Periodontology Flashcards
what are the features of healthy gingivae?
pink, firm, stippled, knife edge margin, no bleeding
how do the gingivae maintain health?
JE, shedding of epithelial cells, collagen fibres maintain form and attachment to tooth, GCF, antibodies, phagocytosis by neutrophils and macrophages, complement activity
what is gingivitis?
reversible inflammation of the gingivae
what are the clinical signs of gingivitis?
redness starting at papillae and progressing along gingival margin
loss of stippling
smooth and glossy surface
swelling
rolling of the gingival margin
loss of triangular shape of interdental papillae
bleeding on probing
what are the histological features of plaque induced gingivitis?
increased GCF
increased vasodilation and capillary permeability
collagen breakdown
more inflammatory cells
what is periodontitis?
irreversible inflammation of the gingiva and loss of attachment and bone
what are the clinical signs of periodontitis?
some/all signs of gingivitis true pocketing on probing recession suppuration mobility drifting furcations radiographic evidence of bone loss
what is the prevalence of chronic periodontitis?
47% of US population over 30 have periodontitis
8.5% mild, 30% moderate, 8.5% severe
what is the prevalence of aggressive periodontitis?
ethnic variation
periodontal disease is…
polymicrobial
describe the specific plaque hypothesis
specific microorganisms are responsible for the development of periodontal disease
eg Aa linked to LAP and Pg linked to generalised aggressive periodontitis but both found at non diseased sites
describe the non specific plaque hypothesis
disease results from sheer mass of pathogens
describe the environmental disease hypothesis
pathogenic species are required in sufficient numbers in the biofilm, species are co dependent
describe the microbial complexes of varying virulence
clusters of bacteria in discrete micro environments
how can host factors contribute to periodontal tissue destruction?
inflammatory and immunological responses —> modulation of host response e.g. drugs, diabetes, smoking —> modulated by subject specific risk factors e.g. PMNL function
how can parasite factors contribute to periodontal tissue destruction?
bacterial load and composition —> virulence factors, toxins, cell signalling molecules —> modulated by site based risk factors e.g. plaque retention factors
what is the role of the host immune response in the pathogenesis of periodontal disease?
in health PMNL are predominant defence cell, innate immunity functions at low level, no tissue damage
increased plaque –> increased endotoxin –> complement activation, increased inflammatory response, epitheliotoxin, gingival tissue damage
T lymphocytes kill bacterial cells
B lymphocytes produce antibodies and activate complement
untreated disease in susceptible patients exceeds the threshold where tissue damage occurs
active periodontal lesions full of plasma cells causes collateral damage due to enzymes and free radicals
what type of inherited genetic disease/predisposition is chronic periodontitis?
complex
what percentage of variance for gingivitis, probing depth and clinical attachment loss is due to genetic variation?
38-82%
which polymorphism is linked to chronic periodontitis?
IL-1 polymorphism
what type of inheritance risk is associated with aggressive periodontitis?
familial pattern of inheritance, autosomal dominant, x - linked
what genetic alterations are involved with complex diseases such as chronic periodontitis?
normal variants
present in everyone
subtly alter the gene and protein
what are the effects of smoking on the periodontium?
3-6 times more periodontal disease than non-smokers
more sites with deeper pockets
more clinical attachment and bone loss
more furcations
more likely to suffer from necrotising ulcerative periodontitis
accumulate more calculus
less likely to respond to therapy
what are the effects of nicotine on the periodontium?
vasoconstriction, prolonged thermal and chemical irritation of oral mucosa causing smokers keratosis, speckled leukoplakia
changes oral microflora resulting in predisposition to candiosis
increased staining
etc (see handout)
when is diabetes mellitus a risk to periodontal tissues?
when poorly controlled
when is the incidence of periodontitis greatest in diabetics ?
post puberty
what effect does HbA1/HbA1c have on tissues in diabetics ?
the higher the level the worse the bone loss particularly interproximally
what are the histological effects of diabetes on the periodontium?
