Periodontology Flashcards
free gingiva location
located at the crest of the alveolus, not attached, outer boundary of the sulcus (called free because it is unattached)
free gingival groove location
located at the inferior border of free gingiva, point opposite of alveolar crest, depression
attached gingiva location
located below free gingival groove, lies over underlying bone
mucogingival junction
located where gingiva ends.
junction between gingival and oral mucosa
alveolar mucosa
located under mucogingival junction
gingival sulcus
denotes space between gingiva and tooth
col* consists of? location?
consists of NONKERATINIZED TISSUE located between lingual and facial papilla
interdental papilla
denotes tissue that occupies space between two adjacent teeth
epithelial attachment
located at the base of the sulcus, where epithelium attaches to the tooth
where does keratinization of the attached gingiva end
ends at the free gingival margin
masticatory mucosa
KERATINIZED tissues
protect the gingiva and hard palate
keratinization of the attached gingiva ends at the free gingival margin
lining mucosa? contains what areas
NONKERATINIZED TISSUES:
alveolar mucosa, soft palate, vestibular mucosa, buccal mucosa, and sublingual area as well as the sulcular and junctional epithelium
lining mucosa typically supports what
removable partial denture
specialized mucosa
dorsum of tongue
oral mucosa is composed of what layers and separated by what
composed of a stratified squamous epithelial layer and a connective tissue/lamina propria and are
separated by basement membrane
what is the prominent cell in the PDL**
fibroblasts
what are fibroblasts in the PDL responsible for
collagen synthesis and degradation
what is the healthy collar of tissue around the around the neck of the tooth*
gingival sulcus
in a healthy situation, gingival sulcus is called
gingival sulcus
in a periodontal situation, gingival sulcus is called
oral mucosa is what layer*
stratified squamous epithelial layer
3 types of mucosa
- masticatory mucosa
- lining mucosa
- specialized mucosa
lamina propria aka
connective tissue
connective tissue (lamina propria) underlies the _____ in the _____
connective tissue (lamina propria) underlies the _stratified squamous epithelium____ in the _oral mucosa____
connective tissue (lamina propria) encircles
the tooth
connective tissue (lamina propria) contains
blood vessels, nerve endings
is vascular and has nerve tissue
connective tissue (lamina propria) contains what cells . what do these cells do
contain fibroblasts,
they produce collagen and elastic fibers
what gives connective tissue (lamina propria) its strength
collagen
rete pegs*
epithelial extensions that project into underlying connective tissue. (think stakes in the ground to prevent tent from flying away)
rete pegs purpose*
aid in increased strength between the epithelium and connective tissue and enable the epithelium to obtain its blood supply from the connective tissue papilla
rete pegs hold what together
hold epithelium and connective tissue together
marginal tissue is stippled or not stippled *****
marginal tissue is NOT stippled
attached gingiva is stippled or not stippled
attached gingiva is STIPPLED**
attached gingiva is stippled or not stippled
attached gingiva is STIPPLED**
rete pegs give the observation of
stippling
PDL consists of what tissue and connect what
connective tissue (collagen)
connect tooth to bone
is PDL visble on radiographs
NO
PDL is not visible on a radiograph, but the PDL space can be seen as what
radiographic lucency surrounds the root of the tooth
widening of PDL space on radiograph can indicate what
occlusal trauma
PDL has _____ endings but no _____
PDL has __nerve___ endings but no __blood vessels___
PDL functions (4)
- resists the impact of occlusal forces (shock absorber)*
-attach cementum to the bone by sharpeys fibers**
-transmit occlusal forces, touch, pressure, and pain through sensory nerve fibers
-protect nerve and vessels from injury by surrounding root with soft tissue
sharpeys fibers anchor into
anchor into cementum
Principal fiber groups ***
transseptal
alveolar crest
horizontal
oblique
apical
interradicular
transseptal— trans=across. septal= bony septum
transseptal connect
tooth to tooth.
