Perio Diagnosis Update Flashcards
1
Q
There are 2 main categories of terms in the perio diagnostic system, what is the first one?
Which 3 categories all under the main category?
A
2
Q
What is the second main category of periodontal diagnosis in the new system?
What 4 categories are contained within it?
A
3
Q
What be the terminology when describing this scenario?
A
Clinical Gingival Health on an Intact Periodontium
4
Q
The new diagnosis system contains this term where as the previous did not…what terminology would you use to describe this case?
A
Clinical Gingival Health on a Reduced Periodontium
(stable periodontitis patient)
5
Q
What terminology would you use to describe this scenario?
A
Clinical Gingival Health on a Reduced Periodontium (non-periodontitis patient)
- No history of periodontitis
- No bone loss radiographically
- Generalized recession and clinical attachment loss (or a reduced periodontium) mostly confined to the facial surfaces
6
Q
The diagnosis system outlines 4 levels of Periodontal Health…What are they?
A
- Pristine Periodontal Health
- Well maintained clinical periodontal health with a structurally sound/intact periodontium
- Periodontal disease stability with a reduced periodontium
- Periodontal disease remission/control with a reduced periodontium
7
Q
Describe pristine periodontal health…
A
- Rare (not likely to be observed clinically), but realistic
- No attachment loss, no BOP, no PD > 3 mm
- No erythema, swelling/edem, or suppuration
- Associated with physiologic immune surveillance, not pathological inflammation
8
Q
Describe a well-maintained clinical periodontal health patient with a structurally sound/intact periodonium…
A
- Clinically health = tissue that has absence of or very low levels of clinical indicators of inflammation (i.e. no BoP)
- Radiographically intact lamina dura, no evidence of bone loss in furcations, 2mm from most coronal portion of alveolar crest to CEJ
9
Q
Describe the 3rd level of Periodontal Health named Periodontal disease stability with a reduced periodontium…
A
- Periodontitis has been successfully treated (by control of local and systemic factors)
- Minimal BoP, improvements in PD and attachment levels
- Lack of progressive destruction
10
Q
Finally we are the 4th level of periodontal health which is called Periodontal diseaes remission/control with a reduced periodontium…can you describe this?
A
- Reduction of inflammation and improvement in PDs, but may not be fully resolved
- Lack of optimal control of local and/or systemic factors
- If local/systemic factors not controlled, then may result in progressive attachment loss
11
Q
What are the Indicators of Periodontal Health?
A
- Minimal to no BoP: absence of BoP at repeated exams is a reliable indicator for periodontal stability
- Shallow pockets or deep “healthy” pockets: unless in the presence of BoP and radiographic bone loss
- Minimal to No Radiographic Bone Loss: intact lamina dura, no furcal bone loss, 2mm distance from CEJ to alveolar crest
- Periodontal health can occur on a reduced periodontium (history of bone loss) but cannot be diagnosed with radiographs alone
- Physiologic tooth mobility < 0.2 mm - unless associated with widened PDL, then likely a sign of occlusal trauma
- Increased tooth mobility (no widened PDL) may be associated with a healthy reduced periodontium due to the loss of alveolar support
12
Q
PERIODONTAL HEALTH and GINGIVAL HEALTH
What are 3 determinants of Clinical Periodontal Health?
A
13
Q
Is periodontal disease a simple bacterial infection?
A
No!
- Multifactorial disease process that involves:
- Subgingival microorganisms
- Host immuno-inflammatory response
- Environmental modifying factors
14
Q
What causes a patient to go from sound periodontal health to a gingivitis patient?
A
- Once the 3 determinants of health (bacteria, host reponse, and environmental factors) exceed a certain threshold (which varies between individuals), you will see a transition from ehalth to a state of gingivitis
15
Q
What is the 2nd category in the Periodontal Health, Gingival Diseases, and Conditions category?
A
16
Q
GINGIVITIS: BIOFILM-INDUCED
What factors can influence systemic or local factors?
A
- Biofilm induced gingivitis is primarily associated with the bacterial biofilm. This type of gingivitis can be modified (or exacerbated) by several different factors such as:
- Sex steroid hormones
- Hyperglycemia
- Leukemia
- Smoking
- Malnutrition
- Priminent Subgingival Restorations
- Hyposalivation
17
Q
What are 3 categories of drugs that can cause Drug-Influenced Gingival Enlargment?
