Periodontology Flashcards
Describe the appearance of healthy gingiva.
- knife edge, scalloped gingival margin
- stippling
- pink
What is clinical gingival health?
- < 10% bleeding sites
- probing depths < or = 3mm
- intact periodontium, absence of bleeding and swelling, absence of bone loss
Describe the appearance of gingivitis.
- red inflamed gingiva
- loss of knife edge margin
- smooth, shiny gingiva
- bleeding on probing
What is clinical gingivitis?
- bleeding on probing > 10% but <30%
- pocket depth is not greater than 3mm
- no attachment or bone loss
- clinical changes are reversible
Describe the appearance of periodontitis.
- gingiva inflamed
- gingival margins receded
- teeth appear longer / root visible
- spacing
What is clinical periodontitis?
- pocket depths > 3mm
- bleeding on probing
- loss of periodontal attachment
- loss of alveolar bone
- irreversible
What is the difference between a true and a false pocket?
- false pocket occurs when the sulcular epithelium proliferates due to irritation caused by plaque, the gingiva becomes inflamed, therefore the probe will “disappear into pocket”, but there is no actual attachment loss
- true pocket occur when there is attachment loss, and the probe can be seen to sink into the pocket
What is the normal distance from the cemento-enamel junction to the alveolar bone ?
- 1-2mm
- can be observed on radiographs
Describe horizontal bone loss.
- bone loss in a consistent, flat pattern between teeth
Describe vertical or angular bone loss.
- bone loss is not consistent between teeth
- bone loss is greater on one side than the other between two teeth
- “deep angular defects”
What affects the chance of horizontal versus vertical bone loss?
- narrower sections of alveolar bone between teeth are more likely to result in horizontal bone loss
- this is because when plaque migrates apically it has a “2mm zone of destruction”, therefore can wipe out a narrower pieces of bone
- vertical bone loss is caused when the alveolar bone between teeth is wider than this zone of destruction, so remains intact on the neighbouring tooth
Describe furcation bone loss.
- bone loss between the root functions
- different grades, from 1-3
- grade 3 is a through and through furcation
How much attachment loss is considered rapid progression of periodontitis?
- greater than or equal to 2mm over 5 years
What is the keystone pathogen of periodontitis?
- p gingivalis
- changes the behaviour of the biofilm
Describe the microbial balance and immune response in gingival health.
- symbiosis
- proportionate immune response
Describe the microbial balance and immune response in gingivitis.
- dysbiosis
- proportionate immune response
Describe the microbial balance and immune response in periodontitis.
- dysbiosis
- disproportionate immune response
= this results in soft and hard tissue loss
What is involved in the innate host immune response of periodontitis?
- saliva
- epithelium, which acts as a physical barrier, sheds cells and produces inflammatory mediators
- gingival crevicular fluid (GCF)
- inflammatory and immune responses
What are MMPs?
- matrixmetalloproteinases
- degradative enzymes that are released by host inflammatory cells
What is involved in hard tissue destruction?
- the immune cell activation of osteoclasts (RANK/RANKL/cytokines)
What are local risk factors for periodontitis?
Anatomical - grooves - furcation - gingival recession Tooth position - malalignment or crowding - migration - occlusal forces Iatrogenic - restoration overhangs - orthodontic appliances - dentures - defective crown margins
How does smoking affect periodontitis?
- vasoconstriction of gingival vessels
- increased keratinisation of the gingiva
- impaired antibody production
- affects t-cell and neutrophil function
- increased production of pro-inflammatoty cytokines which increase speed of tissue destruction
How does smoking affect the assessment of the gingiva?
- due to vasoconstriction the gingiva do not appear as inflamed
- no bleeding on probing
How do genetics affect periodontitis?
- affects around 50% of cases
- polymorphisms for increased IL-1 production predispose someone to periodontitis
What is GCF?
- gingival crevicular fluid
- released in greater quantities during disease
- contains AMP, cytokines, chemokines, lactoferrin, IgG
What virulence factors benefit p gingivalis?
- asaccahrolytic, breaks down proteins for energy
- proteases (gingipans) degrade host proteins for energy
- atypical LPS (endotoxin) blocks the host signalling through TLR 4 receptors
- inflammophillic means that it thrives in inflammatory conditions
Describe the process of gingivitis.
- TLRs detect an accumulation of plaque
- increased activation of TLRs = increased production of pro-inflammatory mediators eg AMPs, cytokines
- clinical signs of inflammation, caused by increased cell migration
What are TLRs?