they extend interproximally over the alveolar crest, embedded in the cementum of two adjacent teeth
transseptal fibers are adjusted during*****
orthodontic treatment (get moved/stretched during ortho)
alveolar crest fibers
located apically to the junctional epithelium and extend obliquely to the cementum to the alveolar crest
horizontal group
extend at right angles to long axis of tooth
(horizontally
oblique
extend from cementum in a coronal direction to the bone
which fiber withstands the masticatory stress in a vertical direction***
oblique
***what is the largest and most significant fiber group
oblique
apical
extend from cementum at root apex to the base of socket
interradicular: inter=between. radicular= root
in between the root
interradicular
found between root
found only in multirooted teeth.
extend from cementum at furcation to bone in furcation area
**interradicular tooth is only present in which teeth
multirooted teeth
sulcular fluid aka
crevicular fluid ,gingival crevicular fluid
definition: sulcular fluid (crevicular fluid ,gingival crevicular fluid)
a serum-like fluid that passes from the connective tissue (lamina propria) and flows into the gingival crevice
sulcular fluid (crevicular fluid ,gingival crevicular fluid) contains what elements
calcium, sodium, phosphorus, along with cells and bacteria
how much sulcular fluid (crevicular fluid ,gingival crevicular fluid) do you have in health vs inflammation
flow is minimal to absent in health
increases due to inflammation from plaque accumulation
sulcular fluid (crevicular fluid ,gingival crevicular fluid) presence of fluid depends on
the rate of passage is dependent on the absence or presence of inflammation in the connective tissue
purpose of sulcular fluid (crevicular fluid ,gingival crevicular fluid)
cleanses the sulcus
how can sulcular fluid (crevicular fluid ,gingival crevicular fluid) be destructive
can provide a source of nutrients for subgingival bacteria & supports subgingival calculus formation
what can be released in sulcular fluid (crevicular fluid ,gingival crevicular fluid) and example
some antibiotics are concentrated in this fluid.
ex: tetracycline
how is cementum arranged***
arranged in layers or lamellae
like a rings in tree
patterns of formation for cementum
the continuous process with periods of greater and lesser activity.
forms more readily at the apex
acellular cementum does not contain
does not contain cells
cellular cementum does contain
does contain cells
acellular cementum is located more
coronoal
cellular cementum is located more
apical
acellular cementum contains calcified _____
what is their significant role
calcified Sharpey’s fibers
play a significant role in supporting the tooth in the socket
cellular cementum contains less _____ and fewer______
cellular cementum contains less __calcification___ and fewer___sharpeys fibers___
cellular cementum compensated for
lost tooth crown length that occurs with attrition
cementum consists of ____ tissue covering ________
cementum consists of _calcified__ tissue covering ___tooth root _____
CEJ defines the
tooth’s anatomic crown
CEJ is useful in assessing
useful in assessing attachment loss
what is the most common CEJ orientation**
overlap
cementum overlapping the enamel 60% of cases
what forms first, enamel or cementum
enamel
bone is referred to
alveolar process
alveoli are
tooth sockets
alveoli- multiple
alveolus- one
cancellous bone is
spongy, trabeculae pattern
cortical bone
is smooth bone
interdental septum
bone in the interdental space.
area of bone between teeth
bone coverings are composed of
composed of vascular connective tissue containing osteogenic cells
periosteum
covers outer bone surface
endosteum
covers inner bone surface
alveolar bone shape is determined by
size and shapes of crowns of approximating teeth
are there periodontal pockets in gingivitis?