A
- Anti-Epileptic Drugs (phenytoin, sodium valproate)
- Calcium Channel Blockers (nifedipine, amlodipine, verapamil, diltizaem, felodipine)
- Immmunoregulating Drugs (cyclosporine, high dose oral contraceptives)
- Appreciate biofilm in attached picture
18
Q
GINGIVITIS: BIOFILM-INDUCED
What are the signs/symptoms of biofilm-induced gingivitis?
A
- Inflammation confined to free and attached gingiva
- BoP and gingival erythema/edema
- Presence of high bacerial load (plaque)
- Stable attachment levels
- Tenderness to probing
- Halitosis
- PREREQUISITE for developemnt of periodontitis
- REVERSIBLE with disruption of biofilm
19
Q
What is the 3rd category in the Periodontal Health, Gingival Diseases, and Conditions?
A
20
Q
GINGIVAL DISEASES: NON BIOFILM-INDUCED
What are 4 categories that fall under Gingival Diseases: Non Biofilm Induced?
A
- Genetic/Developmental Disorders
- Specific Infections
- Inflammatory and Immune Conditions
- Reactive Processes
21
Q
GINGIVAL DISEASES: NON BIOFILM-INDUCED
What is an example of a genetic/developmental disorder?
A
Hereditary Gingival Fibromatosis
22
Q
GINGIVAL DISEASE: NON BIOFILM-INDUCED
What are some examples of Specific Infections related to Gingival Diseases: Non Biofilm-Induced?
A
- Bacterial: necrotizing periodontal disease, acute streptococcal gingivitis, neisseria gonorrhoeae, orofacial tuberculosis
- Viral: coxsackie, HSV/herpetic gingivostomatitis, HPV, VZV
- Fungal: candidosis, histoplasmosis, aspergillosis
23
Q
GINGIVAL DISEASE: NON BIOFILM-INDUCED
What are some examples of Inflammatory and Immune Conditions related to Gingival Diseases: Non Biofilm-Induced?
A
- Hypersensitivity reactions - contact allergy, plasma cell gingivitis, erythema multiforme
- Autoimmune disease: pemphigus vulgaris, pemphigoid, lichen planus, lupus erythmatosis
- Granulomatous Inflammtory Conditions: orofacial granulomatosis, Crohn’s disease, sarcoidosis
24
Q
GINGIVAL DISEASE: NON BIOFILM-INDUCED
What are some examples of Reactive Processes (epulides) as they relate to Gingival Diseases: Non Biofilm Induced?
A
- Fibrous epulis
- Calcifying fibroblastic granuloma-ossifing fibroid epulis, peripheral ossifying fibroma
- Pyogenic granuloma
- Peripheral giant cell granuloma
25
GINGIVAL DISEASES: NON BIOFILM INDUCED
What is this a picture of?
Fungal Infection
Candidosis associated with a maxillary implant retained denture
26
GINGIVAL DISEASES: NON BIOFILM INDUCED
What is this a picture of?
Lichen Planus
27
GINGIVAL DISEASES: NON BIOFILM-INDUCED
What is this a picture of?
Pemphigus
28
GINGIVAL DISEASES: NON BIOFILM-INDUCED
What is this a picture of?
Pemphigoid
29
GINGIVAL DISEASES: NON BIOFILM INDUCED
What are 4 categories of the above mentioned topic?
1. Neoplasms
2. Endocrine, nutritional, metabolic disorders
3. Traumatic lesions
4. Gingival pigmentation
30
GINGIVAL DISEASES: NON BIOFILM INDUCED
What are some examples of Neoplasms as it related to the above category?
* Premalignant: leukoplakia, erythroplakia
* Malignant: SCC, leukemia, lymphoma
31
GINGIVAL DISEASES: NON BIOFILM INDUCED
What are some examples of endocrine, nutritional, and metabolic disorders as it relates to the above topic?
Vitamin deficiencies - i.e. Scurvy/vitamin C deficiency
32
GINGIVAL DISEASES: NON BIOFILM INDUCED
What are some examples of Traumatic Lesions as it relates to the above topic?
* Physical/mechanical insults-frictional keratosis, toothbrushing induced gingival ulceration, factitious injury
* Chemical (toxic) insults - etching, chlorhexidine, ASA, cocaine, hydrogen peroxide, dentifrices, paraformaldehyde or calcium hydroxide
* Thermal insults - burns
33
GINGIVAL DISEASES: NON BIOFILM INDUCED
What are some examples of Gingival Pigmentation as it relates to the above category?
