Periodontology Flashcards
What is the decoy molecule that will provent Osteoclastic differentiation?
Osteoprotegerin (OPG)
What is the antagonist to MMP?
TIMP: tissue inhibitor of MMP
List the pro-inflammatory cytokines involved with Perio
IL-1b, TNFa, IFN-g, PGE2, MMP
List the anti-inflammatory cytokines involved with perio
IL-1ra, IL-10, TGFb, TIMPs
Large numbers of RANKL require what to progress to bone loss
- Low levels of OPG from Osteoblasts
2. Large numbers of pre-osteoclasts expressing RANK receptors
What can be given to block MMPs to prevent bone loss
Low dose of 20mg doxycycline antibiotic for 2 weeks
How do Biphosphonates affect bone loss
Reduces bone loss by inhibiting osteoclast activity
What are the grades of mobility?
Grade 1 – mobility up to 1mm
Grade 2 - mobility up to 2mm
Grade 3 – mobility more than 3mm and vertical
What are the grades of furcation?
I: Horizontal loss of supporting tissue not exceeding 1/3 the width of the tooth
II: Horizontal loss of supporting tissue exceeding 1/3 the width of the tooth, but not encompassing the entire furcation area (can not stick probe straight through the tooth
III: “Through and through” destruction of supporting tissues in furcation (sticking probe through gap will result in it going right through to the other side)
What are the available tests to detect periodontal disease?
6 examples given, probably reasonable to list 4?
- Medical history (predisposing/modifying systemic diseases, medications, blood tests)
- Social history: (smoker, stress, alcohol, diet)
- Intra-oral exam (including perio exam/probing/mobility/furcation + searching for features that pre-dispose attachment loss (vertical root fracture, enamel pearls, overhanging restorations)
- Vitality test (for perio-endo lesions)
- Subjective assessment of calculus
- Radiographs (BW, OPG, Full mouth survey/FMS)
What are the 3 irritating factors in gingivitis
Gram Negative Endotoxins
Proprionic Acid
Butyric Acid
How is the Junctional Epithelium anchored to the basement membrane?
Hemidesmosomes
Remodelling of transseptal PDL in the early stages of periodontitis results in what?
Development of deeper pocket depths
Why is LPS destructive for the periodontal apperatus?
Elicits a host immune response that promotes destruction of the gingiva and PDL
On what bacteria can LPS be found?
Gram Negative
What stimulates the release of Matrix Metallo-Preteinase (MMP)
Presence of LPS in the JE. JE epithelial cells stimulate inflammatory cytokines including MMP
In periodontitis, during the upregulation of inflammation , what do fibroblasts produce instead of collagen?
MMP and TIMP
What influences macrophage activity during gingivitis/periodontitis?
1) Genetics - hyper responsive phenotype
2) Smoking
3) NSAIDS suppress PGE2 production
What is the role of plasma cells in periodontitis?
Effective plasma cells can make an individual less susceptible to periodontitis. Plasma Cells do this by
1) Agglutinate Microbes
2) Prevent epithelial adhesion
3) Work with complement to kill microbes
4) Allow effective phagocytosis by PMNs
Define Clinical Attachment Loss
CAL = Pocket Depth + Recession
How long can Biphosphonates be biologically active in the body
18 months to 10 years
Which has a worse prognosis? 1 walled or 3 walled bony defect?
1 Walled Bony Defect , only 1 side of bone left. Surgical / Regeneration impossible
What are Suprabony pockets?
Suprabony pockets are formed when bone loss occurs in a horizontal pattern
What are Infrabony pockets?
Infrabony pockets occurs when bone loss occurs in a vertical/angular direction
What are 3 ways to splint mobile teeth?
Wire Splint
Composite Resin Splint
Removable Acrylic Splint
Clinically, when would you do a splint?
- Mobile teeth where mobility is getting worse: eg occlusal trauma
- After removal of extensive calculus with a patient with severe perio and CAL
When would expect to see more physiological tooth movement?
In the evenings after eating, talking
What is Naber’s Probe used for?
Measuring furcations
What class furcation is it when you can probe to a depth of more than 2mm with periodontal probe
Furcation Class II
What are the 3 sites of furcation on an maxillary molar?
Buccal, Distal Palatal, Mesial Palatal
What congenital tooth defect would make a furcation less likely?
Taurodontism
What is the root trunk?
Distance from the CEJ to the roof bifurcation
How do you manage Class I Furcation?
Debridement and Maintenance
Interdental Brush for patient to clean under tooth
What is a furcation plasty used for?
For Class II Furcation, use a bur to smooth the area around the furcation to make it easier to clean.
In stage 1 of periodontitis, describe the pathogenesis of periodontitis in terms of molecular biology
- Initial reaction to plaque: Presence of LPS and other irritants stimulates JE to produce proinflammatory mediators eg: IL8, TNFa, PGE2 and MMP.
