PERIODONTICS Flashcards
suppuration is an important measure of the inflammatory response to periodontal infection because it is due to the presence of large numbers of ___ in the periodontal pocket
neutrophils
normal, physiologic tooth movement of about ___mm is present in health
0.25mm
grade I mobility is defined as mobility slightly more than normal, less than ___mm in the buccolingual direction
1mm (0.25mm is normal)
grade II mobility is defined as mobility moderately more than normal, about ___mm in the buccolingual direction
1-2mm
grade III mobility is defined as severe mobility faciolingually or mesiodistally (or both) of greater than ___mm, combined with ___
- greater than 2mm
- vertical displacement (the tooth can be depressed in the socket)
describe the 4 furcation grades
- grade I - incipient
- grade II - culdesac with definite horizontal component
- grade III - complete bone loss in the furcation
- grade IV - complete bone loss in the furcation and recession of the gingival tissues resulting in a furcation opening that is clinically visible
what are the factors that can predispose a tooth to furcation involvement?
short root trunk length, short roots, narrow interradicular dimension, and the presence of cervical enamel projections
the average distance from the CEJ to the crest of the alveolar bone in health is approximately ___mm
2mm
which periodontal diagnosis is described by the following: no inflammation and no loss of clinical attachment and alveolar bone
periodontal health
which periodontal diagnosis is described by the following: gingival inflammation with no loss of clinical attachment and alveolar bone
gingival disease
which periodontal diagnosis is described by the following: periodontal inflammation that has extended into the PDL and alveolar bone, resulting in loss of clinical attachment and alveolar bone; usually accompanied by increased probing pocket depths, although deep pockets may not be present if recession of the gingival margin occurs at the same rate as attachment loss
periodontitis
which periodontal diagnosis is described by the following: usually accompanied by necrotic ulceration of the marginal gingival tissues, bleeding, pain, and fetid breath; may sometimes be accompanied by fever, malaise, and lymphadenopathy
necrotizing ulcerative gingivitis or periodontitis
gingivitis is frequently associated with changes in color, contour, and consistency that are due to changes in levels of inflammation. color changes are due to increase in ___; contour changes are due to increase in ___ or ___; and consistency changes are due to levels of ___ or ___ that frequently occurs when gingivitis is long-standing and chronic
- blood flow
- inflammatory exudates or edema within the gingival tissues
- inflammation or fibrosis
which medications can cause gingival enlargement?
- phenytoin
- cyclosporine (immunosuppressive drug)
- mifedipine, verapamil, and diltiazem (calcium channel blockers)
- sodium valporate
- oral contraceptives
deficiency in what vitamin can precipitate gingival diseases?
vitamin C deficiency (scurvy)
gingival conditions, although uncommon, can occur in response to specific infections, including what?
- sexually transmitted infections (neisseria gonorrhoeae, treponema pallidum)
- viral infections (herpesviruses)
- fungal infections (candida)
the clinical appearance of necrotizing diseases is unique among periodontal diseases because of the characteristics ___ and ___ of the marginal gingiva
- ulceration and necrosis
- gingiva may be a yellowish white or grayish slough or pseudomembrane and have blunting of the papillae, bleeding on provocation or spontaneous bleeding, pain, and fetid breath
what are predisposing factors to necrotizing periodontal diseases?
stress, smoking, and immunosuppression
periodontitis associated with endodontic lesions can be endo-perio lesions, perio-endo lesions, or combined lesions. what are characteristics of each?
- endo-perio lesions result from pulpal necrosis leading to periodontal problems as pus drains through the PDL
- perio-endo lesions result from bacterial infection from a periodontal pocket that spreads to the pulp causing pulpal necrosis
- combined lesions result when pulpal and periodontal necrosis occur together
if there is evidence of pulpal disease and periodontal involvement, which should be treated first?
endodontic treatment should be completed first
which bacteria is commonly (but not universally) found in aggressive periodontitis?
aggregatibacter (formerly actinobacillus) actinomycetemcomitans
abnormalities in ___ function are commonly (but not universally) found in aggressive periodontitis
phagocyte
what are the specific features of localized aggressive periodontitis?
- circumpubertal onset of disease
- localized first molar or incisor disease with proximal attachment loss on at least two permanent teeth, one of which is a first molar
- robust serum antibody response to infecting agents
what are the specific features of generalized aggressive periodontitis?
- usually affects people <30 years old
- generalized proximal attachment loss affecting at least three teeth other than first molars and incisors
- pronounced episodic nature of periodontal destruction
- poor serum antibody response to infecting agents
periodontitis may be observed as a manifestation of what hematologic disorders?
acquired neutropenia and leukemias
periodontitis may be observed as a manifestation of what genetic disorders?
