell lymphocytes and b cell lymphocytes (immune cells)
what role do t cells play in the acquired immunity response?
T-cells work once they’re activated.
- T-lymphocytes make up the cell mediated immune response. It is called this because the ANTIGEN SPECIFIC MOLECULE on the t-cell is not released from the cell, but remains stuck to the t-cell surface.
- SO, DIRECT, contact between the T-cell and bacteria is necessary to cause BACTERIAL DESTRUCTION!
- A cell called an antigen-presenting cell (APC) locates evidence of the intruder/foreign bacteria and attaches it to a structure called major histocompatibility complex (MHC).