Perivascular mast cells release histamin causing endothelium releasing IL8 to attract PMN (which palisade over the biofilm and phagocytose bacteria)
In stage 2 of periodontitis, describe the pathogenesis of periodontitis in terms of molecular biology
- Activation of macrophage: Vascular reaction cause complement protein to enter and activates the inflammatory reaction
Leukocytes and monocytes are then recruited
Monocytes then differentiated into macrophage which is responsible for phagocytosis and releasing inflammatory mediators (IL1, PGE2, TNFa, MMP, IFN) and chemotaxins (MCP, RANTES, MIP)
In stage 3 of periodontitis, describe the pathogenesis of periodontitis in terms of molecular biology
- Upregulation of Inflammatory cell activity: Activated T-cells coordinate response via cytokines (IL2-6 10-13, TNFa, TGFb, IFNg)
Plasma cells produces Igs and cytokines
Activated PMN synthesise cytokines, leukotrienes and MMP
Activated fibroblast produce MMP and TIMP instead of collagen and infiltrate expands
In stage 4 of periodontitis, describe the pathogenesis of periodontitis in terms of molecular biology
- Initial Attachment Loss: Immunocompetent cells produce cytokines MMP and TIMP leading to tissue destruction and bone resorption
Plasma cells becomes dominant in the ilfiltrate
What bacteria are involved with the Red Complex for periodontitis?
P. gingivalis, B. forsythus, T. denticola
- A. actinomycetemcomitans now part of Yellow Complex
What is the significance of the Red Complex in periodontitis?
They are the bacteria found in plaque that are pathogenic through the adaptative to the gingival environment and release of endotoxins that elicit a host response. They are found in cases of severe periodontitis.
What is the difference between a predisposing vs a modifying factor in Periodontitis?
Predisposing Factor: something that interferes with patient’s ability to reduce plaque
Modifying Factor: modifies
Why are restoration overhangs a periodontal risk?
Overhangs harbour increased number of gram-negative anaerobes that initiate perio at these sites
Which gender has a higher predisposition to periodontitis?
Females
What congenital aspects of tooth anatomy are predisposing risk factors for Periodontitis?
Cervical Enamel Projections Palatal Invaginations Accessory Root Canals Close Roots / Root Proximity Root Concavities Enamel Pearls Tooth Malposition (Crowding/Rotation) Gingival Contours Age Gender
What modifying dental factors increase risk of periodontitis?
Furcation Involvement Dental Restorations Overhanging Margins Poor Maintained Dental Prostheses Oral Hygiene (Plaque Levels) Presence of Calculus
A “Cup” bone loss indicates what?
There has been bone loss around all aspects of the tooth. Prognosis is poor, usually involving extraction.
What are 5 ways that furcation involvements can develop?
- Chronic and aggressive forms of periodontitis
- Cervical enamel projections (rare)
- Perforations in floor of pulp chamber during endo will cause periodontal inflammation and loss of attachment with pocket formation
- Accessory/furcation canals can create pockets
- Fenestrations, dehiscence
What are some invasive treatment options for Furcation Involvement?
- Root Resection (removing a root to eliminate furcation)
- Hemisectioning (split the tooth into half, recrown, to eliminate the plaque trap)
- Guided Tissue Regeneration
- Implants
What is the indication for root resectioning?
- Severe bone loss on only one root of multi-rooted teeth
2. Root Fracture
Is continuous eruption part of periodontitis?
No
What are the 5 main etiological causes of Periodontitis?
- Pathogenic Anaerobic Gram Negative Bacteria
- Host (Genetics, Systemic Disease, Heightened Immune Response, Nutrition)
- Habits (Smoking, Alcohol, Diet)
- Social Factors (SES, Education, Upbringing)
- Psychological Factors/Stress
What are environmental factors needed for Perio?
Plaque Calculus Rough Tooth Surfaces Defective Restorations/Appliances Tooth Anatomy Crowding/Rotation Traumatic Occlusion Smoking
Define periodontitis
Inflammation of gums, resorption of alveolar bone and degeneration of periodontal membrane
It is a complex reaction initiated when subgingival plaque bacteria are in close contact with epithelium of gingival sulcus.
Injury arises from toxins and enzymes produced by bacteria and host-mediated defense responses.
Results in apical movement of junctional epithelium indicating attachment loss and alveolar bone loss
What are Socransky’s Postulates?
- Improvement of disease after elimination of pathogen by therapy
- Activation of host immune response to specific infection
- Detection of putative virulence factors e.g. endotoxin (LPS), exotoxin, enzymes, antigens
- Elicitation of similar periodontal disease symptoms in animal experiments
What is the primary risk factor for Periodontitis?
Specific pathogens from plaque associated with severe periodontitis such as the red complex
What are 5 non-alterable secondary risk factors for Periodontitis?
Genetics IL-1 Gene Polymorphism Ethnic Origin Gender Age (ANUP more common in young people)
What is the role of host response in periodontitis?
Influences the clinical presentation and rate of progression of the disease
How can high frenal attachment affect gingival health?
Excessive tension on gingival margin makes brushing very sensitive. People stop brushing this area and it becomes a site for plaque attachment
4 types of bacteria responsible for causing periodontitis
P. gingivalis, B. forsythus, T. denticola, A. actinomycetemcomitans
List 2 main secondary risk factors that are alterable in periodontitis
Smoking and stress
In what situation will the palatal wall be resorbed first in a 3walled defect
Anatomical variation ie: enamel pearls, palato-radicular grooves and cervical enamel projection
When assessing an individual tooth for periodontal prognosis, what are factors to bear in mind?
1) Strategic Value
2) Perio Value
- % Bone Loss
- Probing Depth
- Distribution / Type of Bone Loss
- Mobility
- Crown to Root Ratio
- Presence/Severity of Furcation
- Root Form
3) Tooth Factors
- Caries
- Pulpal Involvement
- Tooth Position / Occlusal Relationship
What are 9 factors to take into account when doing an overall periodontal prognosis
Age Medical Status Individual Tooth Prognosis Rate of Progression Patient Cooperation Economic Considerations Knowledge and Ability of Dentist Risk Factors Oral Habits
What would define a questionable periodontal prognosis?