- familial and cyclic neutropenia
- down syndrome
- leukocyte adhesion deficiency syndromes
- papillon-lefevre syndrome
- chediak-higashi syndrome
- histiocytosis syndrome
- glycogen storage disease
- infantile genetic agranulocytosis
- cohen syndrome
- ehlers-danlos syndrome (types IV and VIII autosomal dominant)
- hypophosphatasia
tooth-associated supragingival plaque is composed of ___
gram positive cocci and short rods
the mature outer surface of supragingival plaque is composed of ___
gram negative rods and filaments and spirochetes
subgingivally, tooth-associated plaque in the cervical region is composed of ___
gram positive rods and cocci
subgingivally, tissue-associated plaque in the cervical region is composed of ___
gram negative rods and cocci, filaments, flagellated rods, and spirochetes
subgingivally, tooth-associated plaque deeper in the sulcus/pocket is composed of ___
gram negative rods
subgingivally, tissue-associated plaque deeper in the sulcus/pocket is composed of ___
gram negative rods and cocci, filaments, flagellated rods and spirochetes
what are the major organic constituents of plaque biofilm?
polysaccharides, proteins, glycoproteins, and lipids
what are the major inorganic constituents of plaque biofilm?
calcium and phosphorus, with trace amounts of sodium, potassium, and fluoride
___ is the main source of inorganic components in supragingival plaque, and ___ is the main source in subgingival plaque
- saliva
- gingival crevicular fluid
what are the 3 phases of dental plaque formation?
- pellicle formation
- adhesion and attachment of bacteria
- colonization and plaque maturation
what does the pellicle consist of?
glycoproteins (mucins), proline-rich proteins, phosphoproteins (statherin), histidine-rich proteins, enzymes (amylase) and other molecules that serve as attachment sites for bacteria
during the adhesion and attachment of bacteria phase of plaque formation, the initial adhesion is mediated through ___ and ___ forces. is it reversible?
- van der Waals and electrostatic forces
- yes
what are the two early colonizers?
streptococcus and actinomyces
what are the 7 late colonizers?
- prevotella intermedia
- prevotella loescheii
- capnocytophaga species
- campylobacter species
- porphyromonas gingivalis
- treponema species
- aggregatibacter actinomycetemcomitans
___ serves as an important middle or bridging microorganism in plaque formation because of its ability to coaggregate with both early colonizers and other secondary colonizers
fusobacterium nucleatum
bacteria grown in biofilms communicate with each other through ___
quorum sensing
during plaque formation, as the biofilm matures, there is a shift from a predominance of ___ microorganisms to ___ microorganisms
facultative, gram positive microorganisms to gram negative, anaerobic microorganisms
the red complex is associated with ___, and consists of which bacteria?
- bleeding on probing and deeper pockets
- p. gingivalis, tannerella forsythia, and treponema denticola
does the presence of orange complex microorganisms precede or succeed the presence of red complex microorganisms?
precede
what microorganisms make up the orange complex?
fusobacterium species, prevotella species, and campylobacter species
gram positive early colonizers use ___ as an energy source and ___ as a carbon source
- sugars
- saliva
anaerobic microorganisms that predominate in mature plaque are asaccharolytic and use ___ and ___ as energy sources
amino acids and small peptides
endotoxin is a constituent of ___ microorganisms that is an important initiator of the inflammatory host response
gram negative
the ___ hypothesis states that periodontal disease results from the elaboration of noxious products by the plaque biomass, indicating that the quantity of plaque is of most importance in the initiation of disease
- nonspecific plaque hypothesis
- this hypothesis is contraindicated by the finding that some patients with little plaque have severe periodontitis
the ___ hypothesis states that the pathogenic potential of plaque depends on the presence of, or increasing numbers of, specific microorganisms
specific plaque hypothesis
the ___ hypothesis states that putative periodontal pathogens are present in both healthy and diseased states
ecologic plaque hypothesis
the microflora associated with periodontal health is primarily composed of ___; these microorganisms are primarily of the genera ___ and ___
- gram positive facultative cocci and rods
- streptococcus and actinomyces
in the transition to gingivitis, the microbiota is composed of ___
gram negative rods and filaments, followed by spirochetal and motile microorganisms
the microflora of chronic periodontitis is composed predominantly of ___ species. what are the names of the bacteria?
- gram negative, anaerobic species
- p. gingivalis, t. forsythia, p. intermedia, campylobacter rectus, eikenella corrodens, f. nucleatum, a. actinomycetemcomitans, peptostreptococcus micros, treponema species, and eubacterium species
there is evidence that microorganisms from which herpesviruses are associated with chronic periodontitis in the presence of p. gingivalis, t. forsythia, p. intermedia, and t. denticola?
epstein-barr virus 1 and human cytomegalovirus
___ is generally accepted as the primary etiologic agent of localized aggressive periodontitis
a. actinomycetemcomitans
other than a. actinomycetemcomitans, what are the microorganisms associated with aggressive periodontitis?
p. gingivalis, e. corrodens, c. rectus, f. nucleatum, b. capillus, eubacterium brachy, capnocytophaga species, and spirochetes
generalized aggressive periodontitis is primarily associated with which microorganisms?
p. gingivalis, p. intermedia, t. forsythia, and treponema species
high levels of what microorganisms are found in necrotizing periodontal disease?
p. intermedia, spirochetes, and fusobacterium species
what microorganisms are associated with abscesses of the periodontium?
f. nucleatum, p. intermedia, p. gingivalis, p. micros, and t. forsythia
the pockets associated with periimplantitis are colonized by high proportions of what microorganisms?
- anaerobic gram negative rods, motile microorganisms, and spirochetes
- may also be colonized by other species such as pseudomonas aeruginosa, candida albicans, and staphylococcus species
describe a. actinomycetemcomitans.
nonmotile, gram negative straight or curved rod
what are the specific virulence factors of a. actinomycetemcomitans?