NO PERIODONTAL POCKETS *
dental plaque-induced gingivitis Is associated with only
PLAQUE ONLY
dental plaque-induced gingivitis is modified by
systemic factors, nutrition, endocrine disorders, blood dyscrasias, drug-induced enlargements
for non-dental plaque-induced gingivitis will debridement help
debridement will not help because the gingivitis is not related to the plaque
non-dental plaque-induced gingivitis can be caused by
viral, fungal, bacterial, or genetic in origin
it is a gingival manifestation of systemic conditions
foreign body reactions
gingivitis results from the*** important questions
ulceration of the sulcular lining/base of the sulcus
if you have a patient with non-dental plaque-induced gingivitis you would***
refer the patient to a primary case physician to evaluate the etiology of disease
gingival inflammation can also be caused by
open contacts and subgingival margins of restorations
example- patient complaint of fraying of floss
necrotizing periodontal disease are in what patients **
patients with no known systemic disease or immune dysfunction
*****microbe associated with necrotizing periodontal disease
spirochetes & vibrios
what is encouraged for necrotizing periodontal disease
antiobiotic therapy is encouraged
what is the drug of choice for necrotizing periodontal disease? and why****
the drug of choice is tetracycline because it is released in GCF
- it has anti-collagenase properties (antibiotic stops the enzyme)
tetracycline is intrinsic or extrinsic
intrinsic
NUG and NUP primary sign**
punched out papilla
NUG affects the what component of the periodontium***
the interdental gingival component of the periodontium
NUG and NUP signs and symptoms
primary- punched out papilla*
pseudomembrane
fetid odor
pain
severe inflammation
is a patient has punched out papilla, what disease do they have*
NUG or NUP
you only stage and grade if the patient has *
active periodontal disease
staging
severity
grading predicts
rate of progression of disease + risk factors
________ is not a diagnosis.
Diagnosis is _________
___staging and grading_____ is not a diagnosis.
Diagnosis is _periodontitis_____*
staging and grading help clarify
clarify extent, severity & complexity to potential rate of disease progression (how complex it is to treat the patient)
a patient who has a history of periodontitis is considered what and why?
an at-risk patient because they require a more intensive level of maintenance and evalulation
a stable perio patient should not return to*
to a level of evaluation and maintenance identical to a patient who has never had periodontitis
stage 1- disease severity
mild disease
stage 1 probing depths and cal
<4 mm
CAL- <1-2mm
stage 1 bone loss
horizontal bone loss
stage 1 treatment
non-surgical treatment
we should not be able to see patients CEJ
stage 1 post-treatment
no post-treatment tooth loss is expected
this indicated the case has a good prognosis going into maintenance
stage 2 disease
moderate disease
stage 2 probing depths + CAL
<5 mm- max probing depth
CAL: <3-4 mm
stage 2 bone loss
horizontal bone loss
stage 2 treatment requirement
will require non-surgical and surgical treatment
stage 2 post-treatment expectations
no post-treatment loss is expected , indicating the has a good prognosis going into maintenance (same as stage 1)
stage 3 disease
severe disease
stage 3 probing depths + cal
> 6mm or greater
CAL->5mm
stage 3 bone loss
vertical or angular bone loss/ furcation involvement of class 2 or class 3
stage 3 treatment
requires surgical and possibly regenerative treatment
stage 3 risk
risk of losing teeth (0-4 teeth )
could have already lost 4 or less teeth
stage 3 prognosis
fair prognosis going into maintenance
stage 4 disease
very severe disease
how long will stage 4 remain
stage 4 will remain stage 4 for life
can stage 3 become stable?
stage 3 can become stable on a reduced periodontium
stage 4 bone loss
(same as s3)
may have vertical bone loss and/or furcation involvement of class 2 or 3
stage 4 probing depths and CAL
(same as S3)
probing depths >6mm
CAL : >5MM
stage 4 tooth loss***
possibly fewer than 20 teeth remain
the patient has lost or will lose 5 or more teeth****
stage 4 treatment
will often require multi-specialty treatment
advanced surgical treatment/regenerative therapy may be required
very complex implant/restorative treatment may be needed
stage 4 prognosis
questionable prognosis going into maintenance
what is more common. staging or grading
garding is more common
what does grading aim to do
aims to indicate the rate of periodontitis progression, responsiveness to standard therapy and potential impact on systemic health
grade A speed
slow rate
grade B rate
moderate rate
grade C rate
rapid rate
direct evidence for grading
probing depths and radiographs over 5 years
indirect evidence for grading
amount of bone loss a patient has based on age
amount of debris in the mouth and how the body responds to debris (how much destruction there is )
grading modifiers
smoking status
diabetes status
where is CDC located
atlanta georgia
1999 used what descriptions of stage
used slight, moderate, and sever periodontitis and could be divided into severity levels in different parts of the mouth
the new classification on introduced what view
a multidimensional view based on full-mouth diagnosis
***a diagnosis of periodontitis is determined first with
staging and grading providing supplemental data
which area determines the stage
the area with the most severe destruction
a perio patient who has been treated and is now stable should receive what maintenance
they should not return to a level of evaluation and maintenance identical to a patient who has never has periodontitis