1) When local + systemic factors are not controllable
2) Clinical signs include:
- Severe Attachment Loss
- Poor Crown / Root Ratio
- Class II-III Furcation with difficult access
- Class II-III Mobility
- Root Proximity
What would define a poor periodontal prognosis?
1) When local + systemic factors might not be controllable
2) Clinical signs include:
- Moderate Attachment Loss
- Class I-II Furcation with difficult access
What is the main aspect of patient acceptance for a periodontal plan?
The patient takes responsibility for the treatment option selected.
In order to do so:
1) Understanding the risk factors,
2) Role of plaque in gingivitis 3) Steps they need to do improve the local/systemic factors
What are steps in treatment planning for advanced generalised chronic periodontitis?
1) Risk Factor Management
2) Detailed Oral Hygiene Instruction
3) Changing Microflora
4) Systematic Subgingival Debridement
5) Removal of irritating factors
6) Periodontal Surgery
7) Periodontal Maintenance
In some very seriously medically compromised patients, what are something to do whilst address the systemic phase of periodontal care?
1) Address medical history
2) Need for antibiotic cover
3) Address hemostatic issues
4) Interaction with GP/Haematologist/Specialists
5) Assess the presence and severity of risk factors
If a patient has a blood clotting issue, what are some considerations before periodontal treatment?
1) Check with their GP/Haematologist
2) Cessation of warfarin
3) INR check (Blood Clotting Measure)
4) Tranexamic Acid Mouthwash (Prevents excessive bleeding)
What are the 5 periodontal treatment goals?
- Control of Infection
- Removal of predisposing factors
- Regulate/Control any modifying factor
- Regenerate to original form/function
- Maintain lifespan/function/aesthetics of remaining dentition
Can you have gingivitis and periodontitis at the same time?
No, periodontitis infers that the microbial composition subgingivally has changed. You can have gingival inflammation (that clinically appears the same as gingivitis) coming from the specific periodontitis microbes
What is supportive periodontal therapy?
SPT is the cleaning procedure performed to thoroughly clean the teeth.
It is an important therapy for halting the progression of periodontal disease and gingivitis by keeping the oral cavity in good health and also halt the progression of gum disease
What are important patient factors to take into consideration for perio diagnosis?
Age Smoking Medical Conditions: Uncontrolled Diabetes Medications Stress Compliance / Motivation Initial Diagnosis: Aggressive Perio + Advanced Chronic Perio Genetics: IL-1 Polymorphism
What are important oral factors to take into consideration for perio diagnosis?
Oral Hygiene Parafunctional Habits Previous Tooth Loss History Bone Loss Gingival Biotype Mucocutaneous Disorders Prosthesis: Dentures + Bridge Access
What are important tooth factors to take into consideration for perio diagnosis?
Levels of Calculus CAL = Probing Depth + Recession BOP Furcation: using Naber’s Probe Bone Loss (if > 75%) Suppuration Mobility
What groups are high risk for IL-1 Polymorphism that affects susceptibility to perio?
Caucasian people
What are important predisposing factors to take into consideration for perio diagnosis?
Enamel Projections Grooves + Fissures on Root Surfaces Carious Lesions, Resorptive Defects Subgingival Restorations, Overhang Restorations Vertical Root Fractures Endodontic Considerations
What 6 factors can be measures to determiner periodontal risk assessment?
Smoking Genetic / Systemic BOP Bone Loss divided by Age Tooth Loss Number of sites PD > 5mm
How would differentiate between buccal and palatal bone loss?
- Check clinically - with perio probe
2. Horizontal Shift with Radiographs
You have two patients of differing ages - one in their 30s and another in the 60s with the exact same perio symptoms. Are their diagnosis the same?
No, older patient’s damage is cumulative and could be indicative of past aggressive perio which is now stabilised and considered chronic rather than acute.
An individual with perio in their 30s is more likely to facing aggressive forms of perio that is not indicative of plaque levels. This would then be considered more likely to be acute aggressive forms of the disease
T/F: Smoking is the main cause of periodontitis
False. Bacteria are the main causative factor for periodontitis but smoking is the main modifying risk factor.
What are the main modifying risk factors for periodontitis?
- Smoking
- Systemic diseases (diabetes)
- Genetics
- Stress
- Neutrophil Dysfunction
What are some clinical signs of a patient with periodontitis if they are a smoker
- Pale Pink Gingiva
- Reduced BOP for the amount of calculus present
- Smoker’s Breath
- Extrinsic staining of teeth
- Pale complexion in peripheries (eg fingers)
T/F: In Australia, more than half of severe cases of periodontitis would have been prevented if smoking could be eliminated in the population
True
For smokers where is the likely area of greater periodontal attachment loss?
Areas where nicotine has more contact with the mucosa eg Maxillary palatal aspects
What symptoms of gingivitis are you likely to see in a heavy smoking patient with perio?
Less gingivits and less bleeding on probing
Why is there more severe alveolar bone loss in smokers?
Vasoconstriction of nicotine decreases nutrient supply to bone, increase resorption rates
What effect does smoking have to bacterial flora?
Smokers have more plaque and virulent (red complex) periodontal bacteria
What effect does smoking have to host response?
