Spectrum of Perio Disease Flashcards
chronic periodontitis
what level in pedigree?
characterized by?
**II
infectious disease resulting in inflammation within the supporting tissues of the teeth, progressive attachment loss and bone loss
characterized by pocket formation and or gingival recession
variable in age and severity
most frequently occurring form of periodontitis
primary etological factor for periodontitis?
PLAQUE – initiator but HOST RESPONSE (inflammation mounted) are responsible for the MAJORITY of the loss we are seeing
clinical features and characteristics of chronic gingivitis?
what is a frequent finding in chronic periodontitis?
amount of destruction is consistent with the presence of local factors
slow to moderate rate of progression but can have periods of rapid progression
subgingival calculus is a common finding
most prevelant in adults, but can occur in children and adolescents
severity / destruction of perio is consitant with what?
the presence of local factors
how is chronic perio modified? what can it be associated with?
associated with – local predisposing factors (tooth -related or iatrogenic factors)
- modified/associated with systemic diseases like diabetes or HIV infection
- factors like smoking and emotional stress can also modify this
biggest environmetnal factor for perio?
SMOKING
Extent and severity in chronic perio characterized by what two things?
localized or generalized
localized?
if less than or equal to 30% of sites affected
generalized
if more than 30% of the sites are affected
refractory perio or recurrent perio?
cannot separate these but recurrent = represents a return of periodontitis and is NOT a separate disease entity
refractory = for identifiable and non-identifiable reasons, bot all cases of perio have successful tx outcomes
severity is categorized by?
basis of the amount of clinical attachment loss
levels of CAL
correlated to?
correlated to the CEJ
slight = 1- 2mm of CAL
moderate = 3-4 mm of CAL
severe = >or equal to 5mm CAL
aggressive perio AKA
early-onset perio
describe localized aggressive perio
*attachment loss usually in first molar and incisor
- circumpubertal onset
- robust serum antibody response to infecting agent s
- localized first molar/incisor presentation with interproximal attachment loss on at least two permanent teeth, one of which is a first molar, and involving no more than two teeth other than first molars and incisors
generalized aggressive perio
- usually affecting persons under 30 yesrs of age, but patients may be older
- poor serum antibody response to infecting agents
- pronounced episodic nature of the destruction of attachment and alveolar bone
- generalized interproximal attachment loss affecting at least three permanentn teeth other than first molars and incisors
category of aggressive perio?
Category III
aggressive perio term replaces what?
early onset periodontal disease / localized juvenile/ generalized juvenile
what separates aggressive perio from chronic?
- except for presence of periodonitis; patients are otherwise clinically healthy in aggressive
- rapid attachment loss and bone destrcution
- familial aggregation
secondary aggressive perio features
- microbial deposits are inconsistent with severity of perio tissue destruction
- elevated levels of AGGREGATIBACTOR ACTINOMYCETEMCOMITANS and in some populations porphyromonas gingivalis may be elevated
- phagocyte abnormalities
- hyper-responsive macrophage phenotype including elevated levels of PGE2 and IL-1b
- progression of attachment loss and bone loss may be self-arresting
primary ‘culprite’ for localized aggressive perio?
elevated levels of AGGREGATIBACTOR ACTINOMYCETEMCOMITANS and in some populations porphyromonas gingivalis may be elevated
T/F all characterisitcs must be present to asign a diagnosis or classify the disease?
FALSE
- diagnosis may be based on clinical, radiographic, and historical data
category IV is?
periodontitis as a MANIFESTATION OF SYSTEMIC DISEASE
- usually cannot mount a response to the bacteria present and destruction is due to bacteria having ‘free range’
3 characteristics/groups of perio as manifestation of systemic disease
A) associated with hemtological disorders
B) Associated with Genetic disorders
C) non-otherwise specified
Associated with hematological/ blood disorders in perio as manifestation of systemic disease
- acquired neutropenia
- leukemia
- other
acquired neutropenia
lower white blood cells so low levels of PMN’s and are first responders - so if do not have bacteria invade
rare and is an autoimmune against neutrophil-specific
Leukemia
white blood cells are immature
so immature cells cannot manifest response
ulceration and necrosis
what is common between all these?
all have or are characterized as severe periodontitis – manifestations same
perio associated with genetic disorders?
look at slide and know these manifest the same but causes are different
normal neutrophil cound
5000-10,000 cells/mm3
neutropenia level od wbc’s
less than 2,000 cells/mm3
agranulocytosis level
less than 500 cells/mm3
Leukpocyte Adhesion Deficinecy
not producing the adhesion but have plenty of white blood cells - cant deal with bacterial inection
Trisomy 21
associated with severe periodontitis
Papillon Lefevre syndorm
palmar/ plantar keratosis – LARGE calices that form on hands and feet and severe periodontal destruction and starts in primary and can effect the permanent
familial chronic benign neutropenia
disroder of inheretence in decreased neutrophul count, but overall low risk of infection
cyclic neutropenia
disease of unknown etilogy characterized by a regular 7-day period of depressed neutrophil count
oral manifestations of congenital neutropenias include?