* Melanoplakia due to drugs, heavy metals, genetics, endocrine disturbances, syndromes, post inflammatory
* Smoker's melanosis
* Drug-induced pigmentation - antimalarials, minocycline
* Amalgam tattoo
34
GINGIVAL DISEASES: NON BIOFILM INDUCED
What are these pictures of?
* First picture is likely amalgam tatoo
* Second picture is likely racial pigmentation
35
Under the category of Periodontitis, what 3 sub categories are there?
36
What are the 3 kinds of Necrotizing Periodontal Diseases?
1. Necrotizing Gingivitis
2. Necrotizing Periodontitis
3. Necrotizing Stomatitis
37
Describe what is going on here...
Necrotizing Gingivitis
* Necrosis/ulcer of papillae, gingival bleeding, pain
* Halitosis, pseudomembranes, lymphadenopathy, fever, sialorrhea
38
What is going on here?
Necrotizing Periodontitis
* Necrosis/ulcer of papillae, gingival bleeding, pain
* Halitosis, pseudomembranes, lymphadenopathy, feber, sialorrhea
* Rapid bone loss
39
What is going on here?
Necrotizing Stomatitis
* Soft tissue necrosis extending beyond the gingiva
* Bone denudation through alveolar mucosa
* Osteitis, bone sequestrum
* Severely systemically compromised patient
40
What type of bacteria is associated with all 3 various stages of the Necrotizing Periodontal Diseases?
Spirochetes
41
What are some predisposing factors for Necrotizing Periodontal Diseases?
* Compromised host immune response
* HIV/AIDS
* Malnutrition
* Psychologic stress
* Lack of sleep
* Inadequate OHm pre-existing gingivitis, previous history of NPD
* Tobacco, alcohol use
* Young age, Caucasian
* Winter months
42
NECROTIZING PERIODONTAL DISEASES
Describe the category of Necrotizing periodontal disease in chronically, severely compromised patient...
43
NECROTIZING PERIODONTAL DISEASES
Describe Necrotizing Periodontal disease in temporarily and/or moderately compromised patients...
44
Describe the definition of a Periodontitis patient...
* Interdental CAL at \> or equal to 2 non-adjacent teeth
* Buccal or lingual CAL \> or equal to 3 mm with pocketing \> 3 mm detactable at \> or equal 2 teeth
45
When describing a periodontitis patient, the CAL CANNOT be ascribed to...
* Gingival recession of traumatic origin
* Dental caries on cervical aspect of tooth
* Presence of CAL on distal of 2nd molars due to malposition/extraction of 3rd molars
* Endo lesion draining through marignal gingiva
* Vertical root fracture
46
Describe the 4 stages of Periodontitis?
* Stage I: Initial periodontitis
* Stage II: Moderate periodontitis
* Stage III: Severe periodontitis with potential for additional tooth loss
* Stage IV: Severe periodontitis with potential for loss of dentition
47
Describe the Extent and Distribution of Perionditis diagnosis...
Extent and Distribution
* Localized (\<30% of teeth involved)
* Generalized
* Molar-incisor distribution
48
Describe the 3 Grades as they relate to Periodontitis diagnosis...
Grades
* Grade A: Slow rate of progression
* Grade B: Moderate rate of progression
* Grade C: Rapid rate of progression
49
Describe Stage I of Periodontitis...
50
Describe Stage II as it relates to Periodontitis Diagnosis...
51
Describe Stage III as it relates to Periodontitis...
52
Describe Stage IV is relates to Periodontitis diagnosis...
53
How does a clinician arrive at the proper stage for Stage I periodontitis?
* Mild Disease
* Patient's will have PD \< or equal 4
* CAL \< or equal 2 mm
* Horizontal bone loss
* Require NON SURGICAL TREATMENT
* No post treatment tooth loss is expected
* Case has a good prognosis going into maintenance
54
How does a clinician arrive at a Stage II periodontitis diagnosis?
* Moderate disease
* Patients will have PD \< or equal to 5 mm
* CAL \< or equal to 3-4 mm
* Horizontal bone loss
* Will REQUIRE NON SURGICAL AND SURGICAL treatment
* No post-treatment tooth loss is expected
* Good prognosis going into maintenance
55
How does a clinician arrive at a Stage III Periodontitis diagnosis?
