Quiz 2 - Chapter 7 & 8 Flashcards
Periodontitis & Other Conditions Affecting the Periodontium
What is Periodontitis
a complex microbial infection that triggers a host-mediated inflammatory response within the periodontium, resulting in progressive destruction of the PDL and supporting alveolar bone.
What does Periodontitis affect?
Periodontitis affects all parts of the periodontium - mainly gingiva, PDL, bone, and cementum.
What is Periodontitis a result of?
a complex interaction between the plaque biofilm that accumulates on tooth surfaces and the body’s efforts to fight this infection.
What is the number one cause of tooth loss in adults?
Periodontitis
Why is periodontitis considered a significant health problem?
Because approximately 47.2% of adults above the age of 30 years suffer from periodontitis.
What does Periodontitis begin as?
Begins as plaque-induced gingivitis (reversible)
What can happen if plaque-induced gingivitis is left untreated?
Gingivitis may progress into periodontitis
Periodontitis is (reversible/irreversible)
Irreversible because loss of attachment
What are the major forms of Periodontitis?
Necrotizing Periodontal Diseases
Periodontitis
Periodontitis as a manifestation of systemic disease
What is the most common age for Periodontitis?
Onset can be at any age but age 35 is most common
Why were the two subgroups of the 1999 Disease Classification of Periodontitis eliminated from the 2017 disease classification?
The two subgroups (chronic periodontitis and aggressive periodontitis) were eliminated because there is little consistent evidence that aggressive and chronic periodontitis are different diseases.
Signs and Symptoms of Periodontitis
Clinical signs and symptoms of periodontitis include swelling, redness, gingival bleeding, periodontal pockets, bone loss, tooth mobility, suppuration, moderate or heavy deposits of plaque biofilms and dental calculus.
Distinguishing features of periodontitis
the presence of alveolar bone loss and clinical attachment loss
What are included with alterations in color, texture, and size of marginal gingiva?
Reddish or Purplish tissue
or
Pale pink tissue
Reddish or purplish tissues in Periodontitis
clinical signs of periodontitis are very evident, gingiva appears swollen, pale red to magenta in color, alterations of gingival contour and form are evident, such as rolled gingival margins, blunted or flattened papillae
What does the clinical appearance of tissue that is pale pink mean with periodontitis?
The clinical appearance of tissues is not a reliable indicator of the presence or severity of perio, gingival tissue may appear pale pink and have an almost normal-looking appearance.
(Periodontitis affects deeper tissue, surface tissue is not a reliable indicator)
Is spontaneous gingival bleeding or bleeding in response to probing common in Periodontitis?
Yes
Is it common in Periodontitis to have increased flow of gingival crevicular fluid or suppuration from perio pockets?
Yes
Plaque biofilm and Calculus deposits in Perio
Mature supra- and subgingival plaque biofilms and calculus deposits
Very complex thick deposits of plaque biofilm on affected root surfaces.
What is Periodontitis initiated and sustained by?
Plaque Biofilms
What determines the pathogenesis and rate of progression of Periodontitis?
Host Factors
A measurement of the amount of destruction affecting tooth-supporting structures that have been destroyed around a tooth.
Clinical attachment loss
Loss of attachment occurs in Periodontitis and is characterized by
- apical migration of JE
- destruction of fibers of the gingiva
- destruction of PDL fibers
- loss of alveolar bone - changes are significant because loss of bone can result in tooth loss.
Clinical attachment loss of ___-___mm at one or several sites can be found in nearly all members of the adult population.
1 - 2 mm
Clinical characteristics of attachment loss may include:
Loss of alveolar bone, periodontal pockets or recession, furcation involvement, tooth mobility and/or drifting
How is the loss of gingival/PDL fibers and alveolar bone detected?
Clinical attachment loss by assessment of the dentition with a periodontal probe as measured from the CEJ
What is the extent of the probe penetration influenced by?
The inflammatory status or the periodontal tissue
What is CAL?
Apical migration of the JE to the tooth root
Contributing Factors that may modify Periodontitis and increase the susceptibility of a patient to the disease
- Environmental factors - smoking
- systemic factors - diabetes or HIV
- genetic factors
- Local Intraoral factors - tooth crowding or overhanging margins
Symptoms of Periodontitis
*Usually Painless* Gums bleed when brushing, spaces occur between teeth, teeth have become loose, food impaction, sensitivity to hot or cold due to exposed roots, or dull pain radiating into the jaw.
What may be regarded as a risk factor for periodontitis?
Gingivitis
When does gingivitis manifest
only after days or weeks of plaque biofilm accumulation
In most cases, how long of plaque biofilm and calculus exposure does periodontitis require to develop?