- Impeded ability to combat bacterial egress due to vasoconstriction
- Decreased PMNs in JE
- Increase in pro-inflammatory cytokines (PGE2, IL-4, IL-8, TNF-α in GCF)
- Decrease in anti-inflammatory cytokines (IL-6)
- Decreased IgG antibodies to A. actinomycetemcomitans
- Poor B Cell Function
What effect does smoking have epithelial cells?
Smoking increases proliferation of gingival keratinocytes
Increases the levels of keratin in the epithelium
What effect does smoking have on fibroblasts
Poor periodontal regeneration due to:
1) Altered Cell Morphology
2) Poor Adhesion to root surfaces
3) Reduced soft tissue/PDL healing
How would you gauge if your diabetic patient is at risk for perio?
1) Ask about their resting blood glucose levels
2) Is their diabetes controlled via medications or diet
What constitutes controlled diabetes?
HbA1c-glycated haemoglobin measure over a 3 month period reading 4-8 mmol/L
Is controlled blood glucose levels a risk factor for gingivitis?
No
What are the clinical signs of gingivitis in an uncontrolled diabetic?
Increased gingival bleeding and gingivitis irrespective of plaque levels
T/F: A patient with long term Type 2 Diabetes is at high risk of periodontal disease
False - diabetes is only a risk modifier and the risk factors only increase if it is not well controlled
The production of advanced glycation end products (AGEs) in the periodontal apparatus occurs under what conditions?
Non enzymatic glycosylation occurs under chronic hyperglycaemia with uncontrolled diabetes (Type I/II)
Advanced glycation end products (AGEs) does what to collagen?
Alters the structure and turnover rate of collagen.
What are the long term immunological implications of AGEs build up in the periodontal apparatus?
- AGEs alter the structure and turnover rate of collagen.
- In the Junctional Epithelium, there is too much collagen forming and the basement membrane becomes too thick. This results in:
- Impairs oxygen diffusion
- Waste elimination
- Leukocyte migration
- May contribute to pathogenesis of periodontitis
- AGEs modify the phenotype expression of macrophages and interfere with macrophage ability to help repair
What does hyperglycemia do to PMNs?
Increased glucose concentration inhibits:
- PMN migration/chemotaxis
- Phagocytosis of pathogens
- Respiratory burst
What does hyperglycemia do to Macrophages?
1) Phenotype of macrophages altered due to cell surface interactions with AGEs
2) Prevent the development of macrophages associated with repair
What interactions does Hyperlipidemia have with macrophages?
Upregulates pro-inflammatory cytokines (IL-1, PGE2 and TNFα )
How does hyperglycaemia result in poor wound healing
1) Impaired host response leading to infection
2) Decreased cellular proliferation and fibroblast numbers
3) Defective remodelling and rapid degradation of newly synthesized, poorly linked collage
4) Upregulation of inflammation
What interactions does HIV have on periodontitis?
More severe and extensive chronic periodontitis related attachment loss, particularly with CD4 positive T cell counts below 200
What medications can result in gingival enlargement?
Phenytoin, calcium channel blockers and cyclosporine
Why can stress play a role in periodontitis?
- Cortisol released HPA axis upregulates proinflammatory cytokines
- Sympathetic nervous innervation releases adrenaline and noradrenaline is indirectly immunosuppressive => provoking periodontal tissue breakdown
What are the 3 ways genetics can influence periodontitis?
Different expression for innate immunity, adaptive immunity and nonspecific inflammatory mediators
What effects can puberty have on gum health?
High prevalence of gingivitis due to spikes in sex hormones
What effects can menstruation have on gum health?
Swollen gingiva + bleeding due to:
Increase in progesterone
Increase in vascularisation
Increased collagen production in gingiva
Increased prostaglandins and chemotaxis of PMNs
What effects can pregnancy have on gum health?
Increases risk of perio
Pregnancy Gingivitis
How can Osteoporosis affect periodontitis?
Decreased bone mineralisation + density means resorption (if present) occurs at a faster rate
How can Menopause affect periodontitis?
Production of pro-inflammatory cytokines in response to oestrogen withdrawal at menopause is responsible for characteristic loss of bone density through effects on osteoclast activity
What is an example of a neutrophil dysfunction that affects gingival health?
Cyclic Neutropenia - very fiery red gums due to low PMN count
What are the 4 ways to control Periodontal Disease
1) Control host response modifying factors (diabetes, smoking)
2) Elimination of plaque retentive factors (fissures, overhangs)
3) Disruption and reduction of plaque biofilm (Supportive Periodontal Therapy)
4) Shift of microbial flora composition (Antibacterials)
What sort of antibiotics would be more appropriate for Periodontal bacteria?
Metronidazole (Flagyl) - narrow spectrum for anaerobes
Are penicillin based antibiotics appropriate for Periodontal therapy?
No, Prevotella in periodontal pockets contains beta-lactamase.
Is tetracycline appropriate for periodontal therapy?
No due to increased antibiotic resistance to tetracycline
How as dentists can we prevent antibiotic resistance in perio treatment?
- Prescribe antibiotics carefully
- Must select appropriately and use the appropriate agent in each clinical scenario
- Salivary/Exudate swab to identify species (expensive)
When is metronidazole contraindicated for AB treatment for perio?
If patient is currently on Warfarin - increases bleeding time
Alcohol - overtaxes liver
What opportunistic infections can occur during AB treatment for perio?
