Perio- Classification Flashcards
What is periodontal health?
Patients with an intact periodontium or reduced periodontium (not caused by peridontitis)
What is characteristic of periodontal health?
<10% bleeding sites
Bone levels 1-3mm (no pockets >3mm)
What is plaque induced gingivitis?
Patients with
- Visible plaque around the gingival margins
- redness and gingival inflammation at the papilla.
What is characteristic of plaque induced periodontitis?
No bone loss or interdental recession
Bleeding on probing
What can increase a patient’s susceptibility to plaque induced gingivitis?
Puberty- Plaque causes gingivitis but the hormones exagerate it.
Poor restorative margins- enabling greater plaque build up and inflammation.
Drug induced gingivial enlargemement.
What is shown here and what causes it?
Drug induced gingival enlargement.
Drugs such as:
Calcium channel blockers
Immunosuppresants.
What has caused the red gingivae in this image?
Primary herpetic gingivostomatitis
(infection)
What has caused this gingival appearance?
A vitamin C deficiency has caused this skin discoloration.
What do you need to assess to diagnose periodontitis?
Stage-Bone loss
Grade-progression of bone loss (D for development)
Extent How much disease there is and where?
- Current periodontal Status
- Risk factors.
Some Giants Eat Sour Raspberries.
Compare grading and staging?
Staging is how much bone has been lost. (S for severe)
Stage 1/2/3/4
Grading is how quickly the bone loss has progressed is (D for Development)
Grade A/B/C
How do you stage bone loss?
Look at the maximum bone loss at the worst site and give it stage 1-4
What is stage 1 bone loss?
Early/mild with interproximal bone loss of 2mm at the worst site.
What is stage 2 bone loss?
Bone loss to the coronal third of the root.
What is stage 3 bone loss?
Interproximal bone loss to the mid third of the root.
What is stage 4 bone loss?
Interproximal bone loss to the apical third of the root.
Or if the patient has lost teeth due to periodontal disease.
How do you grade bone loss?
You find the worst site of bone loss and assign a percentage of bone that has been lost:
Grade= percentage bone loss/ age.
What is grade A bone loss?
When the percentage bone loss/age is <0.5.
The bone is being lost slowly.
What is grade B bone loss?
When the percentage bone loss/ age 0.5-1.
The bone loss is moderate.
What is grade C bone loss?
When percentage bone loss/age is >1.
The bone is being lost rapidly.
How do you describe the extent of periodontal disease?
Can be
- Localised <30% of teeth
- Generalised >30% of teeth.
- Molar incisor pattern (younger patients)
What is characteristic of perio disease that is currently stable?
<10% teeth bleed on probing.
Periodontal pocket depth <=4mm
No BOP at 4mm sites.
What do we mean if the periodontal patient is in remission?
The patient had periodontitis and now has bleeding gums.
What is characteristic of a perio patient that is currently in remission?
Bleeding on Probing >=10%
Periodontal pocket depth <4mm
No BoP at 4mm sites
What is characteristic of a currently unstable periodontal patient?
Periodontal pocket depth >5mm
or
Periodontal pocket depth >4mm WITH bleeding on probing.
Why is the periodontal pocket depth cut off 4mm?
As these deep pockets are less stable and cannot be cleaned.
Why is the patient’s periodontal history vital for clincial examination?
A deep pocket without bleeding may be inactive disease. Therefore, you need to know patient history as the pocket may be in the process of, but have not healed yet.
What are the symptoms of necrotising gingivitis?
Necrosis and ulcers in the interdental papilla and gingvial margins
Ulcers covered in sloughing
Deep pocket formation at the ulcers.
Pain
Readily provoked bleeding.
First lesions are seen inter-proximally at the mandibular anterior region
No fever.
Whatis the sloughing formation
A layer of yellowish/ white/ grey debris that is made of necrotic tissue,bacteria and cells on the tissue.
What are the symptoms of necrotising periodontitis?
Necrotising gingivitis symptoms +
* Ulcers covered in sloughing
* Deep pocket formation at the ulcers
* Pain
* Readily provoked bleeding.
* First lesions are seen inter-proximally at the mandibular anterior region
* No fever.
+Destruction of the periodontal attachment and bone
Bone sequestrum (in severely immunocompromised patients)
What is a bone sequestrum?
The seperation of dead bone .
What is this clinical image showing?
Necrotising stomatitis
Infection of the oral mucosa that can cause loss of chunks of bone from the alveolar bone.
Describe this clinical image.
Necrotising gingivitis
The infection is restricted to the soft tissues. (usually papilla)
There is:
Ulceration around the gingival margin.
Sloughing- the white/grey fibrous coating that peels.
Describe this clinical image
Necrotising periodontitis.
The infection causes attachment loss.
The interdental papilla and bone are destroyed (greater defect)
What is this clinical image?
Herpetic gingivostomatitis.
This involves the Herpes simplex virus and affects the gingival mucosa.
We see multiple vesicles and the patient has a fever.
This does not permanently destruct tissue.
How does peridontitis manifest as systemic disease?
Some rare diseases don’t affect the periodontitis proccess, they just cause it to present earlier (as a result of their affected immune system)
e.g. down’s syndrome
Papillion lefevre syndrome.
What is Papillion lefevre syndrome?
When the patient loses 80-90% of the bone around their deciduous teeth.
& they have premature loss of their permanent dentition at a young age.
How does uncontrolled diabetes mellitus affect the periodontal tissues?
The uncontrolled diabetes causes the breakdown of periodontal conditions. This mimics periodontitis.