Longer periods, Years
The prevalence and severity of Periodontitis increases with
Age
Warning signs of Periodontitis
red or swollen gingiva, bleeding during brushing, bad taste in mouth, persistent bad breath, sensitive teeth, loose teeth, and pis around teeth and gingiva.
Why do is it that some patients do not see treatment early and do not follow through with treatment after diagnosis with periodontitis?
With periodontitis, pain is usually not a symptom
Progression in untreated periodontitis is usually a (continual & slow / rapid) process.
continual and slow - moderate
Can periods of remission or exacerbation with Periodontitis occur?
Yes
Does tissue destruction in untreated periodontitis affect all teeth evenly?
NO
can be site specific
Rapid progression of periodontitis occurs more frequently in what areas?
Interproximal areas and may be associated with areas of greater plaque biofilm accumulation, specific subgingival pathogens, and inaccessibility to plaque biofilm control measures (sites of malposed teeth, restorations with overhanging margins, areas of food impaction, deep perio pockets, and furcation areas)
In a limited number of people, there is rapid progression that is
4x typical of destruction of PDL and bone
The distribution of the disease throughout the entire oral cavity; thought of as the degree to which the disease has spread
Extent
Extent is characterized based on
percentage of affected teeth
localized or generalized
What is the desired outcome of periodontal therapy?
To stop the progression of the disease to prevent further attachment loss
What is a best predictor of future disease occurrence?
Previous disease experience
What are good predictors of future disease occurrences?
The number of sites of attachment loss, bone loss, and/or deep pockets.
Refers to the change or advancement of periodontal destruction
Disease progression
Loss of attachment in Grade C periodontitis progresses _________ than in cases of typical disease progression
3-4 times faster
Can some disease sites remain unchanged for long periods of time with Periodontitis?
YES
Therapeutic endpoints of Periodontal therapy
- elimination of microbial etiology and contributing factors that perpetuate periodontal inflammation
- preservation of the state of the teeth and periodontium in a state of health, function, and stability
- prevention of disease reoccurrence.
Therapeutic Goals of Periodontal therapy
Reinforcing daily self-care; periodontal instrumentation to remove microbial etiology; elimination of local intraoral factors; periodontal surgery if there is still persistent periodontal inflammation following nonsurgical therapy; and adherence to a PM regimen.
T/F
In some cases, periodontitis treatment that is not intended to attain optimal results may be warranted?
True
Treatment that is not intended to attain optimal results
Compromised Periodontal Maintenance
Compromised Periodontal Maintenance patients
patients who have a serious health condition, poor motivation/compliance, advanced age, or severe periodontal disease.
The end point for a severely reduced periodontium
Compromised maintenance
Return of destructive periodontitis that had been previously arrested
Recurrent form on Periodontal Disease
Anyone with a prior history of disease and who has noncompliant self and professional care is at risk for
Recurrent Periodontal Disease
What much the patient and practitioner refocus their attention on with recurrent periodontal disease?
Arresting the disease and establishing patient adherence to perio treatment, meticulous self-care, and frequent professional maintenance
Periodontitis in a patient who has been monitored over time and who exhibits continued attachment loss despite conditions like the patient receiving appropriate and continuous professional periodontal therapy, satisfactory self-care, and the patient follows the recommended program of PM visits.
Refractory Periodontal Disease
Etiology of Refractory Periodontal Disease
Unknown, but may be due to a complexity of unknown factors such as the emergence of opportunistic pathogens or compromised host response to the bacterial attack
Periodontal Therapy for refractory Periodontal Disease
should slow down and control the progression since it does not respond favorably to conventional therapy
Treatment for Refractory Periodontal Disease
Includes, but not limited to, pt. education and behavior modification, perio instrumentation, antibiotics, removal of periodontally hopeless teeth, correction of restorations that may be contributing to plaque retention, surgical therapy, and strict adherence to a PM regimen
Periodontitis Case Definition System
Interdental CAL is detectable at 2 or more nonadjacent teeth
OR
Facial or Lingual CAL of 3mm or more with pocketing of more than 3mm at 2 or more teeth
CAL can not be caused from non-periodontitis causes, such as recession, caries extending to or apical of CEJ, distal of 2nd molar associated with malposition/extraction of 3rd molars, endodontic lesion draining through marginal gingiva, and vertical root fractures.
The study of the pathological manifestations of periodontitis
Pathophysiology
Pathophysiology does not deal directly with the treatment of disease, rather it does what?