Pseudomembranous colitis
Oral Candidiasis
When is AB prophylaxis indicated before perio therapy?
To high risk patients 1 hour before treatment.
- Immunocompromised patients
- Infective Endocarditis + Heart Valve implants
- ANUG
- Aggressive Refractive Perio
Low benefit for prevention of post-operative infection or regenerative outcomes. Only considered for very invasive procedures
Why is there a barrier to diffusion for systemic AB treatment of perio?
Mature biofilm prevents diffusion of AB from GCF. High concentrations need.
AB will work better after debridement/disturbing biofilm with SPT.
Which AB is appropriate for very aggressive perio bacteria?
Azithromycin (500 mg once daily for 3 days (a tablet)
What is Refractory perio and what are treatment options
When perio does not respond to treatment. Antibiotic therapy is indicated as well as addressing major risk factors (diabetes/smoking)
Is Tetracycline effective for generalised aggressive perio
No
What type of antibiotic is Azithromycin?
Macrolide - a protein synthesis inhibitor
How often can you prescribe Azithromycin for perio?
Once every 6 months. High AB resistance - particularly against pneumonia
When is Azithromycin contraindicated?
Patients with CVD
2nd Generation chemical control agents have what type of substantivity
High substantivity = can bond to the surface so several hours
What are the 3 main ingredients in mouthrinses?
1) Alcohol
2) Surfactant
3) Flavouring Agents
What are the main group of chemical agents to control plaque / gingivitis?
- Bisbiguanide antiseptics
- Quaternary ammonium compounds
- Essential oils (EO)
- Natural products
- Oxygenating agents
- Amine alcohols
- Other
T/F: Chlorhexidine removes/kills existing plaque bacteria
False, it is a surfactant that prevents recolonisation of surfaces after plaque removal
How long is the action of surfactant in Chlorhexidine?
48 hours
Why should Chlorhexidine not be taken straight after brushing?
Fluoride binds to the positivity charged CHx, rendering it useless
What are short term indications for Chlorhexidine use?
- After periodontal/oral surgery
- Acute periodontal conditions: ANUG, periodontal abscess (1-2 weeks)
- Apthous ulcers
- Severe chronic gingivitis (1-4 weeks)
- Rampant caries
What are long term indications for Chlorhexidine use?
- Patient with physical/mental handicap
- Medically compromised
- Patients with jaw fixation
What are side effects of Chlorhexidine?
- Bitter, unpleasant taste
- Interfere with sense of taste
- Staining of teeth/restorations
- Enhanced supraginginval calculus formation
- Allergy/sensitivity, possible anaphylaxis
- Uni/bilateral parotid swelling (very rare)
Cetylpyridinium Chloride (CPC) is what type of chemical agent and what product can you find this in?
Quaternary Ammonium
Colgate Plax
T/F: Quaternary Ammonium are high substantivity chemical agents
False, low substantivity
What is the mode of action of essential oils on microbes?
- Microorganisms killed by disrupting their cell walls and inhibiting enzyme activity
- Prevents bacteria from aggregating hence slowing bacterial proliferation
- Reduces bacterial load
What are the concerns of long term essential oil usage for plaque control?
Listerine contains alcohol which can dehydrate mucosa. Long term use can cause metaplasia - alter cell architecture / histology.
No definitive link to cancer
What is considered gold standard for chemical plaque control?
Chlorhexidine, as adjunct to daily mechanical oral hygiene
What are indications for use of mouthrinses as an adjunct?
- After surgical procedures: as toothbrushing may be difficult
- In medically compromised patients
What are the only 2 systemic diseases that have bi-directional aetiology with periodontitis?
- Diabetes
- Rheumatoid Arthritis
How does a focal periodontal infection affect the body on a systemic level?
Chronic Inflammation places a burden at the systemic level due to increased circulation of pro-inflammatory cytokines
What is the Periodontal medicine hypothesis?
That focal periodontal infection presents a chronic inflammatory burden at the systemic level
How might periodontal pockets influence systemic conditions
- Bacteria and their products may pass through periodontal pockets systemically into the bloodstream (eg for infective endocarditis)
- Chronic perio inflammation: pro-inflammatory mediators released systemically
What is a focal infection?
Where a bacterial infection limited to a specific organ or region causing symptoms elsewhere in the body:
1) Perio => Infective Endocarditis
2) Systemic infections: Gangrene, TB, Meningitis, Septicaemia, Pneumonia
How could perio bacteria enter the bloodstream
Toothbrushing/flossing (can cause bleeding) Mastication Scaling Subgingival irrigation Endodontic treatment Tooth extraction
How does diabetes influence perio?
Worse symptoms
Increase likelihood of abscesses
What are the current links between CVD and Perio?
- 44% of carotoid atheromas contain perio pathogens
- CVD patients have elevated C-reactive protein: a marker for bacterial infections
- Perio pathogens are linked to platelet aggregation: increase chance of stroke
Overall: elevated risks/poorer outcomes for CVD for patients with perio
What are indirect effects that perio bacteria might have on modifying CVD symptoms?
Release of bacterial LPS:
- May affect liver
- Inflammatory Factors: C-reactive protein
- CRP Fibrinogen: increased heart attack risk
- Lipid abnormalities
- Coagulation factors
What are direct effects that perio bacteria might have on modifying CVD symptoms?
Release of bacterial LPS:
- Increase mobilisation of macrophages
- Pro inflammatory Mediators:
Il-1, Il-6, TNF-alpha, PGE-2
Why might perio symptoms be worse in uncontrolled diabetic?