* Severe Disease
* PD \> or equal to 6 mm
* CAL \> or equal to 5 mm
* May have vertical bone loss and/or furcation involvement of Class II or III
* Will REQUIRE SURGICAL and possibly REGENERATIVE TREATMENTS
* There is potential for tooth loss from 0 to 4 teeth
* The complexity of implant and/or restorative treatment is incrased
* Overall case ha a fiar prognosis going into maintenance
56
How would a clinician arrive at the Stage IV periodontitis diagnosis?
* Very severe disease
* PD \> or equal to 6 mm
* CAL \> or equal to 5 mm
* May have vertical bone loss and/or furcation involvement of class II or III
* Less than 20 teeth may be present and there is the potential for tooth loss of 5 or more teeth
* Advanced surgical treatemnt and/or regenerative therpy may be required
* Very complex/restorative treatment
* Overall case has a questionable prognosis going into maintenance
57
Describe Grade A in regards to the Periodontitis patient...
58
Describe Grade B in regards to the Periodontitis patient...
59
Describe Grade C in regards to the Periodontitis patient...
60
What is the intent of staging and grading?
* Do not help arrive at a diagnosis
* Staging and grading help clarify extent, severity, and complexity of the condition
* Also help clarify rate of disease progression, predicted reponse to standard therapies, and potential impact on systemic health
* Also include pattern of bone loss, tooth loss, furcation status, treatment difficulty
* Prognosis for tooth loss
* Degree of restorative difficulty and complexity
61
Can I use a stage for each quadrant or sextant like I did with a severity-based diagnosis of slight, moderate, or severe?
* No
* Stagging is designed to give information about the whole mouth relative to the severity and complexity, including prognosis
62
Does the area with the most severe destruction determine the stage?
* Yes
* The staging system is designed to highlight the patient's most sever areas of destruction
63
Can the stage change for a periodontitis patient?
* The stage typically does not regress or move to a lower stage
* Exception
* If Stage III due to presence of vertical defect \> 3 mm or Class II furcation involvement and those sites are successfully regenerated such that the CAL throughout the dentition is not 3-4 mm, the furcation involement is a Class I or not clinically detectable, and PD are \< or equal to 5 mm, the stage could change from Stage III to Stage II
64
Why do I need to utilize grading?
* Grading provides the likelihood of post-treatment disease progression
* The disignations recommended are A, B, or C, signifying slow or no progression, moderate progression, and rapid progression
* The assessment is baed on past progression, presence of risk factors such as diabetes and/or smoking, and the systemic impact of periodontitis
65
How should I use grading?
* Only one grade is assigned to the patient
* Based on either direct or indirect evidence of the rate of disease progression and risk for future progression
* Grade modifiers include smoking and diabetes
66
Describe the 4 step approach to Staging and Grading...
1. Initial Overview of Case
2. Fine-tune the stage
3. Determine Grade
4. Diagnose
67
In your journey of arriving to a Periodontitis diagnosis, describe Step I...
68
In your journey of arriving to a Periodontitis diagnosis, describe what you're doing during Step 2...
69
During your journey in arrive to a Periodontitis diagnosis, what are you doing during Step 3?
70
What is the default Grade?
Grade B!
71
Finally, in arriving to a diagnosis of your Periodontitis patient, what are you doing during Step 4?
72
Can you name the 3rd category under Periodontitis?
73
Have there been any notable changes in the Periodontitis as a Manifestation of Systemic Disease category?
No!
74
What are some diseases associated with immunologic disorders?
* Down syndrome
* Leukocyte adhesion deficiency
* Papillon-Lefevre syndrome
* Haim-Munk syndrome
* Severe neutropenia
* Primary immunodeficiency diseases
* Cohen syndrome
75
PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASE
What are some diseases affecting connective tissue?
* Ehlers-Danlos syndrome
* Angioedema
* Systemic lupus erthematosis
76
PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASE
What are some metabolic and endocrine disorders?
* Glycogen storage disease
* Gaucher disease
* Hypophosphatasia
* Hypophosphatemic rickets
* Hajdu-Cheny syndrome
* Diabetes mellitus
* Obesity
* Osteoporosis
77
PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASE
What is going on in these pictures?
Agammaglobulinemia
78
PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASE
What is going on in this picture?
Leukocyte Adhesion Deficiency
79
PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASE
What is going on in this picture?
Leukocyte Adhesion Deficiency
80
What are some examples of Acquired Immunodeficiency Diseases?
* Acquired Neutropenia
* HIV Infection
81
What are some examples of Inflammatory diseases that affect the periodontium?
