Periodontics Flashcards
Why do we need a classification system for gingivitis?
The classification systems are necessary in order to provide a framework in which to scientifically study the aetiology, pathogenesis and treatment.
What is gingivitis?
It is generally regarded as site-specific inflammatory condition initiated by dental biofilm accumulation and characterized by gingival redness and oedema and the absence of periodontal attachment loss
How does gingivitis diagnosed?
It is a purely diagnosed condition. Use signs and symptoms. Look, feel and SMELL it. Listen to the patient – do their gums bleed? Are they experiencing soreness in gums? Increased BOP? Halitosis smell? Discomfort on probing?
What if you see any bone loss in the radiograph and think it is gingivitis?
NO IT IS PERIODONTITIS. Any attachment loss = periodontitis (except for reduced periodontium).
What is the prevalence of gingivitis and periodontitis?
Gingivitis of some degree – 95% of the population
Periodontitis – 60-65% of over 65 population
How do we define cases of gingivitis in an intact periodontium?
Localised gingivitis : Probing attachment loss – No, Radiographic bone loss – No, BOP score – between 10% and 30%
Generalised gingivitis: Probing attachment loss – No, Radiographic bone loss – No, BOP score – above 30%
How do we define cases of gingivitis in a reduced periodontium without history of periodontitis?
Localized gingivitis: Probing attachment loss – Yes, Radiographic bone loss – Possible, Probing depth all sites – less than 3mm, BOP score – between 10% to 30%
Generalised gingivitis: Probing attachment loss – Yes, Radiographic bone loss – Possible, Probing depth all sites – less than 3 mm, BOP score – above 30%
How do we right diagnostic statement for gingivitis?
- Extend - localised of generalised
- Disease - gingivitis
- Specification - biofilm induced, mediated by pregnancy or leukaemia
What is the pathogenesis of gingivitis? (Initial reaction)
- Biofilm accumulates
- Biofilm produces metabolites (fatty acids), peptides (FMLP) and LPS
- Junctional epithelium cells stimulated to synthesize inflammatory mediators (cytokines)
- Free nerve peptides produce neuropeptides and histamine in response to cytokines
- Perivascular mast cells release even more histamine
- This cause an increase in local vascular activity
- Endothelium releases IL-8 into vessels to attract PMNs
What is the pathogenesis of gingivitis? (PMNs migration)
- Mast cells release histamine
- Direct activation – LSP or OMP react with endothelial cells
- Indirect activation – after contact with LPS/OMP macrophages release proinflammatory cytokines
- ELAM-1 is expressed
- Contact between leucocytes adhesion receptor integrin beta 2 with endothelial Integrin ICAM-1
- PMNs leave vessel by amoeboid diapedesis
- PMNs follow gradient of chemotactic factors
What is the pathogenesis of gingivitis? (Post PMNs migration)
- Biofilm stimulates JE cells to produce cytokine IL-8
- IL-8 is a chemo-attractant for PMNs
- PMNs follow IL-8 concentration gradient
- PMNs reach the sulcus
- Complement and antibodies support phagocytosis of bacteria and their products
What is the pathogenesis of gingivitis? (Early gingivitis)
- PMNs form dense layer over biofilm
- PMNS and tissues release pro-inflammatory cytokines nad enzymes
- Activation of macrophages (more proinflammatory things)
- Lymphocytes infiltrating connective tissues (T cells mostly)
- Increase in vascular dilation
- Lateral proliferation of junctional epithelium basal cells
What is the pathogenesis of gingivitis? (Established gingivitis)
- Intense PMN infiltration in junction epithelium
- Lymphocytes dominate the infiltrate
- Activated T cells coordinate the response via cytokines
- B cell differentiation and conversion to plasma cells
- Plasma cells produce Igs and cytokines
- Activated fibroblasts produce MMP and TIMP instead of collagen
- Loss of collagen fibres to provide space for expanding infiltrate
- Lateral proliferation and apical migration of junction epithelium (creation of pseudopocket)
Why do we say that gingivitis “takes two”?
Because gingivitis take 2 important factors to develop –1 the microbes and 2 the host response to the microbes
What is a risk factor?
It is something that increases the chance of developing a disease or disorder
What are the two categories of risk factors of gingivitis?
- Systemic
- Local
What are the systemic risk factor for gingivitis?
It is something that modifies disease expression and may influence disease progression by altering the host’s immune response
What are some of the systemic risk factors for gingivitis?
- Smoking
- Hyperglycemia
- Nutritional factors
- Pharmacological agents
- Sex hormones
- Hematological conditions
What are the impacts of smoking on gingival tissues
- Decrease immunoglobulin G2 production
- Chronic reduction in blood flow and vascularity – THIS ALSO REDUCES THE BOP AND POTENTIALLY REDUCING POCKET DEPTH
3Increase prevalence of potential periodontal pathogens
- Shift in neutrophil function towards destructive activities
- Negative effects on cytokine and growth factor production
- Inhibition of fibroblast growth attachment and collagen production
How does hyperglycaemia impact gingivitis?
