Peter Pascoe Flashcards
What is the definition of Gingivitis?
Gingivitis is an inflammatory condition of gingival tissue. It’s mainly caused by the accumulation of dental plaque in healthy adults, with several local and systemic factors contributing to the development of gingivitis through various cellular and molecular processes. Specifically, This condition is characterized by redness, swelling, and bleeding of the gums, but does not involve loss of attachment of the periodontium (periodontal ligaments or alveolar bone)
Describe systematically and sequentially the process of plaque-induced gingivitis -> how does biofilm lead to inflammation of the gingival tissues.
Biofilm Formation (Plaque Accumulation): Within hours of cleaning, a pellicle forms on enamel, allowing bacteria (e.g., Streptococcus) to adhere and create biofilm, particularly near the gingival margin.
Initial Lesion (2-4 Days): The body responds to plaque with an immune reaction. Neutrophils infiltrate the gingival tissue, increasing blood flow, though inflammation is not yet visible.
Early Lesion (4-7 Days): Plaque accumulation continues, prompting lymphocyte infiltration and tissue degeneration. Early signs of gingivitis appear, such as redness and swelling.
Established Lesion (14-21 Days): The inflammation escalates, with plasma cells and thickened epithelium present. Clear signs of gingivitis include redness, swelling, and bleeding, but the condition is still reversible.
Advanced Lesion (If Untreated): Untreated gingivitis may progress to periodontitis, causing irreversible damage to bone and periodontal ligaments.
How many days does it take to have established gingivitis?
- Gingivitis can become established within 14-21 days of consistent plaque accumulation. During this time, biofilm formation and the body’s inflammatory response escalate to the point where clinical signs of gingivitis are visible.
- If all plaque is removed: Within 24 hours, the bacterial load is significantly reduced, and the inflammatory response starts to decrease.
- After 7-10 days, the clinical signs of gingivitis, such as redness and swelling, usually resolve. The junctional epithelium regenerates, and the immune system clears out inflammatory cells.
- Within 14 days, the gingival tissues typically return to a healthy state, provided no new plaque forms.
What are the Key Cellular & molecular inflammatory and immunological processes involved in Gingivitis
In gingivitis, plaque formation initiates the immune response, as bacterial colonization on the tooth surface triggers the release of cytokines like IL-1, IL-6, and TNF-α, which mediate inflammation. Neutrophils (PMNs) are recruited to the junctional epithelium via chemokines like IL-8, releasing proteolytic enzymes and reactive oxygen species, contributing to tissue inflammation. As the condition progresses, T-cells and B-cells infiltrate the gingival tissues, with plasma cells producing antibodies against bacterial antigens. Matrix metalloproteinases (MMPs), especially MMP-8, degrade the extracellular matrix, further driving inflammation. The increase in gingival crevicular fluid (GCF), rich in immune cells and cytokines, flushes out bacterial toxins, while vascular changes like increased permeability and vasodilation cause redness, swelling, and bleeding. These cellular and molecular processes underlie the inflammatory and immunological mechanisms in gingivitis.
Peter’s gingival tissues are red, swollen and have bleeding on probing. Discuss the host response and the tissue changes associated with these 3 signs of gingivitis.
Red: Inflammatory response to bacteria => Vasodilation due to vasoactive chemicals released => Increased blood flow => redness
Swollen: Inflammatory mediators released (eg: histamine by mast cells) increase in capillary permeability => immune cells, fluid, and plasma proteins accumulate => edema
BOP: Tissue necrosis factor released during inflammation => matrix metalloproteinases & inflammatory mediators released => Collagen degredation => fragile blood vessels that bleed easily under slight probing/pressure
Is there any benefit in Peter using an antibacterial mouthrinse eg Curasept 0.2% 2x day for 2 weeks? If Yes, why? If No why not?
Yes:
1) Chlorhexidine binds to negatively charged cell walls of bacteria ⇒ Disruption of bacterial membrane ⇒ Leakage of cellular contents ⇒ bacterial cell death ⇒ reduce bacterial load in oral cavity
2) Plaque inhibition ⇒ Prevents formation & adherence of plaque on tooth surfaces by inhibiting initial colonization of bacteria on dental surfaces ⇒ gingivitis & periodontitis
3) Even with just short-term dosage (2 wk), has long lasting effect because chlorhexidine exhibits substantivity ⇒ Binds to oral tissues & released slowly over time ⇒ Prolonged antimicrobial activity even after product used
Describe the key Signs of early caries
a. Buccal surface incipient caries:
White spot lesions are the most common early sign. These appear as chalky or opaque spots on the smooth buccal enamel surface, indicating demineralization.
b. Proximal surface incipient caries:
Radiographic detection is typically required as these lesions are often hidden between teeth. Early lesions appear as faint radiolucencies on a bitewing radiograph, indicating demineralization between adjacent tooth surfaces.
c. Occlusal surface incipient caries:
Chalky white demineralized areas or small, opaque discolorations within the pits and fissures of the occlusal surface. These lesions can be difficult to detect visually due to the anatomy of the tooth.