a maintenance patient with active sites becomes an
unstable case of recurrent periodontitis
***does the patient typically drop down to a lower stage?
NO
what does periodontitis as a manifestation of systemic disease mean
it means if the patients have any of those diseases it will manifest into periodontitis
familial and cyclic neutropenia oral manifestations
recurrent aphthous ulcers
episodic periodontitis
neutropenia means
disease or problem associated with neutrophils
down syndrome aka
trisomy 21
in down syndrome patients congenital heart defects are seen in what % of cases
30-55% of cases
(patients can be premedicated because heart defects)
down syndrome patients have a higher incidence of
cleft lip or palate
in down syndrome what occlusion can occur
prognathism/protrusion of mandible,
posterior cross bite
severe crowding
in down syndrome what occlusion can occur
prognathism/protrusion of the mandible,
posterior crossbite
severe crowding
in down syndrome patients we can see macroglossia which is
the enlargement of tongue
in down syndrome what we can see what sizes of tonsils / nasopharynx and can see what condition
- open mouth
- small/narrow nasopharynx
-enlarged tonsils - can see xerostomia
leukocyte adhesion deficiency syndrome can be classified as
periodontitis as a manifestation of systemic disease
what systemic disorders can be classified as periodontitis as a manifestation of systemic disease (12)
familial and cyclic neutropenia
down syndrome
leukocyte adhesion deficiency syndrome
Papillion-le feuvre syndrome
Chediak-Higashi syndrome
Histiocytosis syndromes
glycogen storage syndrome
infantile genetic agranulocytosis
cohen syndrome
Ehlers-danlos syndrome
hypophosphatasia
associated with hematological disorders: acquired neutropenia
how does Papillion-le feuvre syndrome show up
shows as hyperkeratosis (palmar-plantar)- meaning there is an overgrowth of keratinization on the palms and base of the foot
Papillion-le feuvre syndrome can cause what of the periodontal attachment apparatus
generalized rapid destruction
neutrophil defects
chediak-higashi syndrome is an inherited disorder of
impaired neutrophil chemotaxis
chediak-higashi syndrome can demonstrate
osteogenesis imperfect and premature loss of teeth
gingival abscess is
an abscess of the periodontium limited to the gingival margin or interdental papilla without the involvement of deeper structures of the periodontium
limited to gingiva
likely wont see attachment loss or bone loss associated with this
gingival abscess results from**
the injury to or an infection of surface gingival tissue
gingival abscess: pulp, location, pain?
vital pulp, localized, constant pain
periodontal abscess
usually occurs in a site with pre-existing periodontal disease, and affects the deeper structures of the periodontium
periodontal abscess: pulp, location, pain?
vital pulp, localized, constant pain
a periodontal abscess can result from***
infection spreading deep into periodontal pockets and drainage is blocked
may develop from incomplete scaling(clinician cause*
pericoronal abscess develops where? **
develops in inflamed dental follicular tissue overlying the crown of a partially erupted tooth*
streptococci milleri are likely involved
flap of tissue is called
operculum
what bacteria can be involved with pericoronal abscess***
streptococci milleri are likely involved **
periapical abscess= endodontic-periodontal lesion
systemic diseases of conditions affecting periodontal supporting tissues (5)
diabetes (two way street with perio)
obesity
osteopopsis
rheumatoid arthritis
tobacco dependence
the level of glycemic control in diabetes influences the
grading of periodontitis
diabetes should be included in
a clinical diagnosis of periodontitis as a descriptor
compared to women with normal bone and mineral density, postmenopausal women with osteoporosis or osteopenia exhibit what?