Hyperglycaemia causes a production of advanced glycation end products or (AGE) which causes immune disfunction, cellular stress & increase of proinflammatory cytokines.
What is the local risk factor for gingivitis?
It is the retention biofilm or prevent its removal and predispose for disease progression
What are some of the local factor for gingivitis?
- Dental plaque retention
- Oral dryness
What is DIGO?
Drug Induced Gingival Overgrowth
What are some of the medication associated with DIGO?
- Calcium channel blocker
- Immuno-suppressants
- Anticonvulsants
How do you treat patients with DIGO?
- Biofilm control
- Surgical excision
- Drug substitution
What are signs of necrotising gingivitis?
- Necrosis of papilla
- HELLA BOP
- Pain on probing
- Halitosis
- Lympadenopathy
What causes necrotising gingivitis?
It is caused by opportunistic bacteria but it is also influenced by systemic factors
What are the treatments of necrotising gingivitis?
- Debriment under LA
- Local Irrigation with Chlorhexidine 0.2%
- Antibiotic Therapy – Metronidazole 400mg orally, 12-hourly, 3-5 days
- Analgesics
- Review
- potentil referral to a Specialist or GP
What are some of the classifications of the non-biofilm induced gingival disease
- Genetic developmental disorders
- Specific infections
- Inflammatory and immune conditions and lesions
- Reactive processes
- Neoplasms
- Endocrine nutritional and metabolic diseases
- Traumatic lesions
- Gingival pigmentation
What is supra- and subgingival debridement?
It is the removal or disruption of dental deposits and plaque-retentive calculus from tooth surfaces and within the periodontal pockets space without deliberate removal of cementum as done in root planning and often in dental scaling
What is the relevance of debridement in treating periodontal disease?
As biofilm matures, the opportunities to shift from healthy biofilm to pathogenic increases.
Debridement allows for removal of the biofilm or destruction of the bio-environment which encourages the growth of less pathogenic species of bacteria within the biofilm.
What is the rationale of removal of supra and subgingival calculus?
- This eliminate a potential colonisation site for the pathogenic bacteria
- This allows the patient to perform oral hygiene techniques appropriately
What are the instruments available for debridement at the ADH for supragingival removal?
- Sickle Scaler – anterior
- McCall’s Scaler – universal
- Ultrasonic scaler – regular or fine tip
- Gracey Curettes – with limitations around the contact point
What instruments can be used for debridement at the ADH for subgingival removal?
- Ultrasonic scaler – XF tip
- Gracey Curettes
What are the part of the scaler?
- Handle
- Shank
- Working end
How does the power scaler work at the ADH?
- The alternating current is connected to a quartz crystal in the scaler
- The current makes the quartz crystal to expand and contract
- The resulting vibration is passed to the working tip at the end of the scaler
- Ossilating generates hit – thus scaler is in constant use of water
- The blade is oscillating back and forward
What is the benefit of having constant water flow in the power scales on top of cooling?
It flushes the dental deposits that are broken down – this is called lavage
What are some of the other ways power scalers are able to aid in removal of dental deposits?
- Cavitation - build-up of microscopic bubbles
- Acoustic Microstreaming – creation of currents from sound made by the vibrations
What are the steps of debridement?
- Detect biofilm and calculus (dry area, use mirror from different angles, use Tri Plaque Gel, use radiographs)
- Use 11/12 explorer probe by going around the tooth if needed
- Use a systematic stroke technique to clean subgingivaly
- Use ultrasonic scalers
What is recession?
It is the apical shift of the gingival margin. It is common in adult population. The instances of recession increase with age.
What does recession lead to in terms of patient concerns?
- Dentine hypersensitivity
- Impaired Oral Hygiene
- Esthetical concerns
- Easier development of caries
- Non-carious cervical lesions
What can cause recession
- Anatomical component – tooth position, periodontal phenotype, alveolar bone fenestration, frenal attachment
- Inflamatory component – biofilm build up, trauma (chronic or physical or post periodontal treatment)
What is periodontal phenotypes?
It is both the natural thickness of the gingiva as well as the bone. Thin gums are determined when a perioprobe can be seen when inserted into the gingival sulcus.
What is alveolar bone dehiscence/fenestration?
It when the alveolar bone does not fully surround the entirety of the tooth. Fenestrations can be seen and radiographs display bones as thin.
What are frenal attachment?
Places where frenums attach. They may pull on tissues making it hard to clean in the pulled areas.
What are supracrestal attached tissues or biological width?
Thes upracrestal attached tissues are the junctional epithelium + the underlying connective tissue attachment. It is 2 mm wide in general. We need to consider this area when performing restoration, because if the area is violated this could lead to gingival inflammation.
What are Stillman clefts?
They are small, slit like recessions that are usually fast.
What are McCall’s festoon?
They are more rounded and slow progressing recessions.
How do we measure the recession?
- Dry teeth
- Feel with probe
- Find CEJ
- Measure from CEJ to GM
How many recession types are there?