What type of gingival recession is shown in the clinical image?
Type 1-
There is no loss of interproximal attachment
The recession is narrow and localised.
Name and describe the type of gingival recession is shown in the clinical image?
Type 2-
There is loss of interproximal attachment
The apical attachment loss is greater than the interproximal attachment loss. (still something left interproximally)
Name and describe the type of gingival recession is shown in the clinical image?
Type 3-
The papilla is completely lost.
interproximal attachment loss is greater than apical attachment loss.
(there is nothing interproximal left)
Name and describe the abscesses of the periodontium
gingival abscess- localised to the gingiva
Periodontal abscess- related to a pre-exisiting deep pocket due to food packing or margin tightening after HPT.
Peri-coronal abscess- inflammation around the crown of a partially erupted tooth (like a partially erupted wisdom tooth)
What is an abscess?
A swelling in the tissue which is filled with pus and caused by an infection.
What are the signs and symptoms of a periodontal abscess?
- Swelling
- Pain
- TTP laterally.
- Deep periodontal pocket
- Suppuration
- Enlarged regional lymph nodes
- Fever
- Commonly pre-existing periodontal disease.
- Tooth still vital.
How do we treat a periodontal abscess?
- subgingival instrumentation (short of the pocket base)
- If pus is present- drain by incision or through the periodontal pocket.
- 0.2% Chlorohexidine mouthwash- until acute symptoms subside.
- analgesia
- ONLY ANTIBIOTICS IN CERTAIN SITUATIONS.
Why do we instrument short of the pocket base for a periodontal abscess ?
Because the attachment is friable and easily damaged.
Aggresive curetting down to the bone would cause recession rather than healing.
Discuss the use of antibiotics for a periodontal abscess
Only use them when:
There is spreading infection
The pocket is not responding to instrumentation.
We use penicillin V (500mg 4 times daily for 5 days)
(400mg 3 times daily metrondiazole if allergic)
in combination with mechanical therapy.
How can endodontic disease affect periodontal health?
The inflammatory factors spread from the pulp via the apical foramen ,adversely affecting periodontitis progression.
Compare acute and chronic endo-periodontal lesions?
Acute- caused by perforation (iatrogenic damage during periodontal treatment)
Chronic- Due to pre-existing periodontitis- this tends to be slow and chronic progression
What are the signs and symptoms of endo-periodontal lesions.
- Deep periodontal pockets reaching (or close to) the apex.
- Negative or altered response to pulp vitality tests
- Bone resorption in the apical or furcation regions.
- Spontaneous pain.
- Pain on palpitation and percussion
- Pus
- Tooth mobility
- A sinus tract draining buccal or palatally
- Crown or gingival colour alterations.
What are the potential routes of infection for an endoperiodontal lesion ?
- The contamination of dentinal tubules with bacteria to affect the pulp.
- Perforation
- Apical foramen
- Lateral and accessory canals .
- Furcal canals
- Vertical development of the radicular grove (an anomaly found in upper incisors that is exposed due to loa)
How is the apical foramen a potential route of infection?
It is the main route of communication between the pulp and periodontium.
Entrance for inflammatory byproducts to affect the pulp.
Exit from the pulp of microbial and inflammatory by-products to cause peri-radicular pathology.
What questions do we ask to classify an endo-periodontal lesion.
- Is the root damaged.
- Did the patient have previous periodontal disease .
- What is the lesion affecting
How do we treat an endo- perio lesion?
- Incise abscess if present.
- Endodontic treatment of the affected tooth.
- Analgesia.
- 0.2% chlorohexidine mouthwash- until the acute symptoms subside.
- Carry out supra and subgingival instrumentation 10 days later if root surface is still contaminated.
How do we treat necrotising periodontal disease?
First line-
Ultrasonic debridement and 0.2% chlorohexidine mouthwash twice daily.
or 3% hydrogen peroxide mouthwash.
If acute form or initial treatment doesn’t work.
400mg Metrondiazole 3 times daily for 3 days.
*if allergic use 500mg Amoxicillin 3 times daily for 3 days*
How can we further classify a periodontal abscess?
A periodontal abscess can be further classified by wether the patient has periodontal disease.
If it is a Periodontal abscess in a periodontitis patient. This abscess is caused by :
-Untreated periodontitis
-After treatment (e.g., post scaling/surgery/medications)
If there is a Periodontal abscess in a non-periodontitis patient- this can be due to:
-Impaction
-Gingival overgrowth
-Harmful habits
Give some causes of a periodontal abscess in a patient with periodontitis ?
Untreated periodontitis.
Leftover plaque in the pocket after treatment.
Give some causes of a periodontal abscess in a non-periodontitis patient
Impaction.
Gingival overgrowth
Harmful habits e.g. nail biting.
How can we further classify a necrotising disease?
By the compromisation:
-Necrotising disease in chronically, severely compromised patients e.g. HIV +-AIDS/ immunosuppression.
-Necrotising disease patients compromised due to gingivitis or periodontitis.
What has caused this presentation?
A chemical burn e.g. from acid etch.
What has caused this presentation?
A thermal burn.
How can we treat any traumatic presentations to the gums?
0.2% Chlorohexidine mouthwash and pain killers- we don’t want the patient to brush off the fibrin & healing tissues.
How does 3% hydrogen peroxide mouthwash treat Necrotising diseases?
The bacteria involved is spirochete and fusiform (these are anerobic bacteria)
The hydrogen peroxide mouthwash froths up to produce oxygen