exhibit a modest but significantly greater loss of periodontal attachment loss
recent meta-analyses show a significant positive association between ___ and ___
recent meta-analyses show a significant positive association between obesity and periodontitis
mucogingival deformities and conditions around teeth (6)
(changes in display)
gingival/soft tissue recession
lack of keratinized gingiva
decreased vestibular depth
aberrant frenum/muscle position
gingival excess
abnormal color
fenstration*
bone loss occurring apically
hole in the fence
dehiscence
bone loss moving from the margin
primary occlusal trauma
excessive force on a tooth with normal bone support
- is reversible****
no bone loss occurred
secondary occlusal trauma
normal or excessive force on a tooth with loss of support
signs and symptoms of occlusal trauma
- increased mobility**
-tooth migration
-sensitivity
-radiographic widening of the PDL space (no BOP)
a tooth in traumatic occlusion will demonstrate
wear facets
for a patient who is peri-implant health*
you do not need to do tx
for a patient who is peri-implant mucositis*
is reversible (gingivitis)
peri-implant diseases and conditions (4)
peri-implant health
peri-implant mucositistis
peri-implantitis (irriversible)
peri-implant soft and hard tissue deficiencies
hypertrophy
gingival enlargement due to an increase in cell size
hyperplasia
gingival enlargement due to an increase in cell numbers
**what is the primary factor in the reduction or elimination of gingival and periodontal disease
plaque control*****
local etiology of plaque
the ability for plaque to adhere dramatically impacts the risk that plaque will impact oral disease
things that allow more plaque to accumulate
plaque retentive factors- 3
irritating restorations (overhang)
food impactions (open contacts)
poor fitting crown margins
mineralized plaque is calculus
mineralized plaque sources of minerals
become mineralized through precipitated salts in saliva and crevicular fluid
inorganic content of calculus
mainly calcium phosphate with lesser amounts of calcium carbonate
supragingival calculus mineralization results from
saliva deposits occur on buccal surfaces of maxillary molars opposite to Stenson’s duct and mandibular anterior teeth opposite to Wharton’s duct
subgingival calculus mineralization results from
gingival crevicular fluid depoisits occur on all root surfaces in sulcus or pockets
and is more difficult to remove than supra calc
*tobacco use significantly influences the progression of
periodontal disease
tobacco users exhibit
greater bone loss, increased pocket depths, and calculus formation
tobacco use alters _________. this reduces what?
periodontal tissue microvasculature (shrinks microcapillaries) which means less bleeding
this reduces immunoglobin levels and antibody responses to bacterial plaque and biofilm
tobacco users are less likely to develop
aphthous ulcers
tobacco cessation may cause
recurrent aphthous stomatitis
is hairy leukoplakia associated with smoking?
NO
what is hairy leukoplakia associated with
Epstein Barr Virus
Normal Radiographic Bone Patterns (4)
- crest of alveolar bone is typically 1-2mm apical to the CEJ
-contour of the bone follows the contour of the CEJ
(bone in the interdental space follows bone of the contacts) will be a pointer in the anterior contacts and wider in the posterior because wider contacts ) - uniform PDL space
-intact lamina dura
Horizontal bone loss radiographic findings
-typically indicated by >2mm loss of bone height from the CEJ
vertical bone loss radiogarphically
loss of bone in the furcal space
gingiva color in health
pink or coral pink or melanin pigmentation
gingiva contour in health
not enlarged, fits tightly around the tooth
gingiva consistency in health
firm, attached gingiva firmly bound
gingiva texture in health
free gingiva is smooth
attached gingiva is stippled
no bleeding is a criterion for healthy tissue
gingiva color in disease (acute & chronic)*
blue: venous blood, highly vascular
acute: erythema, red associated with inflammation
gingiva contour in disease (acute & chronic)*
enlarged, swollen, blunted, hyperplastic, festooned (rolled margins)
gingiva consistency in disease (acute & chronic)*
acute: soft, spongy, with loss os stippling
chronic: disease is firm, hard, stippled and FIBROTIC *
gingiva texture in disease (acute & chronic)*
acute: edematous. vasodilation of the peripheral circulation is noted in edema
chronic: fibrotic. highly stippled due to an increase in cellular components
hallmark sign of acute inflammation
edematous