oral mucosa ulceration, severe gingivitis, and periodontitis that can affect both primary and permanent dentitions, leading to premature exfoliation of teeth
Ehler’s danlos syndrome
types that are susceptible to perio?
connective tissue disorder that are characterized by defective collagen synthesis
articular hypermobility, dermal hyperplasticity, and widespread tissue fragility
types IV and VIII have increased
- fragile oral mucosa and blood vessels
- clinical appearance of generalized early-onset periodontitis, leading to premature loss of permanent teeth
category V?
necrotizing periodontal disease
breakdown of necrotizing periodontal disease?
- nectrotizing ulcerative gingivitis (NUG)
- Necrotizing ulcerative periodontitis (NUP)
decrease in host response
only difference is difference b/w gingivitis and perio
- loss of attachment levels differs
general description of necrotizing periodontal disease
acute, necrotizing (causing tissue death), ulcerating (causing open sores) form of gingivitis
also causes pain in the affected ares
fever and fatigue may be present
pain can become very bad and eating and swallowing become difficult - inflammation and infection can spread to nearby tissues of the face and neck
main cause of necrotizing periodontal disease
1. frequent poor oral hygeine = main cause also - stress - unbalance diet - lack of sleep
are NUG and NUP separate disease categories?
NO
only difference b/w NUG and NUP?
NUG - limited to gingiva
NUP- there is attachemnt apparatus loss
describe NUP
see attachment loss **
describe NUG
- gingival necrosis presenting as ‘punched-out’ papillae with gingival bleeding and pain
bad breathe and pseudomembrane formationo can be present
describe NUG
- gingival necrosis presenting as ‘punched-out’ papillae with gingival bleeding and pain
bad breathe and pseudomembrane formation can be present
fusiform bacteria, prevotella intermedia, and spirochetes have been associated with gingival lesions
predisposing factors = emotional stress, poor diet, cigarette smoking and HIV infection
describe NUP
see attachment loss **
necrosis of gingival tissues, periodontal ligament, and alveolar bone
these lesions are most commonly observed in individuals with systemic conditions like HIV infection, severe malnutrition, and immunonsupression
could be result or sequel of single or multiple episodes of NUG or may be result of the occurence of necrotizing disease at a previously periodontitis-affected site
category VI?
Periodontal Abscess
Periodontal Abscess
- primarily based on location of the infection
- can be associated with pain, swelling, color change, tooth mobility, extrusion, purulence, sinus tract formation, fever, radiolucency to affected bone, lymphadenopathy
classification of Periodontal Abscess and the three categories
primarily based on location of the infection
- gingival abscess
- periodontal abscess
- pericoronal abscess
definition of abscess
localized purulent inflammation of the periodotnal tissues.
also known as lateral periodontal abscess or parietal abscess
can be acute or chronic
acute abscesses
are painful, edematous, red, shiny, ovoid, with elevations on gingival margin and/or attached gingiva – after the purulent is partially exuded – become chronic
chronic abscess
may produce dull pain and may at tImes can become acute again
What would you call a localized purulent infection that involves the marginal gingiva or interdental papilla?
acute gingival abscess
periodontal abscess
occur with?
more common in?
a localized purulent infection within the tissues adjacent to the periodontal pocket that may lead to the destruction of periodontal ligament and alveolar bone
occur with pre-existing periodontitis – and the acute infection occurs in the walls of the periodontal pockets as a result of the invasion of bacteria into the periodontal tissues
more common in patients with systemic disease like diabeted, where there is already a reduced ability to combat infections
T/F abscess can occur a few days after dental cleaning as a result of mechanical disruption of junctional epithelium, allowing the bacteria to gain entrance into the tissues
TRUE
bacteria composition of periodontal abscess - general
bacteria in abscess are similar composition to what is found in periodontal pockets
they are termed ‘mixed anaerobic infections” due to the microbial findings
tx of perio abscesses
importance
- purpose of acute = alleviate pain, control spread of infection and to establish drainage
- drainage – established through the pocket or by means of an incision from the outer surface
they are very destructive! so if not treated promptly = can result in irreversible damage to surrounding periodontium and can cause exfoliation of the tooth
remove pocket lining and thoroughly scale and root planing to remove plaque and calculus adhering to the root surface
antibiotics will be helpful
guided tissue regeneration / osseous surgery may be indicated as recurrence of abscess can occur
tx of choice for chronic perio abscess
by a flap procedure
pericoronal abscess
a localized purulent infection within the tissue surrounding the crown of a partially erupted tooth
pericoronal abscess symptoms
painful, swollen, gingival tissue in the area of the affected tooth - can be difficult to bite down confortably without catching the swollen tissue between the teeth
bad smell
discharge of pus
common cause/ location of pericoronal abscess
partial eruption of a 3rd molar can create a flap of soft tissue adjacent to the tooth
the flap can trap food particles and debris and can turn into a nidus of infection
Pericoronal abscess treatment
usually surgically removed after a course of antibiotic therapy in order to prevent painful episodes
note the retromolar mass tissue granulation
category VII?