* Rheumatoid arthritis
* Osteoarthritis
* Inflammatory bowel disease
* Epidermolysis bullosa acquisita
82
What are some Systemic disorders that can result in loss of periodontium INDEPENDENT of periodontitis?
* Neoplasms
* Odontogenic Tumors
* Langerhans cell histiocytosis
* Giant cell granulomas
* Hyperparathyroidism
83
There are 5 sub categories below "Other Conditions Affecting the Periodontium"...can you name all 5?
1. Systemic Diseases/conditions affecting the periodontal supporting tissues
2. Periodontal Abscesses and Endo-Perio Lesions
3. Mucogingival Deformities/Conditions
4. Traumatic Occlusal Forces
5. Tooth and Prosthesis Related Factors
84
SYSTEMIC DISEASE/CONDITIONS AFFECTING THE PERIODONTAL SUPPORTING TISSUES
What are some diseases/conditions that influence the course of periodontitis?
* Diabetes mellitus
* Leukocyte adhesion deficiency
* Hypophosphatasia
* Papillon-Lefevre syndrome
\*\*Significant overlap with periodontitis as a manifestation of systemic diseases category
85
SYSTEMIC DISEASE/CONDITIONS AFFECTING THE PERIODONTAL SUPPORTING TISSUES
What are some diseases/conditions that affect ther periodontal supporting tissues INDEPENDENT of plaque biofilm?
* Diseases that cause periodontal breakdown that can mimic the clinical presentation of periodontitis
* SCC
* Langerhans Cell Histiocytosis
\*\*Significnat overlap with periodontitis as a manifestation of systemic diseases category
86
What is going on in this picture?
Langerhans Cell Histiocytosis
87
What is the 2nd category under "Other Conditions Affecting the Periodontium"?
88
What is a Periodontal Abscess?
* Common dental emergency requiring immediate management
* Rapid destruction of periodontium, negatively affecting the prognosis of the tooth
* Possible severe systemic involvement
* Bacterial invasion leading to localized collection of PNs and other inflammatory mediators
* Most common pathogen: P. Gingivalis
89
What are some signs and symptoms of a periodontal abscess?
* Pain, tenderness of gingiva
* Swelling or tooth "elevation"
* Suppuration on probing, deep opcket, BoP
* Increased tooth mobility
* Radiographic bone loss
* Facial swelling
* Elevated body temperature
* Malaise
* Lymphadenopathy
90
What are the new 2 sub groups of Periodontal Abscesses?
1. Periodontal abscesses in periodontitis patients
2. Periodontal abscesses in non-periodontitis patients
91
What are som etiologic factors related to Periodontal abscesses in periodontitis patients?
92
What are some etiologic factors associated with Periodontal abscesses in non-periodontitis patients?
93
What are some possible pathways for Endo-Perio Lesions?
Are there major differences between the microbiology of a perio lesion and a perio lesion?
* Apical radicular foramina
* Accessory/lateral canals
* Dentinal tubules
* No!
94
What are some signs of an Endo/Perio Lesion?
* Fistula/sinus tract
* History of endo treatment, possible trauma
* Loss of pulp vitality with periodontal pocket to the apex of the tooth
* Radiographic evidence of root resorption or fracture
95
What are the 2 sub categories of Endo/Perio Lesions?
* Endo-Perio lesion WITH root damage
* Endo-Perio lesion WITHOUT root damage
96
If there IS root damage with an endo/perio lesion, what is the likely etiology?
* Root fracture or cracking
* Root canal or pulp chamber perforation
* External root resorption
97
If you have an endo/perio lesion WITHOUT root damage, you can further classify this with what 2 types of patients?
* Endo-Perio lesion in PERIODONTITIS patients
* Endo-Perio lesion in NON PERIODONTITIS patients
98
If you have an endo/perio lesion in a patient that has periodontitis, what are the 3 grades?
1. Grade 1: narrow deep perio pocket in 1 tooth surface
2. Grade 2: wide deep perio pocket in 1 tooth surface
3. Grade 3: deep perio pocket in \> 1 tooth surface
99
If you have an Endo/Perio lesion in a non periodontitis patient, what are the 3 grades?
1. Grade 1: narrow deep perio pocket in 1 tooth surface
2. Grade 2: wide deep perio pocket in 1 tooth surface
3. Grade 3: deep perio pocket in \> 1 tooth surface
100
In the new perio diagnostic system, what is the 3rd category under "Other Conditions Affecting the Periodontium"?
101
What are the diagnostic categories in Mucogingival Deformaties/Conditions?