- a leukotoxin that kills human neutrophils, monocytes, and some lymphocytes
- lipopolysaccharide
- collagenase
- a protease that cleaves IgG
describe t. forsythia
nonmotile, gram negative pleomorphic rod
what are the specific virulence factors of t. forsythia?
proteolytic enzymes that cleave immunoglobulins and complement components
describe porphyromonas gingivalis
nonmotile gram negative pleomorphic rod
what are the specific virulence factors of porphyromonas gingivalis?
- fimbriae important in adherence
- presence of a capsule
- proteases that cleave immunoglobulins and complement components
- proteases that cleave other tissue-associated host proteins (gingipains)
- collagenase
- a hemolysin
describe p. intermedia and prevotella nigrescens
nonmotile, gram negative rods
which microorganism is most closely associated with pregnancy gingivitis and necrotizing periodontal disease?
p. intermedia
describe c. rectus
motile, gram negative rod that has a polar flagellum
which microorganism grows anaerobically and grows as a pigmented colony when sulfide is added to the medium?
c. rectus
describe f. nucleatum
nonmotile, gram negative bacillus that has pointed ends
what are the specific virulence factors of f. nucleatum?
- induction of apoptotic cell death in mononuclear and polymorphonuclear cells
- release of tissue-damaging substances from leukocytes
describe spirochetes
motile, gram negative spiral microorganisms
the spirochetes most often associated with periodontal diseases include ___
t. denticola, t. vincentii, and t. socranskii
describe p. micros
gram positive, anaerobic cocci
describe eubacterium
small gram positive, anaerobic, pleomorphic rods
calculus is mineralized bacterial plaque and is initiated by the precipitation of mineral salts in soft plaque, which usually starts within ___ days of plaque formation
1-14 days
what are the inorganic components of supragingival calculus?
- calcium phosphate (75%)
- calcium carbonate (3%)
- traces of magnesium phosphate and other metals
- accounts for 70-90% of supragingival calculus
- composition is similar for subgingival calculus
the organic components of calculus is composed of a mixture of what 4 things?
protein-polysaccharide complexes, desquamated epithelial cells, leukocytes, and microorganisms
calculus attachment occurs through what 4 mechanisms?
- attachment via organic pellicle on enamel
- mechanical locking into surface irregularities
- close adaptation of calculus undersurface depressions to cementum
- penetration into cementum
orthodontic therapy has been shown to increase plaque retention and to result in increases in the numbers of which microorganisms?
prevotella melaninogenica, p. intermedia, and actinomyces odontolyticus
is the pathology of gingivitis reversible?
yes, with the removal of plaque and the resolution of the inflammation
PMNs are considered an important cell in the destruction of the periodontal tissues through the release of what destructive molecules?
- matrix metalloproteinases (MMPs)
- lysosomal enzymes
- cytokines
- reactive oxygen species (ROS)
what is the neutrophil abnormality and periodontal manifestation associated with neutropenia and agranulocytosis?
- decreased number of neutrophils
- severe aggressive periodontitis
what is the neutrophil abnormality and periodontal manifestation associated with chediak-higashi syndrome?
- decreased neutrophil chemotaxis and secretion
- neutrophil granules fuse to form characteristic giant granules called megabodies
- aggressive periodontitis and oral ulceration
what is the neutrophil abnormality and periodontal manifestation associated with papillon-lefevre syndrome?
- multiple functional neutrophil defects, including myeloperoxidase deficiency, defective chemotaxis, and phagocytosis
- severe aggressive periodontal destruction at an early age, which may involve primary and permanent dentition
what is the neutrophil abnormality and periodontal manifestation associated with leukocyte adhesion deficiency type 1 (LAD-1)?
- defects in leukocyte function caused by lack of integrin-2 subunit (CD18)
- neutrophil defects include impaired migration and phagocytosis
- almost no extravascular neutrophils are evident in periodontal lesions
- aggressive periodontitis at an early age and affecting primary and permanent dentition, in individuals who are homozygous for the defective gene
what is the neutrophil abnormality and periodontal manifestation associated with leukocyte adhesion deficiency type 1 (LAD-2)?
- neutrophils fail to express the ligand (CD15) for P and E selectins, resulting in impaired transendothelial migration in response to inflammation
- aggressive periodontitis at a young age
in periodontal disease, periodontal cells and tissues are destroyed by cells and proteins of the ___
immune system
___ are considered the most important proteinases involved in the destruction of periodontal tissues
MMPs
MMPs are inhibited by what class of antibiotics?
- tetracycline class
- doxycycline has been licensed as a systemic adjunctive drug for treating periodontitis
___ produced by inflammatory cells (PMNs and macrophages) are toxic to cells of the periodontium, having a direct effect on cell functions and DNA
oxygen radicals (superoxide and hydrogen peroxide)
which cytokine is important in bone resorption? which is important in attracting inflammatory cells? which is important in activating macrophages?