Higher BGL in blood and GCF provide ample nutrition for bacteria to proliferate
How might symptoms in a perio patient with uncontrolled diabetes be different?
- Higher prevalence of exudate
- Abnormally high response to LPS: exaggerated monocyte response, inflammatory cytokines
- Impaired Wound Healing
Is there a link between obesity and perio?
Possibly, but most likely because of undiagnosed Type II diabetes
What defines low birthweight / preterm birth and what are the long terms health implications?
Low birthweight = < 2500g
Preterm = delivery before 37 weeks gestation
Birthweight considered an important determinant for infant’s chances to survive, grow and mature
What is the epidemiology of low birth weight in SA?
4.5% births in SA
11% indigenous births
What are the links between periodontitis and low birth weight?
2 Hypothesis:
- Indirect mechanism via inflammatory mediators
- Direct bacterial assault on the amnion
However no proof yet that treating maternal perio will result in better birth outcomes
What is the link between respiratory illnesses and perio?
Perio is typically an indicator of poor oral hygiene.
Higher bacterial load in the mouth can spread into the oropharynx
Improving oral hygiene can reduce rate of pneumonia in high risk patients
Why is there a likely link between rheumatoid arthritis and periodontitis?
They have same risk factors therefore assumed to have a relationship:
- Chronic inflammation
- Immunoregulation imbalance
- Initiating bacterial peptides/antigens
- Macrophage presence
- Release of multitude of cytokines
- Genetic/environmental
Why might Rheumatoid Arthritis patients have more perio?
Arthritis limits manual dexterity and the ability to brush well
Why might Perio patients have worse Rheumatoid Arthritis symptoms
Elevated serum CRP levels and additional inflammatory burden
What is the link between osteopenia (pre-osteoarthritis) and periodontitis?
Higher rates of progressive alveolar bone loss when compared to normal bone density patients
How can innate immune cells in the periodontium detect the presence of microbes in the JE?
Sampling microbes by detecting MAMPS/PAMPS via Protein Recognition Receptors (PRRs) such as Toll Like Receptors, C-type Lectin Receptors (CLR) and Mannose Receptors found on the membrane of innate cells such as Macrophages and Dendritic Cells
T/F: The presence of High Endothelial-Like Venules (HEVs) is always pathological
False
Normal: Found near lymphatic tissue (Lymphatic organs, tonsils, peyer’s patches)
Pathological: during chronic inflammation HEVs are created. Being slightly larger than capillaries and creating turbulence in endothelial flow, they encourage innate defense cells to migrate to the site of inflammation.
When are PMNs found during perio related disease
- Initial inflammation of the pocket as first responders
2. Migration in large numbers during chronic inflammation
Low Neutrophil count with normal function would be found in what sort of perio?
Chronic Aggressive Periodontitis
Normal Neutrophil count with compromised function would be found in what sort of perio?
Chronic Aggressive Periodontitis
High Neutrophil count with normal function would be found in what sort of perio?
Acute Periodontitis
What factors would determine the amount of collateral damage could be caused by Neutrophils in periodontitis?
- Duration of chronic inflammation
- Elevated Numbers
- Hyperactivity
How are neutrophils involved with either tissue health in perio?
- Collateral damage during chronic inflammation
- Role in Osteoclast Differentiation
- Role in Tissue Repair
What two chemical mediators add in osteoclastic differentiation and activation that leads to alveolar bone loss?
- Macrophage Colony Stimulating Factor (M-CSF)
2. RANKL / Lack of OPG
What immune cell is involved with down-regulating inflammation response including:
- Blocking CD4
- Blocking Dendritic Cell proliferation
- Signal defence cell apoptosis
T Regulatory Cells
What are the 2 main innate immunity actions that lead to connective tissue breakdown and bone resorption in perio?
Upregulation of pro-inflammatory cytokines leading to:
1: PMN activation/migration via vascular changes (HEVs)
2. Osteoclast differentiation + activation
What are the 2 main adaptive immunity actions that lead to connective tissue breakdown and bone resorption in perio?
Maturation of naive T cells leading to:
1) B-Cell Responses via TH2
2) Cell Mediated Immunity via TH1
3) Lack of Immune Suppression via T-reg
4) Up regulation of pro-inflammatory cytokines via TH17
What are the 6 major PDL fibre types when viewing from a sagittal view?
Transeptal: lie above the alveolar bone in the gingiva
Crestal: lie equal to the crest of the alveolar bone
Horizontal
Oblique: mainly absorbs forces
Apical
Interradicular: between bone in furcations for multi-rooted teeth
What gingival fibres are mostly affected due to heavy occlusal loads
A physiological change occurs to alter the alignment of Transseptal and Alveolar Crest Fibres
What changes in the periodontium can occur due to heavy occlusal load?
Increased Tooth Mobility
Widening of PDL
No attachment loss (without perio)
T/F: Heavy Occlusion is a co-factor in the aetiology of localised perio
Possibly, there is currently limited evidence for this in human studies.
In animal studies heavy occlusion results in physiological remodelling of transseptal and alveolar crest fibres provide a more direct pathway for inflammation to reach the PDL. But does not induce perio.
With existing perio, it can increase the rate of angular bone loss
T/F: Splinting is still required if Class II mobility has been stable for 12 months
False: Splinting is only required if mobility prognosis is getting worse
What are the 3 common types of splints?