- toll-like receptors
- they are pattern recognition receptors that stimulate the innate immune system
What role do neutrophils play in gingivitis?
- degradative enzymes including MMPs
What role do monocytes play in gingivitis?
- differentiate into macrophages and phagocytose
What role do lymphocytes play in gingivitis?
- t-cells coordinate the response
- b-cells release antibodies into the GCF
What cytokines are involved in bone formation and resorption?
- RANKL, stimulates osteoclasts to resorb bone, produced by activated T and B cells
- RANK, receptors for RANKL on the osteoclasts
- OPG, RANKL inhibitor
What is the relationship between RANKL and OPG during periodontitis?
- RANKL > OPG
- excess RANKL means that RANK receptors cannot bind with OPG, meaning resorption is uncontrolled
- during inflammation there are higher levels of RANKL and lower levels of OPG
Describe the process of periodontitis.
- activation of TLRs = increased secretion of pro-inflammatory mediators
- activated lymphocytes express RANKL and OPG which disrupt the bone formation/resorption balance
- pro-inflammatory cytokines inhibit bone formation
- elevated and unregulated MMP production results in connective tissue destruction
What is plaque?
- sticky colourless biofilm
- the microbial composition changes between health and disease
What is calculus?
- calcified plaque
- always covered by a layer of plaque biofilm
- can be supra or sub gingival
- calculus acts as a plaque retentive factor
What is a BPE?
- basic periodontal exam
- used as a screening tool for early diagnosis
What instrument can be used to perform a BPE?
WHO probe
- ball end (0.5mm in diameter)
- black bands at 3.5-5.5mm and 8.5-11.5mm
- the gingiva touching the first black band is indication of unhealthy gingiva
UNC-15 probe
- 15mm long
- markings at each mm
- black band at each 5mm increment
How is BPE recorded?
- dentition is divided into sextants
- 7-4, 3-3, 4-7
- each sextant must have at least two teeth present to qualify
- 3rd molars are only examined when both 1st and 2nd molars are missing
- the probe is “walked” round the sulcus of each tooth
- the worst score from each sextant is recorded, which results in 6 scores in a full dentition
BPE score 0
- pocket depth <3mm
- black band entirely visible
- no BOP
- no calculus or overhangs
BPE score 1
- pocket depth <3mm
- black band entirely visible
- BOP
- no calculus or overhangs
BPE score 2
- pocket depth <3mm
- black band entirely visible
- BOP possible
- calculus or overhangs present
BPE score 3
- pocket depth 4-5mm
- black band partially visible
- BOP possible
- calculus and overhangs possible
BPE score 4
- pocket depth >6mm
- black band not visible
- BOP possible
- calculus and overhangs possible
What does a * denote in BPE?
- furcation involvement
What is the difference between generalised and localised periodontitis?
- localised <30% of teeth
- generalised >30% of teeth
What is the course of action for a BPE score 3?
- radiographs should be taken for all sextets with a code 3
- BSP guidelines indicate that initial hygiene therapy should be completed before a FMPC is completed in that sextant
What is the course of action for a BPE score 4?
- radiographs of the entire mouth
- a FMPC if even one sextant records a score of 4
- then HPT
What kind of radiograph is the gold standard is periodontal assessment?
- periapicals
- show entire root length
What is the basic treatment plan for periodontitis?
- immediate or emergency care
- initial / disease control
- re-evaluation
( - periodontal surgery) - reconstructive
- maintenance
What is involved in disease control?
- extraction of hopeless teeth
- HPT
- caries management
- Endodontic therapy
- provisional prostheses
What is HPT?
Hygiene phase therapy
- dental education
- OHI
- scaling and RSD
- removal of plaque retentive factors eg dentures, orthodontics, defective crowns
NB: the aim of HPT is to keep the teeth and restore lost tissue
What is involved in dental health education?
- educating the patient, otherwise the treatment will fail
- explain the patient’s role in treatment
- modifiable risk factors
- plaque control
- behavioural changes eg smoking
What are Ramfjord’s teeth?
- 16
- 21
- 24
- 36
- 41
- 44
Describe the modified plaque score.
- measures plaque in a partial mouth system
- interproximal, buccal and lingual surfaces used (3)
- score 0 = no plaque visible on probe
- score 1 = plaque only visible when probe used to skim tooth
- score 2 = plaque visible without use of probe
- score N = no measurement possible for this surface
- scores are added up, divided by 36 and x100 to gain a percentage = modified plaque score
Describe the modified bleeding score.
