Perio Health; Gingival Diseases/Conditions Flashcards
What is the importance of noticing the periodontal health?
To find the common reference point for assessing disease and determining the meaningful treatment outcomes
What are the clinical features of marginal/free gingiva?
- The portion of the gingiva surrounding the neck of the tooth
- It is not directly attached to the tooth
- Forms the soft tissue wall of the gingival sulcus
- Extends from the gingival margin to the gingival (marginal) groove
What are the clinical features of gingival sulcus?
- Space bounded by the tooth and the free gingiva
- Has the junctional epithelium at its base
- Non-keratinized epithelium
- No rete pegs
- Semi-permeable membrane
What are the clinical features of attached gingiva?
- Portion of the gingiva that extends apically from the area of the free gingival groove to the mucogingival junction
- Normally covered by keratinized epithelium with rete ridges
- No submucosa
- Bound to the underlying tooth and bone
What are the clinical features of interdental gingiva?
- Portion of the gingiva that extends between the teeth
- Includes the Col area which is composed of a nonkeratinized stratified squamous epithelium in the interproximal space
What are the microscopic features of the periodontium?
- oral epithelium
- sucular epithelium
- juncitonal epithelium
What is oral epithelium?
- Keratinized stratified squamous epithelium
- Rete pegs present
- Resistant to forces from mastication
- It has a turnover rate of 30 days
What is sucular epithelium?
- Non-keratinized stratified squamous epithelium
- No rete pegs present
- Semi-permeable membrane
What is junctional epithelium?
- Non-keratinized stratified squamous epithelium
- Hemi-desmosomal and non-collagenous proteins attachment
- Attachment on the tooth is normally at or near the CEJ
- Can be infiltrated by PMN’s
- High rate of turnover (7-10 days)
What are the features of gingival connective tissue?
- Diffuse amorphous ground substance
- Collagen fibers
- Blood vessels in the papillary projections of the connective tissue
The stability of the gingival connective tissue attachment is a key factor in the limitation of the migration of…
junctional epithelium
What is the new term for biologic width?
supracrestal tissue attachment
When plaque is present, the epithelium lining the sulcus is prone to invasion by ____________________________ due to the nature of the type of epithelium
bacteria and their byproducts
Inflammation can initiate and cause the clinical signs of _______________. This can progress to ___________, if left untreated
gingivitis
periodontitis
What are the features of the gingiva?
- Color
- Contour
- Shape
- Size
- Consistency
- Surface texture
- Position
The color of the attached and marginal gingiva displays a range from brown, orange to pink; it results from the colors of the…
- nvascular supply
- the thickness and degree of keratinization of the epithelium
- the pigment containing cells
What should the color of gingiva look like?
- Marginal and attached gingiva are coral pink
- Alveolar mucosa is red, smooth, and shiny
- There can be physiologic pigmentation present
What should the contour of the gingiva look like?
- Scalloped and collar-like
- Gingival level is higher interproximally
What should the shape of the gingiva look like?
The shape of the interdental gingiva is governed by the contour of the proximal tooth surfaces and the location and shape of the gingival embrasures
What should the size of the gingiva look like?
Should corresponds with the sum total of the bulk of cellular and intercellular elements and vascular supply
What should the consistency of gingiva look like?
- Firm and resilient
- The gingival fibers contribute to the firmness of the gingival margin
What should the surface texture of gingiva look like?
- The attached gingiva is stippled; the marginal gingiva is not.
- Stippling varies with age. It is absent during infancy, it appears in some children, it increases until adulthood, and it frequently begins to disappear during old age.
- Stippling is less prominent on lingual than facial surfaces and may be absent in some persons.
What causes stippling?
Microscopically, stippling is produced by alternate rounded protuberances and depressions in the gingival surface.
What should the position of the gingiva look like?
- The level to which the gingiva is attached to the tooth
What are the determinants of gingival health?
Microbiological Determinants
- Supragingival plaque
- Subgingival plaque
Host Determinants
- Local predisposing factors (Periodontal pockets, Restorations, Root anatomy, Tooth position and crowding)
- Systemic modifying factors (Host immune function, Systemic health, Genetics
Environmental Determinants
- Smoking
- Medication
- Stress
- Nutrition
What are ways to indicate gingival health or disease?
- bleeding on probing
- periodontal probing
- radiographic features
- tooth mobility
The treated and stable periodontitis patient with current gingival health still remains at an increased risk for…
recurrent periodontitis
How periodontal health can present?
- pristine periodontal health
- clinical periodontal health
- periodontal disease stability
- periodontal disease remission/control
__________ is the most common form of periodontal disease
gingivitis
What are the signs and symptoms of gingivitis?