reduced collagen synthesis by fibroblasts
impaired PMNL function
impaired wound healing due to decreased collagen solubility and increased collagenase
advanced glycation end products - increased collagen cross linkage and release of IL-1, TNF alpha, PGE2
what feature in the mouth could be a presenting sign of diabetes ?
atypical or recurrent lateral periodontal abscesses that do not respond to treatment
how does stress affect the periodontium?
decreased saliva flow, increased viscosity, acidity, glycoprotiens favouring plaque accumulation
na and a decrease gingival blood flow
increased salivary cortisol associated with stress and periodontitis
periodontal pathogens utilise catecholamines in GCF in increasing concentrations when stressed
which area is most commonly missed when brushing?
lower right lingual area for right handers (opposite for left)
what are the most common manual brushing techniques?
bass, modified bass, scrub
describe the bass brushing technique
angle bristles towards the gingival margin at 45 degrees keeping parallel to the gingiva using small circles to disturb plaque
describe the modified bass brushing technique
same as bass but rolling the brush head towards the occlusal surface after circular movement
describe the scrub brushing technique
replace circular movement with short scrub action
recommended in scientific basis of dental health education
what brushing technique is recommended for children?
Fone’s - teeth in occlusion, large circles on buccal surface, scrub remaining surfaces
what is the recommended technique for an electric toothbrush?
angle 45 degrees to gingival margin, allow brush to float, do not scrub,
when should electric toothbrush heads be changed?
oscillating 3 months, sonic 6 months
what are interspace brushes used for ?
to clean around partially erupted teeth to clean furcations clean around implants clean around fixed appliances clean around gingival margin
what are super floss and floss threaders used to clean ?
under bridges and around fixed appliances
what is the function of a water pick?
remove food debris and irrigate periodontal pockets with chlorhexidine
what does active periodontal treatment involve?
breakdown of biofilm by instrumentation
removal of calculus and plaque retentive factors that could harbour biofilm
ensure patients plaque control is sufficient enough to prevent re-maturation of the biofilm
what is the rationale for supra gingival scaling?
altering the supragingival biofilm can have a profound effect on the subgingival biofilm
what is dental calculus?
mineralised bacterial plaque covered on its external surface by a living layer of plaque biofilm
why should calculus be removed?
the surface of calculus is irregular and covered with disease causing bacteria so it plays a significant role in causing periodontal disease
it is difficult to control or prevent periodontal disease of calculus deposits are present
what is the rationale for periodontal debridement ?
arrest the progress of disease
create an environment to allow gingival healing and assist maintenance of tissue health
eliminate inflammation
increase effectiveness of patient self care by eliminating plaque retention
what is the endpoint of periodontal debridement ?
a root that is biologically acceptable for the healthy attachment of gingival tissue
for how long should the periodontal tissues be allowed to heal before probing ?
6 weeks
what are the possible results after periodontal debridement ?
pocket shrinks completely
long JE
little or no shrinkage of pocket
what should sickle scalers be used for ?
supragingival scaling
should not be used subgingivally
in what areas are sickle scalers most effective at calculus removal?
proximal surfaces of anteriors
apical to contact area posteriors
what are straight jaquettes used for ?
anterior teeth
what are angled jaquettes used for ?
posterior teeth
what are the features of universal curettes?
two cutting edges per working end
why are grave curettes the instrument of choice for manual root surface debridement ?
rounded toe, curved cutting edge and non-cutting edge prevents tissue damage
what are hoes used for ?
subgingival scaling
areas fo stubborn calculus
what is the vibration range of a sonic scaler ?
2500-16000 Hz
how big is the tip deflection of a sonic scaler ?