* Gingival phenotype
* Gingival/soft tissue recession
* Lack of gingiva
* Decreased vestibular depth
* Aberrant frenum/muscle position
* Gingival excess
* Abnormal color
* Condition of the exposed root surface (NCCLs)
102
Instead of the word "biotype" - the new word is...
103
What are the 3 Periodontal Phenotypes?
1. Thin Scalloped
2. Thick flat
3. Thick scalloped
104
Describe thin scalloped phenotype...
* Slender triangular crown
* Subtle cervical convexity
* Interproximnal contact close to incisal edge
* Narrow zone of KT
* Clear thin delicate gingiva
* Thin alveolar bone
105
Describe the thick flat phenotype...
* Square shaped crowns
* Pronouonced cervical convexity
* Large interproximal contact located more apically
* Broad zone of KT
* Thick fibrotic gingiva
* Thick alveolar bone
106
Describe the thick scalloped phenotype...
* Thick fibrotic gingiva
* Slender teeth
* Narrow zone of KT
* Pronounced gingival scalloping
107
Define Recession...
Apical shift of the gingival margin with respect to the CEJ; associated with attachment loss and exposure of root surface
108
What are some predisposing factors to recession?
* Thin periodontal phenotype
* Absence of attached gingiva
* Ideally 2 mm of KT and 1 mm of attach gingiva for health, but NOT necessary to prevent attachment loss in presence of good OH
* Reduced thickness of alveolar bone
* Incorrect toothbrushing (inconclusive evidence)
* Intracrevicular restorative margins - augmentation recommended if minimal/no gingiva at these sites
* Ortho-augmentation indicated prior to ortho in areas with \<2mm of gingiva
109
What is the new recesion system called?
Cairo Recession Classification
110
How would you classify this recession?
Cairo Recession Type I
* Recession with NO LOSS of interproximal attachment
* Interproximal CEJ clinically non-detectable
* Overlaps with Miller Class I and II
* 100% root coverage anticipated/predictable
111
How would you classify this recession?
Cairo Recession Type 2
* Recession WITH LOSS of interproximal attachment \< or equal to buccal CAL
* Overlaps with Miller Class III
* 100% root coverage can be achieved by not in every case
112
What type of recession is this?
Cairo Recession Type 3
* Recession with loss of interproximal attachment \> buccal CAL
* Overlaps with Miller Class IV
* 100% root coverage is NOT achievable
113
What is the new classificaiton called for NCCLs?
Pini-Prato Classification
114
What is the difference between a Pini-Prato Class A and Class B?
* Class A you can still detect the facial CEJ
* Class B the CEJ has CEJ has been worn away
115
What does the + and - mean in the Pini-Prato classificaiton system for NCCLs?
* The + indicates a step is present
* The - indicates that there is a smooth transition
116
How would you classify these?
* Pini-Prato Class A-
* Pini-Prato Class A+
117
How would you classify these?
* Pini-Prato Class B -
* Pini-Prato Class B+
118
MUCOGINGIVAL DEFORMITIES CONDITIONS
How would you describe this picture?
Excess Gingival Display
119
MUCOGINGIVAL DEFORMITIES/CONDITIONS
How would you describe this?
Aberrant Frenum Position
120
MUCOGINGIVAL DEFORMITIES/CONDITIONS
How would you describe this?
Lack of Keratinized Tissue
121
What is the 4th diagnostic category under "Other Conditions Affecting the Periodontium"?
122
What are some indicators of occlusal trauma?
* Fremitus
* Mobility
* Occlusal discrepancies
* Wear facets
* Tooth migration
* Fractured tooth
* Thermal sensitivity
* Discomfort/pain on chewing
* Widened PDL space
* Root resorption
* Cemental tear
123
What is the definition of Excessive Occlusal Force?
Occlusal force exceeds reparative capacity of periodontal attachment apparatus which leads to occlusal trauma, excessive tooth wear or loss
124
What is the definition of Occlusal trauma?
* Injury resulting in tissue changes to PDL, supporting alveolar bone and cementum
* Occurs in an intact periodontium or in a reduced periodonium
125
How would you define Primary Occlusal Trauma?
* Injury resulting in tissue changes on a tooth/teeth with a NORMAL, healthy periodontium
* Normal CAL, normal bone levels and excessive occlusal force
126
How would you define Secondary Occlusal Trauma?
* Injury resulting in tissue changes on a tooth/teeth with a reduced periodontium
* CAL, bone loss and normal/excessive occlusal force
127
How would you define Fremitus?