- Bleeding when brushing
- Blood in saliva
- Gingival swelling and redness
- Halitosis
What are the clinical findings at dental exam?
- Bleeding upon gentle probing
- Change in gingival clinical features such as color, contour, shape, size, consistency, surface texture, and/or position.
What is important to know about gingival bleeding on probing for those with gingivitis?
- One of the early signs prior to color change or other visual signs of inflammation
- Smoking masks BOP by suppressing the inflammatory response
Absence of BOP is an excellent negative predictor of…
future attachment loss
What does the color look like for gingivitis?
- Color is an important clinical sign of gingival disease
- This can be marginal, patch-like, generalized, or localized
- It can be pale, coral pink, red, bluish-red, or whitish gray
What does the consistency look like for gingivitis?
Chronic forms:
* Soggy puffiness
* Softness and friability
* Firm, leathery consistency
** Acute forms:**
* Sloughing with grayish, desquamative debris
* Vesicle formation
Why does the consistency of gingiva change in gingivitis?
Changes resulting from the predominance of destructive and reparative processes
What does the surface texture look like for gingivitis?
Loss of stippling is an early sign of gingivitis (Not all patients have stippling)
What does the position look like for gingivitis?
- Gingival recession is a common finding
- Gingival overgrowth
What is important to know about gingival recession?
- Prevalence, extent, and severity of recession increase with age
- Recession is more prevalent in males
- Exposed roots with recession are susceptible to caries, hypersensitivity, pulpal symptoms, and plaque/calculus accumulation
What is important to know about gingival overgrowth in gingivitis?
- Gingival level is exaggerated higher than normal
- Can be due to medications, inflammation, tooth position
What does the contour look like for gingivitis?
- Changes in contour can be related to gingival enlargement
- Examples of this are Stillman’s clefts, McCall festoons
What is gingivitis (dental plaque-induced)?
an inflammatory response of the gingiva resulting from plaque biofilm accumulation located at and below the gingival margin
What is the microscopic examination of early gingivitis?
- Dilation and engorgement of the capillaries and thinning or ulceration of the sulcular epithelium.
- Vasculitis of blood vessels adjacent to the junctional epithelium
- Progressive destruction of the collagen fiber network
- Cytopathologic alterations of resident fibroblasts
- Progressive inflammatory immune cellular infiltrate (predominantly lymphocytic)
What are the characteristics of gingivitis?
- Plaque to initiate the inflammation
- Clinical signs and symptoms are confined to the gingival unit
- Systemic modifying factors
- Stable attachment may or may not experience further attachment loss
- Reversibility
What are the modifying factors of gingivitis?
Systemic Conditions:
*Steroid Hormones (Puberty, menstrual cycle,
pregnancy, oral contraceptives)
*Smoking
*Hyperglycemia
*Leukemia
*Malnutrition
Local/predisposing Factors:
*Prominent subgingival restoration margins
* Inadequate interproximal tooth contacts
*Hyposalivation (dry mouth)
What types of medications caused drug-induced gingival enlargement?
- anti-epileptic (dilantin)
- calcium channel-blockers (nifedipine, verapamil, diltiazem, amlodipine, felodipine; most common type of drug-induced gingival enlargement)
- immuno-regulatory (cyclosporin
- endocrine drugs (high dose contraceptives)
What are the types of non-plaque induced gingival disease?
- genetic abnormalities (hereditary gingival fibromatosis)
- specific infection (bacteria, viral, fungal)
- inflammatory and immune conditions (contact allergy, lichen planus, etc.)
- neoplasms (leukoplakia, squamous cell, etc.)
- endocrine, nutritional, metabolic (scurvy, etching, buring)
- gingival pigmentation (amalgam tattoos, nevi, etc.)
What are the diagnostic criteria for gingivitis?
The clinical signs of inflammation are erythema, edema, pain (soreness), heat, and loss of function.
These may manifest clinically in gingivitis as:
* Swelling, seen as loss of knife-edged gingival margin and blunting of papillae
* Bleeding on gentle probing
* Redness
* Discomfort on gentle probing
Radiographs alone can’t be used to diagnose gingivitis
T/F: Radiographs alone can be used to diagnose gingivitis
FALSE
A case of dental plaque-induced gingivitis is defined as ________% bleeding sites with probing depths < 3mm
> 10%
(I feel like it is actually less than)
Localized gingivitis: __________% bleeding sites
10%-30%
Generalized gingivitis: ____% bleeding sites
> 30%
What is desquamative gingivits?
A peculiar condition characterized by intense erythema, desquamation, and ulceration of the free and attached gingiva.
- A gingival response associated with a variety of conditions
Is desquamative gingivitis a diagnosis or a clinical term?
clinical term
What diseases clinically preset as desquamative gingivitis?