- IL-1 bone resorption
- IL-8 attracts inflammatory cells (chemotactic)
- TNF activates macrophages
describe the stages of the development of gingivitis
- stage 1 initial lesion: 2-4 days with vascular dilation, infiltration of PMNs, perivascular collagen loss, and increased gingival crevicular fluid flow
- stage 2 early lesion: 4-7 days with increase invasculature, lymphocyte infiltration, increased collagen loss, and redness and BOP
- stage 3 established lesion: 14-21 days with increased vasculature, mature plasma cells in the tissues, collagen loss, and clinical changes in color, contour, and consistency
- stage 4 advanced stage: transition to periodontitis
list the environmental and systemic factors that may affect the progression of periodontal disease
- cigarette smoking
- smokeless tobacco
- radiation therapy
- diabetes
- hormonal changes
- oral contraceptives
- menopause
T or F:
there are no differences in rates of plaque formation in smokers vs nonsmokers
- true
- therefore, qualitative rather than quantitative differences in microflora may be involved in the disease process
there is evidence of increased levels of what microorganism in smokers?
t. forsythia
smoking not only dampens the response of host defense cells such as neutrophils, but also leads to increased release of ___ enzymes
tissue-destructive
there appear to be alterations in the gingival microvasculature in smokers, resulting in decreased ___ and ___
decreased blood flow and decreased clinical signs of inflammation
smokeless tobacco use can lead to ___ and ___ at the site of tobacco product placement
localized attachment loss and recession
radiation therapy to oral tissues can result in increased ___ and ___ on the irradiated side
increased periodontal attachment loss and tooth loss on the irradiated side
describe how puberty and related conditions affect periodontal disease
- increases in gonadotropic hormones during puberty may lead to increased levels of p. intermedia and capnocytophaga species in the bacterial plaque
- associated with increased in gingival bleeding
what hormonal changes affect periodontal disease?
- puberty and related conditions
- menstruation
- pregnancy
pregnancy gingivitis increases in severity beginning in which month of pregnancy, due to increased levels in which hormone?
- 2nd or 3rd, due to increased levels of progesterone
- gingival tissues can become enlarged to the point that they appear as large masses called pregnancy tumors (pyogenic granulomas), which are usually reversible post partum
increased levels of which microorganism have been found during pregnancy? they are associated with elevation of systemic levels of which hormones?
- p. intermedia
- estradiol and progesterone
describe periodontal treatment during pregnancy
- oral hygiene instruction and SRP
- can be performed anytime during the pregnancy, but elective treatment is best performed during the 2nd trimester
- recommend no radiographs during the 1st trimester
why should tetracycline not be given during pregnancy?
- depressed bone growth
- enamel hypoplasia
- tooth discoloration
- hepatic damage
which antibiotic medications should be used with caution or avoided during pregnancy?
- tetracycline
- ciprofloxacin
- metronidazole
- gentamicin
- vancomycin
- clarithromycin
which antibiotic medications are safe to used during pregnancy?
penicillin, erythromycin, and cephalosporins
describe the affects of menopause of periodontal disease
- some postmenopausal women present with gingivostomatitis, manifest as dry, shiny oral mucosa that bleeds easily
- osteopenia and osteoporosis have been associated with menopause, and there is evidence for a probably association between osteoporosis and alveolar bone loss
increased numbers of which microorganism have been reported in patients with Down syndrome?
p. intermedia
how does stress contribute to periodontal disease?
increases cortisol production, which can subsequently suppress the immune response
ingestion of which heavy metals can lead to alterations in the periodontium?
bismuth, lead, and mercury
how do the following heavy metals contribute to periodontal disease: bismuth, lead, and mercury
- bismuth intoxication can lead to discoloration of the gingival margin in areas affected by inflammation
- lead intoxication can lead to gingival pigmentation and ulceration
- mercury intoxication can lead to gingival pigmentation and ulceration
what is the primary (short term) goal of periodontal treatment?
elimination of gingival inflammation through the correction of the conditions that cause gingival inflammation
what are the phases of periodontal therapy?
- preliminary or emergency
- nonsurgical (phase I therapy)
- surgical (phase II therapy)
- restorative (phase III therapy)
- maintenance (phase IV therapy)
what are the objectives of phase I nonsurgical periodontal therapy?
alter or eliminate the microbial etiology and contributing factors to periodontal diseases, leading to reduction in inflammation
when should evaluation of phase I nonsurgical therapy occur? why?
- approximately 4-8 weeks after completion of phase I therapy
- this permits time for epithelial and connective tissue healing by the formation of a long junctional epithelium
when should the maintenance phase (phase IV therapy) be completed?
after the completion of phase II therpay
the maintenance (phase IV therapy) can also be called ___
supportive periodontal therapy
what occurs during the preliminary or emergency phase of periodontal therapy?
- dental or periapical emergencies
- periodontal emergencies
- extraction of hopeless teeth and provisional replacement if needed
what occurs during nonsurgical phase I periodontal therapy?
- diet control
- removal of calculus and root planing
- correction of restorative and prosthetic irrational factors
- excavation of caries and restoration
- antimicrobial therapy (local or systemic)
- occlusal therapy
- minor orthodontic movement
- provisional splinting and prosthesis
what occurs during surgical phase (II) periodontal therapy?
- periodontal therapy, including placement of implants
- endodontic therapy
what occurs during the restorative phase (III) of periodontal therapy?
- final restorations
- fixed and removable prosthodontic appliances
- evaluation of response to restorative procedures
- periodontal examination
what occurs during periodontal maintenance (phase IV) therapy?