Wire splint
Composite resin split (no tooth preparation)
Removable acrylic splint
What are some indications for splinting to aid treatment of tooth mobility?
- Post Regenerative treatment to aid healing
- Trauma: Emergency treatment for extremely mobile teeth
- Enhance masticatory comfort in highly mobile teeth
- Post-orthodontic treatment
What components of cigarette smoke are Immunomodulatory?
Nicotine
Carbon Monoxide
Acrolein
Reactive Oxygen Species
How can cigarette smoke modular oral immunity?
- Activation of Epithelial and Immune Cells
- Subsequent recruitment of other immune cells
- Impairs Immune Host Defense Mechanisms to pathogens
- Chronic Inflammation
- Autoimmunity issues
What immune suppression action may result in increased oral cancer risk?
- Suppression of Natural Killer Cell function
- Disregulation of Signal Transducer (Ras) => upregulation of cell growth/division
Why might oral tissue healing be impaired by cigarette smoke in a perio patient?
- Chronic thermal/chemical trauma
- Decreased innate/adaptive cell activation
- Insufficient cell numbers/responsiveness to deal with excessive cellular debris and phagocytosis needed for chronic inflammation from perio
How might smoking result in increased pro-allergic factors in a perio patient?
Up regulation of TH2 Helper Cells, resulting in an IgE response, resulting more progressive periodontal lesions
What is the overall effect of smoking on perio?
- Persistent Mucosal Epithelial Activation
- Diminished antimicrobial functions relevant to the clearance of infection
- Higher likelihood of smokers to develop colonisation + subsequent perio infection
What is the main modifiable risk factor in chronic periodontitis?
Smoking
How can advanced periodontitis result in an endodontic lesion? (Class II Lesion)
Pulpal inflammation via the egress of bacteria through the root apices, lateral canales or furcation
How can an advanced endodontic lesion result in periodontitis? (Class I Lesion)
Egress of pulpal bacterial through lateral canals or the root apices to induce a primary inflammation response in the PDL.
What are possible reasons a combined perio + endo lesion can occur?
- Infection of one/both of the dental pulp + periodontium
- Iatrogenic damage: Perforation of the root apex during endodontic treatment
- Trauma: vertical root fracture
What would be your treatment approach for a Class 1 Primarily Endodontic lesion that has perio involvement?
- Treatment of Endodontic Lesion first and observe.
- Redress pulp every month
- Delay perio treatment whilst observing
- Allow cementum + PDL to regenerate
- If unresponsive, start perio treatment
- If nil improvement: hemisection of affected root or extraction
What would be your treatment approach for a Class 2 Primarily Periodontal lesion that has endo involvement?
- Endodontic Treatment first
- Subsequent periodontal treatment
- Extraction if unresponsive - typically severe perio involvement will have poor prognosis
What would be your treatment approach for a Class 3 Combined Endo + Perio lesion?
- Extraction
2. Endodontic Treatment: if tooth is important as an abutment for fixed/removable pros work
What is the zone of co-destruction?
The addition of
- Zone of Irritation from biofilm
- Zone of Adaptive changes resulting from heavy occlusal loads
Combined periodontitis + heavy occlusal loading can result in what?
- Stretched PDL
- Increased CAL
- Angular Bone Loss
- Increased Tooth Mobility
Do iatrogenically restoration overhangs directly cause perio?
No, they create a a plaque trap but perio requires a compromised host response to occur.
What are the characteristics of the microbiome in a healthy gingival crevice?
- Relatively low microbial numbers
- Mainly Gram Positive
- Cocci: Streptococcus 40%
- Rods: Actinomyces 35% - Low Redox Potential
- Nutrition: Mostly from GCF
What shifts in the microbiome occur from healthy to plaque induced gingivitis?
- 10-20x mass and diversity of microbial numbers
- Shift to Capnophilic and Anaerobic Gram Negatives
- Decreased redox position (as a result of bacterial metabolism)
- Host Response via inflammation
What would be the broad characteristics of bacteria involved with chronic periodontitis?
- Asaccharolytic: doesn’t metabolise carbohydrate. Metabolism is via Amino Acid,
- Bacteria prefer high pH:
Protease-producing
Liberation of Ammonia as by-product => increases pH - Anaerobic: being subgingival
What AB prophylaxis indicated before perio therapy for a patient at risk of infective endocarditis?
Oral Amoxycillin 2g 1hr before appointment
If allergy/adverse reaction, past long-term penicillin treatment, then use Clindamycin 600mg
What are causes of gingival recession?
Morphology of Teeth Abrasion Chronic Inflammation Frenum Pulls Ortho extraction/movement Bruxism Aging Continuous Eruption
Does recession necessary equate to perio?
No. Recession can occur from non-perio related causes including
Morphology of Teeth Abrasion Chronic Inflammation Frenum Pulls Ortho extraction/movement Bruxism Aging Continuous Eruption
Which of the following sharpening stones is a natural fine grit stone?
A. Arkansas
B. India
C. Ceramic
Arkansas stone
Which hand and at what angle of the clock should you be holding the perio instrument to be sharpened?
12 o clock with the non-dominant hand, end to be sharpened facing the floor
What should happen with the acrylic test strip if the instrument is sharp?
The blade will catch against the strip and make a ping noise
What were some limitations with the old classification of periodontitis?
- Lots of overlap of categories
- Absence of gingival disease
- Inappropriate emphasis of age of onset
What is the difference in microbiology between acute/chronic perio?