* Palpable or visible tooth movement when subjected to occlusal forces
128
How would you define Bruxism?
* Habit of grinding/clenching/clamping of teeth
* Has the potential to damage the periodontal attachment apparatus
129
Can traumatic occlusal forces lead to periodontal disease?
* Excessive occlusal forceds DO NOT initiate plauqe induced periodontal diseases or loss of periodontal attachment
* Insufficient evidence to conclude that excessive occlusal forces result in abfraction or gingival recession
130
How does ortho affect the periodontium?
* Ortho forces can be detrimental to the periodontium if forces are non-controlled; however, evidence suggests there is minimal overall effect on the periodontium (especially with good OH)
131
What is the 5th category under "Other Conditions Affecting the Periodontium"?
132
What are some tooth related factors that affect the periodontium?
* Tooth anatomic factors
* Root fractures
* Cervical root resorption
* Cemental tears
* Root proximity
* Altered passive eruption
133
What are some localized dental prosthesis-related factors that affect the periodontium?
* Restoration margins placed within the supracrestal attached tissues
* Clinical procedures related to indirect restorations
* Hypersensitivity/toxicity reactions to dental materials
134
What is the new term for Biologic Width?
Supracrestal Tissue Attachment
135
What happens when restorative margins are placed within or encroaching upon the supracrestal tissue attachment?
* Greater papillary bleeding index scores
* Increased PDs
136
What is Altered passive eruption?
* Developmental condition resulting in abnormal dento-alveolar relationship
* Gingival margin at a more coronal level than normal which leads to pseudopockets and shortened clinical crown heights
137
How do Class II restorations with subgingival margins affect the periodontium?
* Increased ginigval inflammation
* Increased PDs
138
When you have overhangs \> 0.2 mm, how does this affect the periodontium?
* Crestal bone loss
* Increased BoP and PDs
* Removal of overhangs during initial therapy improves parameters
139
How can RDPs have a negative impact on the periodontium?
* Increased prevalence of caries, gingivitis and periodontitis
* Increased plaque levels and gingival inflammation
140
RDPs can have a favorable periodontal prognosis if...
* Periodontal disease is treated and controlled
* Patient maintains OH
* Patient compliance with maintenance
* RDP has been correctly designed and maintained
141
What are some tooth anatomical considerations that could lead to periodontal destruction?
* Cervical Enamel Projections
* Enamel Pearls
* Developmental Grooves
* Tooth Fractures
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How can CEPs and EPs affect the periodontium?
* Increased risk of furcation involvement
* Increased PD and CAL
* CEP found in 82.5% of furcation involved molars
* Prevalence of EPs = 1-5.7% of molars
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How can Developmental Grooves affec the periodontium?
* Palatogingival groove on max lateral incisors
* 1-8.5% prevalence
* 43% do not extend \> 5 mm apical to CEJ
* Commonly present on the interproximal surfaces of other teeth
144
Do tooth fractures always affect the periodontium?
* If the tooth fracture = coronal to gingival margin
* Not usually associated with gingivitis/periodontitis
145
Describe the 3 grades of CEPs...
* Grade I: distinct change in CEJ with enamel projecting toward the furcation
* Grade II: CEP approaching furcation but not making contact with it
* Grade III: CEP extending into furcation proper
146
What is this?
Enamel Pearl
147
What is this?
Palatogingival Groove
148
What is the new diagnostic category regarding implants?
Peri-Implant Diseases and Conditions
149
What is the first category under "Peri-Implant Diseases and Conditions"?
Peri-Implant Health
150
What are the 4 categories under "Peri-Implant Diseases and Conditions"?
1. Peri-Implant Health
2. Peri-Implant Mucositis
3. Peri-Implantitis
4. Peri-Implant Soft and Hard Tissue Deficiencies
151
Describe ideal Peri-Implant Health...
Absence of clinical signs of inflammation (erythema, edema) and no BoP
152
The implant surface of peri-implant mucosa is comprised of what 2 distinct parts?
* Coronal Portion: line by thin barrier epithelium (similar to JE) and sulcular epithelium; connective tissue has delicate vascular plexus with circumferential collagen fibers
* Apical Portion: connective tissue in direct contact with implant surface (zone of connective tissue adhesion) with limited vascular structures
153
Discuss what probing an implant in health looks like?