- measures marginal bleeding (probe run at 45 degrees round the gingival sulcus)
- bleeding is checked for up to 30s after
- all 4 surfaces used
- score 0 = no bleeding
- score 1 = bleeding
- scores are added up, divided by 24 and x100 to gain a percentage = modified bleeding score
What happens if one of Ramfjord’s teeth are missing?
- use an appropriate alternative (ie 16 missing, use 17)
- if no alternative available code N is used
- maximum possible score is modified in the division to reflect missing tooth
What scores would an engaged patient received in the modified system?
- <35% bleeding score
- <30% plaque score
- greater than 50% improvement in both
How should the modified systems be used in smokers versus nonsmokers?
- bleeding score is more valuable in non smokers
- both scores should be valued equally in smokers
How should non engaging patients be treated?
- RSD delayed
- discussion with the patient
- continue with HPT
What are the different grades of furcation?
- grade 1 = initial involvement, less than 1/3 of width
- grade 2 = partial involvement, >1/3 of width but not through and through
- grade 3 = through and through furcation involvement
What are the different grades of tooth mobility?
- grade 0 = 0.1-0.2mm horizontally, normal physiological movement
- grade 1 = >1mm horizontally
- grade 2 = <1mm horizontally
- grade 3 = severe mobility in both horizontal and vertical directions
What is involved in a FMPC?
- gingival margins
- pocket depth
- LOA
- BOP
- furcation
- mobility
What is involved in OHI?
- ask patient to bring their current OH aids
- ask patient to demonstrate and discuss current habits
- use disclosing tablets to identify areas missed
- coach patient
What technique should be used when brushing?
- Bass technique
- bristles directed into the gingival sulcus at 45 degrees
- back and forth motions
When should single tufted brushes be used?
- maligned teeth
- distal surface of last molar
- localised gingival recession
Describe interdental cleaning.
- brushes or floss can be used
- brushes should be a snug fit interdentally, passed through 8-10 times
When should anti-plaque mouthwash be prescribed?
- when mechanical plaque removal is too painful
Define RSD.
- root surface debridement
- the removal of contaminated material leaving the root surface hard and smooth
Describe supragingival instrumentation.
- facilitates patients control of plaque by removing retentive factors
What effects do RSD have on the mouth?
- reduced levels of microflora including p gingivalis
- decreased gingival inflammation
- increase in collagen fibres in connective tissues beneath pocket and formation of the long junctional epithelial attachment
=> decrease in pocket depth
NB: changes are best observed 4-6 weeks post-therapy (8 is better), gradual repair happens over 9-12 months
How are patients evaluated in the maintenance phase?
- probing depths
- bleeding an plaque scores
- attachment levels
- tooth mobility
- furcations
What is the staging of periodontitis?
- the measure of disease severity
- assessed by the amount of bone loss (% root length)
What is the grading of periodontitis?
- the measure of susceptibility and speed of progression
- calculated using the patients age and amount of bone loss
What are the 4 components of the 2017 periodontitis classification system?
- disease stage
- disease grade
- disease stability
- disease risks
What is stage 1 periodontitis?
- early/mild
- <15% or <2mm attachment loss from CEJ
What is stage 2 periodontitis?
- moderate
- coronal third of the root
What is stage 3 periodontitis?
- severe
- mid third of the root
What is stage 4 periodontitis?
- very severe
- apical third of the root
What is grade A periodontitis?
- slow rate of progression
- <0.5
How is grading calculated?
% bone loss ÷ patient age
What is grade B periodontitis?
- moderate rate of progression
- 0.5-1.0
What is grade C periodontitis?
- rapid rate of progression
- >1.0
What are the different stability levels of periodontitis?
- currently stable
- currently in remission
- currently unstable
Describe a stable periodontitis patient.
- BOP <10%
- pocket depth < or = 4mm
- no BOP at 4mm pockets
Describe a periodontitis patient who is in remission.
- BOP > or = 10%
- pocket depth < or = 4mm
- no BOP at 4mm pockets
Describe an unstable periodontitis patient.
- pocket depths > or = 5mm
- BOP at 4mm pockets
What things should be recorded in a patients periodontitis risks?
- smoking, including cigarettes/day
- sub-optimally controlled diabetes
Describe the diagnosis statement for a periodontitis patient.
extent - periodontitis - stage - grade - stability - risk factors
Name an anti-plaque mouthwash.
2% chlorohexadine
What is the average progression of periodontitis?
0.05-0.1mm LoA per year