0.08-0.2 mm
what type of movement is produced by a sonic scaler?
eliptical/circular movement
how are vibrations created in a sonic scaler ?
air enters through tube and is the n forced through angled holes causing the tube to tilt
which scaler is more effective sonic or ultrasonic?
ultrasonic
describe the piezo electric ultrasonic
electrically reactive ceramic discs embedded in instrument handle
alternating current cases contraction and elongation which is transmitted to the tip
vibrations 25000-50000 Hz
describe the ultrasonic magneto strictive
tip connected to a ferromagnetic bar (ferrite) or nickel cobalt strips soldered at ends to create insert
insert slides into handle and spiral generates a magnetic field from the moment the current starts to flow contracting the bar or soldered strips
the alternating current causes vibrations in an elliptical spiral path of movement so all sides of the tip are effective
18000-45000 Hz
what is the purpose of the water flush in magneto stricture ultrasonics ?
cool the handpiece and the tooth and wash way calculus and plaque
what are the effects of ultrasonics on enamel?
reduced hardness, negligible effect for healthy enamel, catastrophic if enamel demineralised
what are the effects of ultrasonics on the root surface ?
cause less damage than hand instruments if used correctly
what are the effects of ultrasonics on pulp?
with water coolant increase 8 degrees
without water coolant increase 35 degrees
what are the effects of ultrasonics on periodontal tissues ?
minor histologic changes
what are the advantages of ultrasonics ?
irrigation of pocket, cavitation effect on plaque removal, possible bactericidal effect, water cleans working field, increased tactile sense of pocket topography, effective with every movement, better access in furcations, size and shape of tip can be choses appropriately, less operator fatigue, faster and easier to remove calculus, shorter learning process
what are the disadvantages of ultrasonics?
contaminated aerosol, aspiration required, expensive, noisy, produces burnished root surface, risk of damage to enamel and dentine, dentine hypersensitivity, reduced tactile feeling of root surface
what are the contraindications to the use of ultrasonics?
TB, compromised immune system, respiratory problems, swallowing problems, primary teeth, newly erupted teeth, decalcified enamel, pacemakers, implants
what are the pre requisites for non surgical debridement therapy ?
good plaque control, 6 point pocket depth charts, appropriate radiographs, periodontal diagnosis and treatment plan
what are the side effects of periodontal therapy?
gingival recession, sensitivity, inter proximal dark triangles
which risk factors affect non surgical therapy outcomes?
poor plaque control, poor attendance, insufficient debridement, systemic conditions e.g. diabetes, smoking, persistent deep pockets, furcations
what is the primary function of a BPE?
screen for disease
describe the WHO probe
ball end 0.5 mm diameter, coloured band extends from 3.5-5.5mm, second coloured band extends from 8.5-11.5 mm
what of the probing force for WHO probe ?
0.2-0.25 N
what does a BPE score of 0 mean?
coloured band completely visible, gingival tissues are healthy, no bleeding after gentle probing
how is a BPE score of 0 managed?
no treatment, screen in 1 year
what does a BPE score of 1 mean ?
coloured band completely visible, no calculus or plaque retentive factors, bleeding on probing
how is a BPE score of 1 managed?
OHI, screen in 1 year
what does a BPE score of 2 mean?
the coloured band is completely visible, calculus or defective restoration margin can be detected by probe tip
how is a BPE score of 2 managed ?
OHI, calculus removal, removal of plaque retentive factors, screen in one year
what does a BPE score of 3 mean?
the coloured band on the probe is only partly visible, indication a PPD of 3.5-5.5mm
how is a BPE score of 3 managed?
OHI, scaling and RSD, reassess and repeat scale and OHI at 3 months, if a number of sextants continue to score 3 after treatment then a full perio assessment should be carried out
what does a BPE score of 4 mean?
the coloured band is fully hidden, indicating a PPD of over 5.5mm
how is a BPE score of 4 managed?
full perio assessment, radiographs, OHI, scaling, marginal restoration correction, RSD, consider referral to specialist, full reassessment after treatment and now treatment plan
what does a * mean in a BPE score ?
furcation involvement
why is a full periodontal assessment necessary?
to assess the site specific nature of disease and extent and severity of disease, treatment planning, monitor disease and hygiene therapy, predict likely treatment outcome, medico-legal record
what is included in the full periodontal assessment?