* Probe fails to reach apical portion of epithelial barrier
* PDs greater at proximal sites vs facial sites
* Peri-implant PDs are greater than PDs at tooth sites
* Soft tissue cuff around implants is less resistant to probing
154
Is probing implants safe?
Yes!
Evidence supports probing with light force is safe and important for complete evaluation
155
What does the probe reach in disease regarding an implant?
Probe reaches apical base of inflammatory cell infiltrate
156
How often should you probe an implant?
* At least once a year
* Peri-implant PDs should be \< or equal to 5 mm (but not necessary fo healthy peri-implant tissue)
* Increase in PD over time may indicate development of peri-implantitis
* BoP should not be present in peri-implant health
157
How often should you take x-rays of implants?
* Baseline (with suprastructure in place) and annually thereafter
* Changes of \> or equal to 2 mm at any time point should be considered pathologic
158
Do you need Keratinized Mucosa for implants?
* Need for minimum amount of KM around implants is controversial
* Some studies suggest that if peri-implant KM \< 2 mm, there is increased PD and marginal inflammation
159
What is Osseointegration?
* Bone to implant contact on light microscopic level
* Direct functional and structural connection between living bone and surface of a load-carrying implant
160
What is the 2nd category under Peri-Implant Diseases and Conditions?
Peri-Implant Mucositis
161
What is Peri-Imlant Mucositis?
* Clinical signs of inflammation (may include erythema, edema, BoP, suppuration) WITHOUT loss of supporting bone or continual marginal bone loss
* Inflammation is REVERSIBLE with plaque control
162
What are some risk factors for developing Peri-Implant Mucositis?
* Plaque accumulation
* Smoking
* Lack of compliance with maintenance
* Implant prosthesis design over-contoured and submarginal restorative margins
* Radiation
* Further evidence needed for potential risk factors like diagetes, lack of KM and excess luting cement
163
What is the third category under Peri-Implant Disease and Conditions?
Peri-Implantitis
164
What is Peri-Implantitis?
* Clinical signs of inflammation (may include erythema, edema, BoP, suppuration) WITH loss of supporting bone and/or progressive bone loss
165
Which disease process is faster, Peri-Implantitis or Periodontitis?
Peri-Implantitis
166
What disease process is going on here?
Peri-Implantitis
167
What is Periapical (retrograde) peri-implantitis?
* Radiolucency at apical portion of implant
* Seen at 2-8 weeks post-implant placement (up to 4 years later)
* With or without clinical signs of inflammation (edema, fistula, abscess)
* Direct correlation between periapical peri-implantitis and existing adjaent periapical endodontic infection
168
What is going on here?
Periapical (retrograde) Peri-Implantitis
169
What are some risk factors for Peri-Implantitis?
* History of Periodontitis
* Smoking
* Diabetes
* Poor OH/Lack of Maintenance
170
Currently there is not enough evidence to determine the risk of the following factors on the development of peri-implantitis...
* Lack of KM
* Excess cement
* Genetic factors
* Systemic conditions
* Iatrogenic factors (inadequate restorative abutment seating, implant malpositioning, design of suprastructure)
171
What is the 4th and final category below "Peri-Implant Diseases and Conditions"?
Peri-Implant Soft and Hard Tissue Deficiencies
172
What are some factors that affect HARD TISSUE PRIOR to implant placement?
* Tooth loss
* Trauma from tooth extraction
* Periodontitis
* Endodontic Infections
* Root fractures
* General Trauma
* Bone height in posterior maxilla (pneumatization of sinus post-extraction
* Systemic Diseases
173
What are some factors that affect Hard Tissue AFTER implant placement?
* Defects in healthy situations
* Malpositioning of implants
* Peri-implantitis
* Mechanical overload
* Soft-tissue thickness
* Systemic diseases
174
What are some factors that affect SOFT TISSUE PRIOR to implant placement?
* Tooth loss
* Periodontitis
* Systemic Diseases
175
What are some factors that affect SOFT TISSUE DEFECTS AFTER implant placement?
* Lack of buccal bone
* Papilla height (2 adjacent implants leads to reduced papilla height)
* Keratinized tissue (minimal KT may be associated with increased plaque and BoP)
* Migration of teeth and life-long skeletal changes
176
What is going on here?
* Seibert Class I
* Buccal-lingual loss
177
What is going on here?
* Seibert Class 2
* Apico-Coronal Loss
178
What is going on here?
* Seibert Class 3
* Combination
179
What cateogry does the Seibert classification fall under in the new perio system?
Peri-Implant Soft and Hard Tissue Deficiencies