- recheck plaque and calculus
- gingival condition (pockets, inflammation)
- occlusion, tooth mobility
- other pathologic conditions
what are the changes in the periodontium associated with age?
- thinning and decreased keratinization of the epithelium
- coarser and denser gingival connective tissues
- decreases in fibroblasts and organic matrix production in the PDL
- increased width of the cementum
- more irregular periodontal surface of bone and less regular insertion of collagen fibers
in localized aggressive periodontitis, several studies support the adjunctive administration of what antibiotic?
- systemic tetracycline or doxycycline
- a combination of metronidazole and amoxicillin has also been shown to enhance the response in patients with aggressive periodontitis
how does gender affect periodontal disease?
- males generally have more local factors and more loss of attachment than females
- likely attributable to preventive habits and practices rather than to physiologic differences
which type of periodontitis is often diagnosed in immunocompromised individuals?
necrotizing ulcerative periodontitis
what are the risk FACTORS for periodontal disease?
- tobacco smoking
- diabetes
- pathogenic bacteria
- microbial tooth deposits
what are the risk DETERMINANTS and background characteristics associated with periodontal disease?
- genetic factors
- age
- gender
- socioeconomic status
- stress
what are the risk INDICATORS for periodontal disease?
- HIV/AIDS
- osteoporosis
- infrequent dental visits
what are the risk MARKERS/PREDICTORS for periodontal disease?
- previous history of periodontal disease
- BOP
is clinical attachment level or pocket depth more important in determining prognosis?
clinical attachment level
do younger or older patients with evidence of periodontitis generally have a better prognosis?
older
do teeth with vertical defects have better or poorer prognosis than teeth with comparable horizontal bone loss?
- typically better, owing to the potential for treating the vertical defect with regenerative therapy
- the success is affected by the contour of the vertical defect and the number of remaining walls
what is the prognosis for the following periodontal situation: no bone loss, gingival health, good patient cooperation, no secondary systemic or environmental factors
excellent
what is the prognosis for the following periodontal situation: adequate alveolar bone support, potential to control etiologic factors and establish maintainable situation, good patient cooperation, no environmental factors, either no systemic factors or well-controlled systemic factors
good
what is the prognosis for the following periodontal situation: inadequate alveolar bone, mobility, grade I furcation involvement, potential to establish maintainable situation, adequate patient cooperation, limited environmental or systemic factors
fair
what is the prognosis for the following periodontal situation: moderate to advanced alveolar bone loss, mobility, grade I and II furcation involvement, questionable patient cooperation, difficult areas to maintain, presence of systemic or environmental factors
poor
what is the prognosis for the following periodontal situation: advanced bone loss, grade II and III furcation involvements, mobility, inaccessible areas, presence of environmental or systemic factors
questionable
what is the prognosis for the following periodontal situation: advanced bone loss, inability to establish maintainable situation, extraction indicated, uncontrolled environmental or systemic factors
hopeless
do patients with aggressive periodontitis usually have a better or poorer prognosis than those with chronic periodontitis?
poorer
which instruments are used to remove supragingival calculus, have two cutting edges and a pointed tip, and have a triangular shape in cross section?
sickle scalers
which instruments are used for removal of tenacious calculus?
ultrasonic scalers, hoe, chisel, and file scalers
which instruments are the instrument of choice for subgingival scaling and for root planing, have a spoon-shaped blade and rounded toe and back, and are shaped like a semicircle in cross section?
curettes
which gracey curettes are designed to adapt to anterior teeth?
gracey 1-2 and gracey 3-4
which gracey curettes are designed to adapt to anterior and premolars?
gracey 5-6
which gracey curettes are designed to adapt to posterior teeth, facial and lingual?
gracey 7-8 and 9-10
which gracey curettes are designed to adapt to posterior teeth mesial surfaces only?
gracey 11-12
which gracey curettes are designed to adapt to posterior teeth distal surfaces only?
gracey 13-14
which curettes combine the shank design of gracey curettes with the universal blade design (90-degree angle of the face and lower shank)?
langer and mini-langer curettes
___ are magnetized instruments designed to retrieve broken instrument tips from periodontal pockets
schwartz periotrievers
the vibrations at the tip of ultrasonic instruments range from ___ to ___ cycles/sec
20,000-40,000
the vibrations at the tip of sonic instruments range from ___ to ___ cycles/sec
2000-6000
what patients is the use of ultrasonic instruments contraindicated in?
- presence of older cardiac pacemakers
- communicable diseases that can be spread by aerosol
- patients at risk for respiratory disease (immunosuppression or chronic pulmonary disease)
- titanium implants (unless plastic ultrasonic tips are used)
what patients is the use of sonic instruments contraindicated in?
- communicable diseases that can be spread by aerosol
- patients at risk for respiratory disease (immunosuppression or chronic pulmonary disease)
- titanium implants (unless plastic sonic tips are used)
which type of ultrasonic instrument has a tip that vibrates in an elliptic pattern (all sides of the tip are activated)?
magnetostrictive
which type of ultrasonic instrument has a tip that vibrates in a linear (back and forth) pattern, meaning that two sides are more active?
piezoelectric
ultrasonic tips operate in a wet field with a water spray. there are small vacuum bubbles within the spray that collapse, releasing energy in a process termed ___
cavitation
what instrument enables the operator to view subgingival deposits and should aid in their removal?
endoscope
what patient’s is the use of a prophy-jet contraindicated for?
respiratory illness, hypertension, electrolyte imbalance, and infectious diseases and patients on hemodialysis
T or F:
in flap design, the base of the flap should be wider than the free margin
true
in flap design, can the lines of the incision be made over defects in bone?
no
in flap design, corners of the flaps should be ___
rounded
what are the classifications of flaps?