Why are there are no symptoms associated with early caries (incipient caries)?
There are various Preventive approaches to manage active incipient caries lesions in general and in Peter Pascoe’s situation. Is there any benefit in Peter using CPP-ACP? If Yes, why? If No why not?
Yes, there is a benefit for Peter to use CPP-ACP (casein phosphopeptide-amorphous calcium phosphate). CPP-ACP can help remineralize early incipient caries by delivering bioavailable calcium and phosphate ions to the demineralized enamel, enhancing the natural repair process and preventing further progression of the lesion. It can stabilize these ions at the tooth surface, aiding in enamel repair, which is particularly beneficial for managing active early caries non-invasively.
What is Transillumination?
Transillumination:
- passing a high-intensity and narrowly-focused light through teeth to detect changes in structure through patterns of scattering and light absorption
- Demineralisation - caries have lower index of light transmission and absorb the light - darker and easily detected in contrast to light enamel
o Enamel lesions = grey shadow, o Dentinal lesions = orange-brown/bluish shadow
What are the indications/contraindications and advs/disadv for this diagnostic method for caries detection?
Indications of transillumination for early caries detection include its ability to identify early lesions on anterior teeth or interproximal surfaces, which are challenging to assess visually. This method is particularly helpful when bitewing radiographs are contraindicated, such as with young children or patients with special needs who may have difficulty cooperating. Transillumination is also excellent for monitoring the progression of demineralization and the effectiveness of remineralization treatments. It is useful for detecting cracks and fractures in teeth as light scattering highlights these areas, providing more detailed information for diagnosis.
However, there are a few contraindications that limit the use of transillumination. Thick restorations, such as metal crowns or amalgam fillings, block light transmission and make this method ineffective in those areas. Similarly, extensive decay or intrinsic staining that has compromised a large part of the tooth structure can interfere with light transmission, making it difficult to interpret the results. These factors reduce the applicability of transillumination in some cases, particularly when the tooth’s integrity has been severely affected.
Despite these limitations, transillumination has several advantages in clinical practice. It allows for the early detection of lesions that may not yet appear on radiographs, providing immediate feedback and the opportunity to implement preventive measures. The device is small and portable, allowing for flexible use and 3D visualization of lesion sites and depths. As a radiation-free technique, it eliminates the risks associated with radiographic imaging, making it safe for repeated use. Being non-invasive, it is comfortable for patients and time-efficient. However, its effectiveness is operator-dependent, as success relies on the clinician’s skill in interpreting light patterns, and its utility can be reduced by restorations or extensive decay.
Why are BWs the most appropriate type of radiograph to take as a diagnostic tool?
Compared to panoramic radiography, bitewing (BW) radiographs offer superior sensitivity in detecting dental caries, particularly in the interproximal spaces, which are difficult to examine clinically. They are also more affordable, with two BWs costing approximately $100 compared to $150 for a panoramic image, making dental care more accessible. BWs provide an optimal view of the crown, allowing for the detection of caries, restorative issues, and early signs of alveolar bone deterioration related to periodontal health. Although bitewings focus more on detecting caries, they cover a significant portion of the tooth, offering a high diagnostic yield without capturing the root structures, which are better assessed with periapical radiographs.
What are the limitations of radiographs in caries diagnosis?
Bitewing radiographs have several limitations. They may fail to detect early-stage caries that haven’t progressed enough to be visible on x-rays, and they tend to underestimate lesion progression. Due to their 2D nature, it can be difficult to distinguish between occlusal, palatal/lingual, or buccal caries. Additionally, the exposure to ionizing radiation, although low, carries risks such as genetic mutations and radiation-induced cancer, especially with repeat exposure. Bitewings also have low sensitivity if lesions aren’t located within the beam, and they can be challenging for certain populations, such as children and individuals with a strong gag reflex, affecting the quality of the image. Furthermore, BWs are not suitable for detecting anterior teeth caries, where transillumination and visual inspection are preferred.
There are several options for Peter in the use of F at home. What are these and what is the aim in suggesting these options in aiding remin?
- water
- toothpaste
- tooth mousse
Topical F application on incipient caries eg., MI Varnish is an option for Peter. What is the rationale for the use of Prof topical F for Peters’ clinical situation?
The rationale for using topical fluoride application, such as MI Varnish, in Peter’s case is to enhance the remineralization of his incipient caries. Fluoride helps to strengthen the enamel by promoting the formation of fluorapatite, which is more resistant to acid attack than hydroxyapatite, the natural form of enamel. This process can reverse early caries by increasing enamel resistance to demineralization and reducing the activity of cariogenic bacteria. Additionally, fluoride helps to inhibit the loss of minerals from the tooth surface and enhances the deposition of calcium and phosphate into the enamel, thereby arresting the progression of incipient lesions and potentially avoiding the need for more invasive treatments.