Explains the processes within the body that result in the signs and symptoms of periodonititis
3 clearly different forms of periodontitis that have been identified based on pathophysiology
- Necrotizing Periodontitis
- Periodontitis as a direct manifestation of systemic diseases
- Periodontitis
Stage of Periodontitis Severity: 1-2 mm CAL RBL coronal to 1/3 of root No tooth loss due to Perio Complexity: Maximum probe depth 4mm Mostly horizontal bone loss
Stage 1 - Initial stage
Stage of Periodontitis Severity: Interdental CAL 3-4mm RBL extending to coronal 1/3 of root No tooth loss due to Perio Complexity: Maximum probe depth 5mm Mostly horizontal bone loss
Stage II Periodontitis - Established Periodontitis
Stage of Periodontitis Severity: Interdental CAL 5+mm RBL extending to Mid-third of root and beyond Tooth loss from Perio 4 or less Complexity: Maximum probe depth 6mm+ Class II or III furcation involvement Vertical Bone Loss 3mm+ Moderate alveolar ridge defect that complicates implant placement
Stage III Periodontitis - Severe Periodontitis
Stage of Periodontitis Severity: Interdental CAL 5+mm RBL extending to Mid-third of root and beyond Tooth loss from Perio of 5+ Complexity: Maximum probe depth 6mm+ Class II or III furcation involvement Vertical Bone Loss 3mm+ Moderate alveolar ridge defect that complicates implant placement Masticatory dysfunction Secondary occlusal trauma Tooth mobility >Class II Bite collapse Drifting Flaring of teeth <20 teeth remaining
Stage IV Periodontitis - Advanced Periodontitis
GRADE:
No evidence of CAL or radiographic bone loss over a 5-year period
Heavy biofilm deposits with low level of tissue destruction
Modified by nonsmokers and normoglycemic patient
Grade A - Slow Progression
GRADE:
Less than 2 mm CAL or radiographic bone loss over a 5-year period
Tissue destruction in line with expectations given amount of biofilm deposits
Modified by smoking less than 10 cigarettes a day
HbA1c of less than 7% in patients with diabetes
Grade B - Moderate Progression
GRADE:
2 mm or more of CAL over a 5-year period
Tissue destruction exceeds expectations given the amount of biofilm deposits
Modified by smoking 10 or more cigarettes in a day
HbA1c of 7% or greater in patients with diabetes
Grade C - Rapid Progression
Observation available with older diagnostic radiographs
Direct evidence
Assessment of bone loss at worst affected tooth as function of age - biofilm tissue destruction
Indirect evidence
Normal HbA1c
below 5.6%
Periodontal Diagnosis includes
- Confirmation of perio case based on detectable CAL at 2 nonadjacent teeth
- Is NP, Perio as manifestation of systemic disease, or Periodontitis
- Description of presentation and aggressiveness by stage and grade
Only differences between Stage III and Stage IV Periodontitis
- Tooth loss of 5+ teeth due to Periodontal Disease
- Max. probe depth 6mm+
- Masticatory dysfunction
- Secondary occlusal trauma
- Severe ridge defect of bone
- bite collapse, drifting, flaring of teeth
- less than 20 remaining teeth (10 opposing pairs)
Localized Tissue Death
Tissue Necrosis
Why might NG, NP, and necrotizing stomatitis represent different stages of the same disease?
They have similar etiology and clinical characteristics
3 typical clinical features of Necrotizing Periodontal Diseases
- tissue necrosis
- spontaneous bleeding
- pain
A broad category of inflammatory destructive infections of the periodontal tissues that is characterized by tissue necrosis.
Necrotizing Periodontal Diseases
Tissue necrosis limited to gingival tissues
Necrotizing gingivitis
Tissue necrosis of gingival tissues combined with loss of attachment and alveolar bone loss in days - Rapid and destructive
Necrotizing periodontitis
Severe tissue necrosis that extends beyond the gingiva to other parts of the oral cavity (tongue, cheek, palate)
Necrotizing stomatitis
All forms of necrotizing periodontal diseases are painful infections characterized by
tissue ulceration
swelling and sloughing of dead epithelial tissue
fetid oral odor
Trench Mouth Vincent infection ANUG NUG NUP
Necrotizing Periodontal Diseases AKA
Why was the terminology “ulcerative” later eliminated?
Ulceration is secondary to the tissue necrosis that characterized NPD
Why do necrotizing periodontal diseases belong in a separate category than periodontitis?
They are clinically noticeably different
NPDS with Sudden onset, pain, necrosis of interdental papillae, pseudomembrane, fiery red gingiva with spontaneous bleeding
NG
NPDS with Sudden onset, pain, necrosis of or ulcerative interdental papillae within a few days, pseudomembrane, fiery red gingiva with spontaneous bleeding, and attachment and bone loss - “Punched out” or “cratered” interdental papillae
NP
*once craters form, PDL and bone become destroyed resulting in LOA
Yellowish white or gray tissue slough that covers gingiva - wipe off and expose fiery red hemorrhagic gingiva
Pseudomembrane
Is pseudomembrane considered a true membrane?