- full thickness (mucoperiosteal)
- partial thickness (mucosal)
which flap classification includes all soft tissue and periosteum reflected to expose the alveolar bone?
full thickness (mucoperiosteal)
which flap classification includes only the epithelium and the underlying connective tissues?
partial thickness (mucosal)
horizontal incisions for full thickness flaps include what 3 horizontal incisions?
- internal bevel incision aka reverse bevel incision
- crevicular incision
- interdental incision
which incision has the purpose of removing the pocket lining, conserving the outer dimension of the gingiva, and producing a thin sharp flap margin that can be adapted to the bone-tooth junction?
internal bevel incision
which incision, when combined with the internal bevel incision, creates a collar of tissue around the teeth?
crevicular incision (made from the base of the pocket to the crest of the alveolar bone)
which incision separates the collar of gingiva from the tooth?
interdental incision
if the flap is to be positioned apically in a pocket reduction/elimination procedure, ___ incisions can be made
vertical releasing incisions that extend beyond the mucogingival junction
vertical incisions should not be made where?
- over the center of the papilla or over the radicular surface of a tooth
- should be avoided on the lingual and in the palate
which flap design uses the three horizontal incisions but is not reflected beyond the mucogingival line?
- modified widman flap
- allows for the removal of the pocket lining and exposure of the tooth roots and alveolar bone but does not allow for apical repositioning of the flap
what are the objectives of a periodontal pack?
- protect surgical wound
- minimize patient discomfort
- maintain tissue placement
- help prevent postoperative bleeding
T or F:
periodontal packs usually enhance the healing rate of the tissues
false
what do periodontal packs usually contain?
- zinc oxide
- may be either eugenol-containing or non-eugenol-containing
- antibiotics have been incorporated into some packs
in the first postoperative week following periodontal surgery (phase II), the patient should rinse with ___ twice daily until normal oral hygiene procedures can be resumed (usually at second postoperative week)
0.12% chlorhexidine
___ is an excision of the gingiva
gingivectomy
___ is performed to reshape the tissues where there are deformities
gingivoplasty
what cases should gingivectomy not be performed?
- if osseous recontouring is needed
- if the bottom of the pocket is apical to the mucogingival junction
- if there is inadequate attached gingiva
- if there is an esthetic concern
can gingivoplasty procedures be used to reduce or eliminate periodontal pockets?
no
which surgical procedures are performed to correct relationships between the gingival and the oral mucous membranes?
- mucogingival surgery
- includes widening of attached gingiva, deepening of shallow vestibules, and resection of aberrant frena
what are the techniques to increase the width of attached gingiva?
free gingival autograft, free connective tissue autograft, and the displaced (apically or laterally) positioned flap
what is the most common donor site for the free gingival autograft and connective tissue autograft? what is the ideal thickness for the free gingival graft?
- palate
- 1-1.5mm
which miller classification for recession is described as the following: marginal tissue recession does not extend to the mucogingival junction; no loss of bone or soft tissue in the interdental area
class I
which miller classification for recession is described as the following: marginal tissue recession extends to or beyond the mucogingival junction; no loss of bone or soft tissue in the interdental area
class II
which miller classification for recession is described as the following: marginal tissue recession extends to or beyond the mucogingival junction; bone and soft tissue loss interdentally or malpositioned teeth
class III
which miller classification for recession is described as the following: marginal tissue recession extends to or beyond the mucogingival junction; severe bone and soft tissue loss interdentally or severe tooth malposition
class IV
for all mucogingival procedures, ___ is the most significant concern
blood supply
in osseous surgery, access to the alveolar bone is accomplished through reflection of what type of flap?
full thickness
___ is an osseous, two-walled concavity in the crest of the interdental bone confined within the facial and lingual walls
osseous crater
how is an osseous crater corrected?
recontouring the facial and lingual walls to restore normal interdental architecture
in vertical or angular defects, the base of the bone defect is located ___
- apical to the surrounding bone
- these defects can have one, two, or three walls, or any combination
how are vertical or angular defects corrected?
resective osseous surgery or by periodontal regeneration
___ is the recontouring and removal of alveolar bone to correct discrepancies in bony contour, restoring the alveolar bone to the contour that was present before periodontal destruction
resective osseous surgery
how can resective osseous surgery be accomplished?
through ostectomy (removal of tooth supporting bone) or osteoplasty (removal of nonsupporting alveolar bone)
___ is a method for preventing epithelial migration along the cemental side of a pocket during wound healing after periodontal flap reflection
- guided tissue regeneration (GTR)
- barrier membranes cover bone and PDL before flap replacement
in periodontal regeneration procedures, the root surface can be treated with agents designed to enhance new attachment of gingival tissues after surgical excision. what are examples of these agents?