pocket depth, bleeding, suppuration, furcations
how is suppuration detected ?
creamy exudate of fluid and inflammatory cells, associated with bad taste
describe Miller’s mobility index
0 - no mobility 1 mm
III - horizontal and vertical mobility
why may furcation involvement reduce the prognosis of a tooth?
difficult access, loss of vitality due to accessory canals form pulp to furcation area
describe Hamps furcation involvement
F1 - BPE probe eneters 3 mm
F2 - probe enters 5mm
F3 - probe fully passes through the furcation
why is it important to measure gingival recession ?
enables calculation of attachment loss and attachment gain following active treatment
describe the Turesky plaque index?
0 - no plaque
1 - flecks of plaque at the cervical margin of the tooth
2 - a band of plaque less than 1 mm at the cervical margin
3 - a band of plaque wider than 1 mm but covering less than 1/3 of the crown
4 - plaque covering 1/3 but less than 2/3 of the crown
5 - plaque covering 2/3 or more of the crown
when do Stillman’s clefts tend to occur ?
when there is an underlying bone fenestration
what are the 4 main causes of excessive occlusal stress?
parafunction, dental treatment, occlusal disharmony, destruction of periodontal tissues by disease
what are excessive occlusal stresses?
those which exceed the limits of tissue adaptation and therefore cause occlusal trauma
what is occlusal trauma?
an injury of the attachment apparatus as a result of excessive occlusal force
what is primary occlusal trauma ?
the effect of abnormal forces acting on normal periodontal structures
what is secondary occlusal trauma ?
the effect of already reduced or weakened structures, or occlusal forces which may not be normal
what is the response of the periodontium to unilateral forces ?
create pressure and tension zones resulting in hyper mobility, normal with of PDL maintained
what is the response of the periodontium to forces from alternating directions ?
PDL width increases and tooth becomes progressively mobile, when the width of the PDL compensates for the forces the tooth remains hyperbole but this is no longer progressive
describe the association between periodontitis and diabetes
diabetics who have severe periodontitis have higher blood sugar levels than those with no periodontitis
the worse the periodontal disease is the more likely a person will suffer damage to other organs because of their diabetes e.g. heart disease
even if the patient does not have diabetes severe periodontal disease causes reduced blood sugar control than if there was no disease
having periodontal disease may increase the chance of developing type 2 diabetes
what are the effects of pregnancy on the periodontium ?
red swollen gingivae, affects up to 5% of pregnant women mostly between 2nd and 8th months, exacerbation of gingivitis due to effects of progesterone on local vasculature, generalised or localised, pregnancy epulis histopathology of pyogenic granuloma
what other factors can affect the periodontium ?
puberty, the OCP and HRT
how does Chron’s disease affect the periodontium ?
irregular long ulcerations, cobblestone appearance
how does scleroderma affect the periodontium ?
increased PDL width
how does osteoporosis affect the periodontium ?
reduced bone density therefore more susceptible
how does HIV affect the periodontium ?
increased incidence of necrotising conditions
how does severe vitamin C deficiency affect the periodontium ?
swollen bleeding gingivae and hyper mobility
how does phenytoin affect the periodontium ?
drug induced gingival overgrowth occurs in 50% of individuals, variable extent of overgrowth altered by serum levels, OH, mouth breathing, and local factors
how does cyclosporin affect the periodontium ?
gingival overgrowth occurs in 30 % of individuals, more hyperaemic than phenytoin induced gingival overgrowth and bleeds readily on probing, related to dose, OH, serum and salary concentrations
what are the effects of calcium channel blockers on the periodontium ?
drug induced gingival overgrowth in 5-20% of individuals, most commonly associated with nifedipine, weak correlation to dose
how do NSAIDs affect the periodontium ?
inhibit release and synthesis of prostaglandins therefore reduced bleeding, swelling and bone loss
how do chemotherapy agents affect the periodontium ?
increased susceptibility to periodontal destruction and haemorrhage