There are 3 recession types
What is recession type 1?
It is gingival recession with no loss of inter-proximal attachment.
What is recession type 2?
It is gingival recession with some loss of inter-proximal attachment. The inter-proximal attachment loss is less than the true buccal attachment loss.
What is recession type 3?
It is gingival recession with loss of inter-proximal attachment. The inter-proximal attachment is more than the recession on true buccal attachment loss.
What is the treatment plan for recession?
- Assessment/documentation
- Identify and Modify Etiologic Factors
- Adress the consequences of root surface exposure
- Monitor progression
- Potential interventions like ortho or surgery if needed
What can we classify as necrotising gingivitis?
Necrotising gingivitis is only when gingival tissues only are involved.
What can we classify as necrotising periodontitis?
Necrotising periodontitis is when gingival tissues are involved as well as attachment loss can be observed.
What can classify as necrotising stomatitis?
When lesions are 1 cm away from the gingival margin, we can classify a disease as necrotising stomatitis.
What is the most sever type of necrotising stomatitis?
It is the NOMA.
What is periodontitis?
It is a multifactorial inflammatory disease associated with dysbiotic microbial dental biofilms and characterized by non-reversible progressive periodontal tissue destruction.
What are the symptoms of periodontitis?
- All sympotms of gingivitis
- Receding gums
- Gaps between teeth
- Increased food debris
- Mobile teeth
- Change in teeth position
- Speech alteration
- Tooth loss
- Pain in acute conditions
What are the signs of periodontitis?
- Periodontl pocketing
- Recession
- Clinical attachment loss
- Evidence of radiographic bone loss
- Increased mobility
- Tooth loss
What can we classify as a patient with periodontitis?
If a patient has clinical attachment loss interdentally at 2 non-adjacent teeth
Or
Buccal or oral clinical attachment loss with pocketing 3 mm at 2 or more teeth
How to classify the staging of periodontitis?
- Severity and extent
- Complexity
How to classify the grading of periodontitis?
- Future risk
- Estimate potential health impact of periodontitis
How many stages of periodontitis are there?
There are 5 stages
What is stage 1 periodontitis?
- 1-2mm attachment loss
- Coronal third bone loss
- No tooth loss
- Maximum probing depth of below 4mm
- Mostly horizontal bone loss
- Extent variable
What is stage 2 periodontitis?
- 3-4mm attachment loss
- Coronal third bone loss
- No tooth loss
- Maximum probing depth of below 5mm
- Mostly horizontal bone loss
- Extent variable
What is stage 3 periodontitis?
- 5mm or more attachment loss
- Bone loss extending to middle or apical third of the root
- Tooth loss due to periodontitis of 4 or less teeth
- Probing depth of 6 mm or more
- Vertical bone loss of 3 mm or more
- Class II or III furcation
- Moderate ridge defect
What is stage 4 periodontitis?
- 5mm or more attachment loss
- Bone loss extending to middle or apical third of the root
- Tooth loss due to periodontitis of 5 or more
- Probing depth of 6 mm or more
- Vertical bone loss of 3 mm or more
- Class II or III furcation
- Moderate ridge defect
- Mastication disfunction
How many grade of periodontitis are there?
3 grades
What is Grade A periodontitis?
When there are no evidence of loss over 5 years
What is Grade B periodontitis?
When there is a below 2 mm loss over 5 years.
What is Grade C periodontitis
When there is an above 2mm loss over 5 years
What are the steps for diagnostic treatment of periodontitis?
- Use the algorithm for new patients
- For patients suspected to have periodontitis proceed to the next algorithm
- Establish stage for periodontitis patient
- Grading for patient with existing previous records
How to write diagnosis for periodontitis?
- Types of periodontal disease
- Disease extent
- Stage
- Grade
- Curretn disease status
- Risk profile
What do we need for a full periodontal examination?
- We need a visual examination of the soft tissues
- A full periodontal chart
- A series of radiographic images
What is a healthy alveolar crest shape?
It is usually pretty flat and is about 1-3 mm below the CEJ. Remember that little “steps” are possible if the adjacent teeth sit in a little bit of a different position.
How can we grade periodontal disease using a radiograph?
- Healthy - not bone loss
- Mild - less than 15% bone loss
- Moderate - 15-33% bone loss
- Sever - above 33% bone loss
What is horizontal bone loss?
When the entire alveolar crest shift won
What is vertical bone loss?
When only part of the alveolar crest shift down
What is the normal periodontal ligament space?
A thin black line. It gets thicker if disease is present.
What is the disadvantage of radiographs?
The early stages of periodontitis cannot be detectable using just radiographs, as usually they underestimate bone loss.
Which radiograph is the best?
Depending on patient needs. But only take it after the gingival assessment and perioprobing.
What is the timeline for periodontal disease therapy?
- Emergency treatments
- Evaluation
- Systemic phase
- Phase I – debridement and non-surgical treatment
- Reevaluation
- Phase II and III – corrective and restorative
- Phase IV