- citric acid, which is often used in conjunction with free gingival grafts, fibronectin, tetracycline, and various growth factors
- enamel matrix proteins (emdogain) have also been used to enhance new attachment
bony defects with how many walls involved are most predictable in terms of response with bone grafting? why?
- 3 wall defects are most predictable due to better blood supply and cell sources proximity
- 1 wall defects should not be treated with bone grafting
can regeneration be attained without the use of bone grafts in 3-walled osseous defects?
- yes, in the following cases:
- meticulously debrided defects, and in periodontal and endodontic abscesses
regeneration through the placement of bone graft material is most successful in which cases? least successful in which cases?
- most successful in 3-walled bony defects
- least successful in through-and-through (class III) furcation defects
titanium implants have a layer of ___ on their surface that is responsible for osseointegration
titanium oxide
implants are frequently loaded after ___ months, when woven bone is still present
2-3 months
greater than ___% success rates can be expected for endosseous titanium implants in healthy patients with good bone and normal healing capacity
90-95%
what are the absolute contraindications for implant therapy?
- psychological and mental conditions
- substance abuse
what is the most common complication reported for single unit crowns?
- abutment or prosthesis screw loosening (2-45%)
- loosening rates are higher in posterior than anterior
implant fracture occurs in ___% of cases
1%
what percent of implant failures occurs due to biologic reasons, like periimplantitis and soft tissue lesions?
7-8%
how do implant failure rates compare between totally edentulous patients and partially edentulous patients?
failure rates in totally edentulous patients are twice that seen in partially edentulous patients
are implant failure rates higher or lower in a totally edentulous maxilla or mandible?
- three times higher in the totally edentulous maxilla compared to the totally edentulous mandible
- no differences for partially edentulous maxilla and mandible
___ is an inflammatory process affecting the tissues around and osseointegrated implant in function, resulting in loss of supporting bone
periimplantitis
dehiscence and recession of periimplant soft tissues occurs when ___
support for those tissues is lacking or has been lost
what are pharmacologic agents that can modify host immune and inflammatory responses to bacterial plaque and can be used as adjuncts to conventional mechanical therapy in the prevention and treatment of periodontitis?
- NSAIDs (ibuprofen, flurbiprofen, naproxen) inhibit formation of prostaglandins
- bisphosphonates inhibit bone resorption by osteoclasts
- SDD (periostat) inhibits MMP destruction of collagen
what is the typical dosage of SDD when used for periodontal therapy?
20mg twice daily for 3-9 months
SDD should not be given to which patients?
- those with a history of allergy or with hypersensitivity to tetracyclines
- pregnant or lactating women
- children younger than 12 years
what does SDD stand for?
subantimicrobial dose doxycycline
which antibiotic is often used in the treatment of localized aggressive periodontitis?
tetracyclines
tetracyclines can concentrate in the periodontal tissues, inhibit the growth of ___, and exert an anti___ effect
- a. actinomycetemcomitans
- anticollagenolytic effect
are tetracyclines bacteriostatic or bactericidal?
bacteriostatic
are tetracyclines more effecting against gram positive or negative bacteria?
gram positive
what are two commonly used tetracyclines in the pharmacologic management of periodontal disease? what are the advantages?
- minocycline and doxycycline
- both are effective in reducing periodontal pathogens
- advantages include decreased dosing (tetracycline 4x/day, minocycline 2x/day, and doxycycline 1x/day) which may improve patient compliance
describe the use of metronidazole in the pharmacologic management of periodontal disease
- disrupts bacterial DNA
- used in conjunction with amoxicillin
- can be a disulfiram (antabuse) reaction when alcohol is used
describe the use of amoxicillin in the pharmacologic management of periodontal disease
- bactericidal, semisynthetic penicillin that is effective against both gram positive and gram negative bacteria
- susceptible to penicillinase (beta-lactamase)
- when combined with clavulonate potassium (augmentin), is resistance to many penicillinases
describe the use of cephalosporins in the pharmacologic management of periodontal disease
- beta-lactam family and are similar to penicillins
- often not used to treat oral infections
describe the use of clindamycin in the pharmacologic management of periodontal disease
- spectrum includes anaerobic bacteria
- can be used in patients sensitive to penicillin
- has been associated with pseudomembranous colitis
describe the use of ciprofloxacin in the pharmacologic management of periodontal disease
-quinolone that is active against facultative and some anaerobic periodontal pathogens
describe the use of erythromycin in the pharmacologic management of periodontal disease
- not effective against most periodontal pathogens
- however, azithromycin is effective against anaerobes and gram negative bacilli, and appears to concentrate in gingival tissues
T or F:
bacteriostatic and bactericidal drugs usually should not be given at the same time
true
what antibiotic topical formulations are available that are used as adjuncts to mechanical debridement in periodontal therapy?
- 10% doxycycline (atridox)
- 2% minocycline (arestin)
what is PerioChip?
resorbable chlorhexidine 2.5mg used as an adjunct to mechanical debridement in periodontal therapy
describe the steps of wound healing of a periodontal flap
- epithelial cell begin to migrate over the border of the flap 1-3 days after surgery
- an epithelial attachment is in place 1 week after surgery, consisting of hemidesmosomes and a basal lamina
- collagen fibers appear 2 weeks after surgery
- within 1 month, the gingival crevice is lined with epithelium, and an epithelial attachment is present
reflection of a full-thickness flap result in ___ at 1-3 days, and ___ that peaks at 4-6 days. what is the resultant bone loss?