No
The necrotizing lesions develop rapidly and are _____
painful
The first necrotizing lesions are often seen
interproximally in the mandibular anterior sextant but may occur in any interproximal papilla.
Usually develop a rounded contour.
Necrotizing Periodontal Disease includes evidence of
materia alba, plaque biofilm, sloughed tissue, blood, stagnant saliva, excess salivation with fetid odor, and excessive oral pain
Why is it common to see patients who do not brush or eat with NPD?
Because of excessive oral pain
Systemic signs and symptoms of Necrotizing Periodontal Disease
Swollen lymph nodes (cervical and submandibular)
and in SEVERE cases, fever, malaise, increased pulse rate, and loss of appetite
Etiology of Necrotizing Periodontal Disease
Compromised host immune response - a critical component because both NG and NP appear to be related to diminished host response to bacterial infection.
Predisposing factors to Necrotizing Periodontal Disease
- Poor self-care
- emotional stress
- inadequate sleep, fatigue
- alcohol use
- caucasian
- cigarette smoking (most pts w/NPD are smokers)
- increased levels of personal stress
- poor nutrition
a. College students
b. young children in developing countries b/c poor nutritional status, esp. low protein intake - Pre-existing gingivitis or tissue trauma
- Young age - typically 22-24 years old
What to recommend with NP
protein drink, home care, smoking cessation, fluid intake
NP characteristics
ulcerated necrotic papilla poor gingival margins sloughing pseudomembrane layer
Abscess characterized by no bone loss, results from injury to or infection of surface gingival tissue.
Gingival Abscess
When can a periodontal abscess happen?
after SRP; when infection spreads into deep pockets and drainage is blocked
Pain can occur until root canal in some cases
Abscess that develops in inflamed dental follicular tissue, overlying the crown of a partially erupted tooth - does NOT show up on radiographs
Peri-coronal abscess
A significant alteration of the morphology, size, and relationship between the gingiva and alveolar mucosa that may involve underlying bone
Mucogingival Deformity
Localized tooth-related factors that may increase the risk of developing gingivitis and periodontitis, or exacerbate these conditions
Gingival recession Lack of attached gingiva Frenum position and "pull" Enlarged/excessive gingiva Occlusal trauma
Most common mucogingival deformity
gingival recession
Apical displacement of gingival margin with respect to the CEJ associated with attachment loss with root exposure
gingival recession
Common place for gingival recession
lower anteriors and around premolars
Risk factors associated with gingival recession
think periodontal biotype, absence of attached gingiva, reduced thickness of alveolar bone due to abnormal positioning in the arch
Common area for tension of a frenum
lower anterior
Traumatic Occlusal Force that includes greater than normal forces placed on teeth - bruxism
Primary occlusal trauma
Traumatic Occlusal Force that includes normal or excessive forces placed on teeth with compromised periodontal attachment.
Secondary occlusal trauma
Traumatic Occlusal Force that includes dragging teeth too quickly, fast bone resorption
Orthodontic forces
*teeth should only move 1 to 1.5mm every 4-5 weeks
Factors that predispose to plaque biofilm retention and exacerbate the condition following onset of disease
Ortho appliances
faulty restorations
dental prosthetics
tooth anatomy factors
Tooth anatomy factors that predispose to plaque biofilm retention and exacerbate the condition following onset of disease
Cervical enamel projections:
Enamel pearls
palatolingual grooves
tooth malalignment
The absence of diseased state, such as gingivitis, periodontitis, and gingival recession
Normal Mucogingival Condition
individual differences in gingival anatomy and morphology
Periodontal biotype
3 categories of periodontal biotypes
- Thin scalloped
- Thick flat
- Thick scalloped
The most widely followed and most widely accepted classification system for recession of the gingival margin
Miller Classification System
Classification system that classifies gingival recession into four classes and is not as reliable and has not been tested in clinical setting
Miller classification system
Miller classification that includes marginal tissue recession that does not extend to MGJ, no periodontal loss in interdental area and 100% root coverage
Class I
Miller classification that includes marginal tissue recession, extends to or beyond the MGJ, No periodontal loss, 100% root coverage
Class II
Miller classification that includes marginal tissue recession extending to or beyond MGJ, Bone or soft tissue loss or malpositioning of teeth, partial root coverage
Class III
Miller classification that includes marginal tissue recession extending to or beyond the MGJ, bone or soft tissue loss and/or malpositioning or teeth so severe that root coverage cannot be anticipated.
Class IV
Classification system for gingival recession that has been proposed and is based on the CAL measurements at both buccal and interproximal sites. Most reliable gingival recession classification system used in clinical practice. Has 3 types.
Cairo Classification System