Acute: Generally Actinobacillus Actinomycetemcomitans infection, with some P gingivalis
Chronic: polymicrobial with red complex (P gingivalis + P forsythus)
What is the terminology for chronic periodontitis that don’t respond to treatment?
Recurrent / Refractory Periodontitis
What invasive treatment modalities are available for mild chronic perio?
Flap Debridement for Access
What invasive treatment modalities are available for severe perio?
Flap Curettages
Regenerative Procedures (GTR)
Implant
What invasive treatment modalities are available for agressive perio?
Comprehensive Flap Debridement
What is a pseudopocket?
If the gingival margin is enlarged above the CEJ (due to inflammation) it goes a false deeper pocket depth
Which teeth have a higher likelihood for accessory canals that can be problematic in endo-perio lesions?
Molars
A Short Root Trunk is more likely to have what perio issue?
Furcation involvement
What is a Hemiseptal Defect:?
Where the bone loss has included either/or buccal/lingual plates. Known as either a 1 or 2 wall bony defect
What are the 6 stages of periodontitis?
- Inflammatory cells invading gingival CT, sulcular + junctional epithelium
- Ulceration of Pocket Epithelium
- Deepening of Pocket Depth
- Downward migration of JE
- Loss of connective tissue attachment
- Loss of Alveolar Bone
What are the predominant microbial species and composition in periodontitis?
Anaerobes 80%
Gram Negative Rods 75%
Reduces Cocci, Non-Motile Rods
Increased Spirochetes: shape designed to burrow into tissue (d Denticola)
What are clinical signs of NUG?
Pain on probing Marginal Bleeding / BOP Fiery Red Blunted Interdental Papilla Grey Pseudomembrane along gingival margin Halitosis Fever
What bacteria are implicated in NUG?
40% Treponema
24% P. intermedia
3% F nucleatum
What Antibiotic cover can be given for NUG?
Antibiotic Cover: Metronitazole (Flagl)
- Targets obligate anaerobes
Metronidazole 400mg 2x/daily for 5 days - If unresponsive / immunocompromised
Metronidazole 400mg 2x/daily for 5 days AND
Amoxycillin 500mg orally 3x / 5 days OR
Clindamycin 300mg orally, 3x / 5 days (if penicillin allergy)
What are Koch’s Postulates for plaque derived diseases?
- The microbe should be present in sufficient numbers to initiate disease
- The microbe should generate increased levels of specific antibodies
- The microbe should possess relevant virulence factors
- The microbe should cause disease in an appropriate animal model
- Elimination of the microbe should result in clinical improvement
What bacterial factors in perio contribute to attachment to host tissues?
Cell Surface Adhesins
What bacterial factors in perio contribute to evasion of host defences?
Proteases/Haemolysin: Enzymes to obtain nutrients
Ability to compete with other flora
Production of bacteriocins
What bacterial factors in perio contribute to bacterial evasion of defences?
Capsule + Slime Layer
Leukotoxin Production
Antibody specific proteases
Complement degrading proteases
What bacterial factors in perio contribute to indirect tissue damage?
- Proteolytic Enzymes: Trypsin-like protease, Collagenase, Hyaluronidase, Chondroitin Sulphatase
- Bone Resorbing Factors
- Endotoxins: TLA, LPS, Capsule, Cytotoxins
- Metabolic Products: Short chain fatty acids, ammonia, volatile sulphur compounds
What bacterial factors in perio contribute to direct tissue damage?
Host Inflammatory Response to plaque antigens
What helps P. gingivalis helps attachment to epithelial cells?
Fimbriae
Red complex proteases serve what function?
- Aid attachment
- Degrade proteins
- Degrade Immunoglobulins
- Release nutrients
- Activates host MMPs
T/F: Periodontitis only has red complex bacteria present
False: microbial research indicates that commensal and early colonisers are all necessary to create conditions to allow red complex to be sufficient in number and virulence
What 3 viruses are implicated in lesions of aggressive periodontal disease?
Herpes Simplex
Cytomegalovirus (CMV)
Epstein-Barr Virus Type 1 (EBV-1)
During orthodontic movement what happens to areas of pressure?
Bone Resorption
During orthodontic movement what happens to areas of tension?
Bone Deposition
What periodontic issues can occur in periodontally healthy patients during orthodontic treatment?
Gingival inflammation, gingival hyperplasia, increased probing depths, loss of connective tissue attachment (between 0.2-0.3mm) and alveolar bone resorption (0.3mm)
What periodontic issues can occur in periodontally compromised patients during orthodontic treatment?
Accelerated bone loss from inflammation (plaque retention) and orthodontic forces
Elastomeric rings in ortho can present what problem in periodontal health?
Areas of increased plaque retention
What microbiological changes can be seen during orthodontic treatment?
Shift towards an anaerobic periodontopathogens
eg. P.intermedia, spirochetes, motile rods and filaments
What recall protocol should occur for periodontally at risk patients option for orthodontic treatment
4 month SPT
Orthodontic treatment terminated if OH can not be maintained or signs of disease progression
What treatment can be done for impacted canines prior to orthodontics?
Apical Repositioning Flap
What is a typical cause of a diastema and what is the treatment
Failure of frenal fibres from maxillary labial frenum to migrate apically.
Residual band of elastic tissue prevents I/P contact of central incisors
Frenectomy is an option after eruption of 1-6 permanent teeth