- bone necrosis
- osteoclastic resorption
- 1mm
in the healing process of a free gingival graft, when does revascularization occur?
the second or third day
what 4 cases should splinting be considered in terms of periodontics?
- increasing mobility of teeth
- mobility that impairs a patient’s function
- migration of teeth
- prosthetics where multiple abutments are necessary
how is acute necrotizing ulcerative gingivitis treated?
- application of topical anesthetic followed by removing the pseudomembrane of necrotic lesions, and removal of local factors such as calculus
- prescribe systemic antibiotics only if there is evidence of lymphadenopathy or fever
- rinse with chlorhexidine
when are the follow up visits after a patient has been treated for acute necrotizing ulcerative gingivitis?
- 1-2 days after treatment for reevaluation and further treatment
- pt should be seen again 5 days later for reevaluation
how is acute pericoronitis treated?
- gently flushing the area to remove debris and swabbing with antiseptic
- drainage should be obtained if there is evidence that the inflamed tissue is fluctuant
- antibiotics should be prescribed if there is evidence of systemic involvment
how is acute herpetic gingivostomatitis diagnosed early (within 3 days of onset) treated?
- antiviral therapy (acyclovir 15mg/kg five times daily for 7 days
- all patients (regardless of when they are treated) should receive palliative care, including plaque removal, systemic NSAIDs, and topical anesthetics
in cases of localized aggressive periodontitis, regenerative surgical therapy may be effective, especially in patients with ___-wall bony defects
localized two-wall or three-wall bony defects
what are the antibiotics that can be used as adjuncts to mechanical debridement in the treatment of aggressive periodontitis?
tetracycline, doxycycline, clindamycin, ciprofloxacin, metronidazole, and combinations of amoxicillin-clavulanate, metronidazole-amoxicillin, and metronidazole-ciprofloxacin
patients who do not respond to periodontal therapy may be classified as ___
refractory
necrotizing ulcerative periodontitis may be associated with ___
- immunosuppression
- therefore it is important to treat the patient in consultation with their physician
in necrotizing ulcerative periodontitis, how are the oral lesions treated?
local debridement, lavage, and oral hygiene instruction that may include daily use of antimicrobial agents such as chlorhexidine
how are periodontal abscesses treated?
- first resolve the acute lesion by the establishment of drainage either through the pocket or through an external excision
- apply chlorhexidine to the area until the signs and symptoms subside (usually 1-2 days)
- area is treated with SRP and evaluated for possible surgical therapy
- antibiotics are indicated if there is evidence of cellulitis, a deep inaccessible pocket, fever, or lymphadenopathy or when treating an immunocompormised patient
what is the most common cause of pulpal disease?
dental caries
pulpal infection is polymicrobial, primarily consisting of which class of microorganisms?
gram negative anaerobic bacteria
of periodontal abscesses and acute endodontic abscesses, which are painful?
acute endodontic abscesses
in cases of periodontitis-related oral malodor, the unpleasant odor originates from ___
volatile sulfur compounds, including hydrogen sulfide, methylmercaptan, dimethyl sulfide, putrescine, cadaverine, indole, skatole, and butyric or propionic acid
most of the volatile sulfur compounds responsible for periodontitis-related oral malodor are formed primarily by which class of oral microorganisms?
gram negative anaerobes
what are some desensitizing agents used by patients for root sensitivity? how do these agents act?
-dentifrices that contain strontium chloride, potassium nitrate, and sodium citrate-they act through the precipitation of crystalline salts that block dentinal tubules
what are some desensitizing agents that can be professionally applied for root sensitivity?
cavity varnishes, zinc chloride-potassium ferrocyanide, formalin, calcium hydroxide, dibasic calcium phosphate, sodium fluoride, stannous fluoride, strontium chloride, and potassium oxalate
what is biologic width?
the space for soft tissue above the alveolar bone
what is the average human biologic width?
2mm (0.97mm for the junctional epithelium and 1.07mm for the connective tissue attachment
biologic width violation can lead to inflammation and localized bone loss. what is biologic width violation?
when a restorative margin is placed less than or equal to 2mm away from the alveolar bone
how frequently should complete plaque removal be accomplished for a normal healthy patient? what about for patients with periodontal disease?
- every 48 hours
- every 24 hours
how often should toothbrushes be replaced?
every 3 months
do powered toothbrushes improve measures of gingival inflammation beyond those found with manual toothbrushes?
no, although studies have shown that they remove more plaque than manual toothbrushes
what is bass brushing?
the toothbrush bristles are placed at the gingival margin at a 45 degree angle to the tooth, extending into the gingival sulcus when pressure is applied to the brush in a horizontal direction
when is the periodontal maintenance phase initiated?
after the completion of phase I therapy and reevaluation, and is performed in a continuum with phase II (surgical) therapy and phase III (restorative) therapy
what is the primary rationale for periodontal maintenance therapy?
continued disruption of bacterial plaque through professional subgingival instrumentation
what should the maintenance interval be for the first year of periodontal maintenance? why is this interval recommended?
- typically every 3 months for the first year
- this is the time required for recolonization of periodontal pockets by proposed pathogens after subgingival debridement
