Perio

Question 1

Abscesses of the periodontium

Answer 1

gingival abscess

periodontal abscess

pericoronal abscess

Question 2

gingival abscess

Answer 2

localized purulent infection that involves the marginal gingiva or interdental papilla

etiology: acute inflammatory response to foreign substances forced into the gingiva

clinical features: localized swelling LIMITED to marginal gingiva or papilla. A red, smooth, shiny surface. May be painful and appear pointed. Purulent exudate may be present. No previous periodontal disease.

Question 3

periodontal abscess

Answer 3

localized purulent infection w/in the tissues adjacent to the periodontal pocket that may lead to the destruction of periodontal ligament and alveolar bone. Usually pre-existing chronic periodontitis present!!! Occlusion of pocket orifice.

Clinical featuers: smooth, shiny swelling of the gingiva, painful, tender to palpation, purulent exudate, increased probing depth, mobile and/or percussion sensitive, tooth usually vital

A PERIODONTAL EVALUATION FOLLOWING RESOLUTION OF ACUTE SYMPTOMS IS ESSENTIAL!!!

Question 4

pericoronitis

Answer 4

special type of acute periodontal abscess that occurs when gingival tissue (operculum) overlies an erupting tooth (usually a third molar)

recurring acute symptoms are usually initiated by trauma from the opposing tooth or by impaction of food or debris under the flap of tissue that partially covers the erupting tooth

Question 5

pericoronitis procedure

Answer 5

relieving the pain is surgical removal of the operculum. Inject local anesthetic directly into the overlying tissue and then cut it away using the outline of the tooth as a guide for the incision. Sutures are not required

irrigate w/ a weak (3%) hydrogen peroxide solution

purulent material can be released by placing the catheter tip of the irrigating syringe under the tissue flap overlying the impacted molar

prescrive oral analgesics for comfort as well as penicillin over the next 10 days

instruct the patient on the importance of cleansing away any food particles that collect beneath the gingival flap

follow-up should be provided to observe the resolution of the acute infection and to evaluate the need for removal of the gingival flap or molar

DO NOT undertake any major blunt dissection while draining pus. This could spread a superficial infection into the deep spaces f the head and neck or follow a deep abscess posteriorly into the carotid sheath

Question 6

Necrotizing Ulcerative Gingivitis (NUG)

Answer 6

infection characterized by gingival necrosis presenting as “punched-out” papillae, with gingival bleeding and pain and foul smell

Question 7

primary herpetic gingivo stomatitis

differential diagnosis

Answer 7

Question 8

necrotizing periodontal disease

Answer 8

treatment: local debridement, oral hygiene instructions, oral rinses, pain control, antibiotics, modify predisposing factors, proper follow-up

the treatment of the necrotizing periodontal diseases is divided into two phases: acute and comprehensive follow up

Question 9

primary herpetic gingivostomatitis

Answer 9

etiology: herpes simplex virus
age: frequently children
site: gingiva and entire mucosa
symptoms: multiple vesicles which burst leaving small round fibrin-covered ulcers which tend to coalesce. Fever and lymphadenopathy common
duration: 7-14 days

contagious

partial immunity

healing: no perm destruction

Question 10

primary herpetic gingivostomatitis treatment

Answer 10

bed rest, fluids - forced, nutrition, antipyretics (acetaminophen, not ASA due to risk of reye’s syndrome)

pain relief (viscous lidocaine, benadryl elixir, 50% benadryl elixir/50% maalox)

antiviral medications (immunocompromised patients)

careful plaque removal to limit bacterial super infection of the ulcerations, which delay their healing

in severe cases, including patients w/immunodeficiency, the systemic use of antiviral drugs such as Acyclovir

Question 11

Recurrent Oral Herpes

Answer 11

Oral lesions usually herpes simplex virus type 1

lesions start as vesicles, rupture and coalesce

limited to keratinized gingiva/mucosa

can cause post-operative pain following dental treatment

treatment: palliative, antiviral medications (consider for treatment of immunocompromised patients, but not for periodic recurrence in healthy patients)

Question 12

Recurrent Aphthous Stomatitis

“canker sores”

Answer 12

Affects mobile mucosa

small, shallow ulcerations with slightly raised erythematous borders

central area covered by yellow-white pseudomembrane

heals without scarring in 10-14 days

predisposing factors: trauma, stress, food hypersensitivity, previous viral infection, nutritional deficiences

treatment: palliative. Pain relief (topical anesthetic rinses), adequate fluids and nutrition, corticosteriods, oral rinses (chlorohexidine has been anecdotally reported to shorten the course of apthous stomatitis), topical “band aids”, chemical or laser ablation of lesions

Question 13

Desquamative lesions

lichen planus (erosive), pemphigoid, pemphigus

Answer 13

first line treatment: topical application of 0.05% fluocinonide (lidex) in an adhesive base - can affect: pemphigoid - ocular lesions and skin, pemphigus - can affect any mucous membranes, lichen planus - any mucous membrane or skin

more aggresive treatment with corticosteroids or immunosuppresants is out of scope of care

definitive diagnosis is with biopsy

Question 14

periodontal restorative considerations

Answer 14

gingival inflammation MUST be controlled before restorative procedures are started!!!

MARGINS are placed in a specific relationship to the host tissues (gingiva and bone). If host tissues are:

undergoing changes (swelling and shrinking from inflammation)

to determine gingival margins of restorations properly

with residual periodontal disease, you CANNOT predictably place margins in desired locations

Question 15

Biologic Width violations and poor contours

overcontoured sub-gingival margins

overhang

Answer 15

Question 16

Biologic Width Violation

Answer 16

On the mesial surface of the left central incisor, bone has NOT been lost, but gingival inflammation occurs.

On the distal surface of the left central incisor, bone loss has occurred, and a normal biologic width has been reestablished (one possibility)

Question 17

The signs of biological width violation

Answer 17

chronic progessive gingival inflammation around the restoration

BOP

localized gingival hyperplasia with minimal bone loss

gingival recession

pocket formation

clinical attachment loss

gingival hyperplasia is most frequently found in altered passive eruption and subgingivally placed restoration margins

Question 18

When will biological width violation occur?

Answer 18

depends on the restoration

better the marginal integrity and contour of the restoration the longer it will take

restoration failure: if there is inadequate tooth structure for the restoration - metal can fatigue, open up margins and caries will happen

Question 19

requirements for biologica width and restoration

Answer 19

clinical crown of tooth must be adequate for retention of artificial crown

to get enough retention you may be tempted to place the margin into the junctional epithelium and connective tissue attachment.

Question 20

Biologic AND Mechanical Requirements for restoration

Answer 20

Apical 1/3 of the prepartion - the greatest retention and resistance of the restoration - ~2mm ferrule height - forces of occlusion dispersed onto the PDL rather than post and core

chamfer/margin = .5 - 1mm

distance from the base of healthy tooth to the crest of bone:

2 + 1 +2 = 5mm

Question 21

Indications for clinical crown lengthening

Answer 21

caries

occlusal wear

altered or delayed passive eruption

root perforation

fracture of the clinical crown

esthetics

Any factor that diminishes the dimension of the clinical crown

Question 22

Factors to consider prior to crown lengthening procedure

Answer 22

remaining crown root ratio

will crown lengthening compromise the periodontium of adjacent teeth?

can that tooth stand alone after treatment?

esthetics