hallmark sign of chronic inflammation
fibrotic
bleeding on probing is a significant indicator of
inflammation
bleeding on probing indicated
diseased gingiva
ulcerated pocket wall bleeds ****
probe is what type of instrument***
calibrated instrument***
what do probing depths depict
the distance in mm from the gingival margin to the base of the sulcus or the pocket as measured with a calibrated probe
allows us to measure the sulcus or pocket
Assessment of normal tissue with a probe
the junctional epithelium offers more resistance (tissue will push back and we know to stop probing)
- probing is stopped by the coronal portion of the junctional epithelium
Assessment of gingivitis & early perio with a probe
the JE offers less resistance
the probe passes farther into the JE
Assessment of advanced perio with a probe
the JE offers little to no resistance
probe may penetrate JE to reach the attached connective tissue fibers
(can probe all the way to connective tissue)
suprabony pocket*
base of the pocket is coronal to the alveolar bone
(supra means above)
above the bone
horizontal bone loss lead to suprabony pocket
infrabony pocket**
the base of the pocket is apical to the crest of the alveolar bone
what is furcation grade measuring
invasion of periodontal infection into the area between and around the roots
class 1 furcation*
curvature of concavity can be felt with probe tip; the probe penetrates no more than 1 mm
class2 furcation*
the probe tip penetrates into furcation greater than 1mm but does not pass through
class 3 fucation*
probe passes completely through furcation, but is not clinically visible
class 4 furcation*
probe passes through and through
entrance to furcation is clinically visible because of the recession of the gingival margin
CAL demonstrates what
enlargement, normal, and recession sites
mucogingival examination determines the
width of the attached gingiva; used to determine width of attached gingiva, used to determine the amount of attached gingiva present
to calculate the width of the attached gingival
subtract the probing depth from the distance between the gingival crest to the mucogingival junction
width of the attached gingival is not calculated for
lingual (palatal) surfaces
mobility grade is checked with *
two hard-handled instruments *
pathologic tooth migration is indicative of
severe periodontis
mobility grade 1
perceptible mobility <1mm in buccolingual direction
mobility grade 2
> 1mm but <2mm in horizontal direction
mobility grade 3
> 2mm or depressibility in the socket (horizontal and/or vertical mobility
fremitus definition and what it is checked with
the palpable vibration of root surfaces when the patient taps their teeth together
checked with the pad of the index finger against the tissue overlying the root
what is periodontal surgery
advanced procedures to address periodontal challenges
gingivectomy *
used to treat pseudopocketing and hyperplasia
most common surgical procedure for pocket reduction is
gingivectomy
2 osseous surgeries *
osteoplasty- remodeling the bone
osteoectomy- removing the bone
in osseous surgery, sutures are used to
close incisal edges and decrease the distance cells must travel for wound healing
pneumatization
a condition in which there is a connection from the sinus to an extraction site
tooth has been extracted and sinus drops in the extraction site (maxilla)
in this area you cannot do an implant you will have to do sinus lift
healing of the periodontium involves :
fibrous repair via proliferation of fibroblasts
healing of periodontium steps
- blood clotting
- wound cleansing
3, rebuilding tissue - wound remodeling
healing of periodontium step 1 : blood clotting
clot forms scaffolding with fibrin and platelets for PMN’s and macrophages to migrate
healing of periodontium step 2 : wound cleansing
macrophages ingest debris/debride clot. PMN’s attack bacteria
healing of periodontium step 3 : rebuilding tissue
fibroblasts deposit collagen
resulting tissue is edematous and highly vascular - “granulation tissue”
healing of periodontium step 4 : wound remodeling
granulation tissue is remodeled into scar tissue via the long junctional epithelium
what primarily treats infrabony defects
periodontal regenerative procedures
reversible pulpitis
mild pulpal inflammation resulting from placement of a deep restoration; associated with episodic temperature-related pain
occlusal trauma does not effect
the attached gingiva
occlusal trauma does not cause gingivitis or periodontits because…
the junctional epithelium is not affected by occlusal trauma