- lichen planus
- pemphigoid
- pemphigus vulgaris
- lupus erythematosus
- erythema multiforme
- necrotizing stomatitis
What is lichen planus?
- immunologically mediated mucocutaneous disorder
- T cells play a central role
- prevelant in middle-aged and older females
What are the five subtypes of lichen planus?
- RETICULAR
- EROSIVE
- PATCH
- ATROPHIC
- BULLOUS
What is phemphigoid?
-A cutaneous, immune-mediated, subepithelial disease
-Separation of the basement membrane zone
What are the three conditions of phemphigoid?
-Pemphigoid gestationis
- bullous pemphigoid
- mucous membrane pemphigoid
Lichen planus
pemphigoid
What is pemphigus vulgaris?
-Pemphigus comprises a group of autoimmune disorders
- Produces cutaneous and mucous membrane blisters
-Pemphigus vulgarisis the most common of all.
Why is it important to be able to diagnosis/refer pemphigus vulgaris?
- Lethal chronic condition (10% mortality rate)
- Predilection in women (after 4th decade of life)
pemphigus vulgaris
What is lupus erythematosis?
An autoimmune disease with three clinical presentations:
* Systemic- can affect the kidneys, heart, skin, and mucosa.
* Cutaneous-butterfly pattern, discoid lesion, scar and atrophy production
* Oral-ulcerative or Lichen Planus-like
Lupus erythematosus
What should you recognize on the lichen planus histology?
- H and E stain and an immunofluorescence stain
- red shows the saw tooth ridges
- blue shows the shaggy border
What should you recognize on the phemphigoid histology?
basement membrane is attached to the epithelium that comes off
What should you recognize on the phemphigus vulgaris histology?
basement membrane is left attached to the underlying connective tissue
What is erythema multiforme?
- Reactive acute vesiculobullous disease
- Mucocutaneous inflammatory disease
- Broad spectrum from self-limiting to severe progression
- Predominant in young individuals
erythema multiforme
What is necrotizing stomatitis?
*An inflammatory, destructive gingival condition
*Young adults, (HIV)‐infected individuals
*May develop fever and malaise
What does necrotizing stomatitis look like?
What could this be…
pigmentation
amalgam tattoo (prolly not)
melanoma
nevus
What could this be…
amalgam tattoo
What could this be…
medications
mouth breathing
What could this be…
poor oral hygiene
reaction to the metal
What could this be…
allergy
What could this be…
chews tobacco
What is a prophy?
- preventive procedure but can be therapeutic depending on the periodontium’s overall health
- for patients with a generally healthy periodontium where any deposits are removed to control irritational factors, and for patients with localized gingivitis to prevent further progression of the disease
Code is D1110
What is scaling in the presence of gingival inflammation?
- procedure is applicable when there is generalized moderate or severe gingival inflammation in the absence of attachment loss.
- This may take more than one visit and most likely will require local anesthesia
Code is D4346
What is scaling and root planing?
- therapeutic procedures and are indicated for patients who require scaling and root planing due to bone loss and subsequent loss of attachment
- Instrumentation of the exposed root surface to remove deposits is an integral part of this procedure
Codes are D4341 and D4342
What is the diagnosis…
- Probing depths are < 3mm
- BOP score of 56%
- Plaque index of 72%
- No radiographic bone loss
Diagnosis: gingivitis
Treatment: scaling in the presence of gingivitis
What is the diganosis…
- Probing depths are < 3mm
- BOP score of 5%
- Plaque index of 8%
- No radiographic bone loss
Diagnosis: healthy
Treatment: do a prophy
What is the diagnosis…
- Probing depths are 3mm to 8mm
- BOP score of 67%
- Plaque index of 35%
- No radiographic bone loss
- Patient has hypertension and is on a blood pressure medicine called Amlodipine
- No other medical conditions
Diagnosis: gingivitis (contributing factor is medication causing gingival overgrowth)
Treatment: scaling in the presence of gingivitis
What is the diagnosis…
* Probing depths are < 3mm
* BOP score of 82%
* Plaque index of 94%
* Localized radiographic bone loss
* Patient complains of having canker sores in her mouth and cannot brush her teeth.
* Patient has hypertension, hypercholesterolemia, anxiety, and lower back pain-all of which are controlled by medication.
* She has had this for 12 months.
Diagnosis: gingivitis in a reduced periodontium or periodontal disease
they have lichen planus
What is the diagnosis…
* Probing depths are <3mm
* BOP score of 67%
* Plaque index of 45%
* Gingiva is red along margins and
bulbous in localized sites
* No radiographic bone loss
* Patient has radiographic subgingival
calculus
Diagnosis: gingivitis
Treatment: scaling in the presence of gingivitis