Periodontitis in combination with endodontic lesions
perio-endo lesions -general
lesions due to inflammatory products found in varying degrees in both periodontium and the pulpal tissues
both tissues are ectomesenchymal in origin and anatomical connections remain through development
NOT based on initial etiology - but just indicated there is BOTH periodontic and ann endodontic component
explain how perio-endo lesions occur?
tubular communication between the pulp and periodontium may occur when dentinal tubules become exposed to the periodontium by the ABSENCE OF OVERLYING CEMENTUM
- these are the pathways that provide pathological agents to pass between tghe pulp and periodontium
clinical findings of perio in combination with endodontic lesions
infections of perio or endo origin may result in increased periodontal probing depths adjacent to the root surface, swelling, bleeding on probing, suppuration, fistular formation, tenderness to percussion, increased tooth mobility, angular bone loss, and pain
symptoms in perio in combo with endo lesions usually due to what?
plaque-associated periodontitis which begins at the margin of the gingiva and spreads apically
how does the endo lesion show the clinical signs of perio in combo with endo lesion?
by the endodontic infections that enter the periodontal ligament AT APICAL FORAMEN or through lateral or accessory CANALs and proceed CORONALLY
treatment / resolution to perio in combo with endo lesion?
what does this not help?
endodontic therapy may lead to complete resolution UNLESS the signs and symptoms are due to root fracture
prognosis of perio-endo lesions
usually poor/ hopeless if true combined lesion especially if perio lesions extensive with a lot of attachment loss
Pallative perio tx and RCT carried out – then root amputation, hemisection, or separation may allow root configuration to be changed for saving the tooth ; perio surgery
prognosis could be increased with bone grafts or guided tissue regeneration - but these decision based on tooth response to other conventional tx
I-VIII classification of periodontal diseases
I- II- III- IV V VI VII VIII
category VIII
Development or Inherited Conditions
Development or Inherited Conditions breakdown (4)
A- localized tooth-related factors that modify or predispose to plaque-induced gingival disease/periodontitis
B- Mucogingival deformities and conditions around teeth
C- Mucogingival deformities and conditions on Edentulous ridges
D- occlusal trauma
localized tooth-related factors that modify or predispose to plaque-induced gingival disease/periodontitis
part of classification of VIII- development or inherited conditions
- tooth anatomic factors
- dental restorations or appliances
- root fractures
- cervical root resorption and cemental tears
tooth related factors (that can bea result of a tooth tx) may contribute to the initiation of periodontal disease
what do localized tooth-related factors that modify or predispose to plaque-induced gingival disease/periodontitis etiology
etiology STILL BACTERIAL - factors that enhance bacterial accumulation or allow the ingress of bacteria into the periodontium should be considered in the classification of perio disease
more site specific problems that require tx in an otherwise intact periodontium
localized tooth-related factors that modify or predispose to plaque-induced gingival disease/periodontitis seperate disease entitiy?
NO - but may serve as localized predisposing and/or modifying factors in the onset or progression of plaque-induced gingival diseases and periodontitis
CONDITIONS CAN BE RELEVANT TO ANYOF THE GINGIVAL OR PERIO CLASSIFICATIONS
cervical enamel projections and enamel pearls are?
associated w/ tooth anatomy that have been associated with attachment loss in molar furcation areas
tooth anatomic factors associated with localized tooth-related factors that modify or predispose to plaque-induced gingival disease/periodontitis - which is classification of Category VII (Development or inhereted conditions)
cervical enamel projections - describe
flat, ectopic deposits of enamel apical to the normal CEJ level in molar furcation areas
these enamel deposits usually have a triangular shape and a tapering form , extending apically into the furcation areas
enamel pearls - describe
larger, spheroid -shaped ectopic deposits of enamel that can also located at furcation or other root surfaces of molars
percentage and location of cervical enamel projections
approx. 15-24 % of mandibular molars and 9-25% of maxillary molars have cervical enamel projections
most likely to be found on buccal surfaces o second molars
percentage and location of enamel pearls
between 1-5.7% among all molar teeth with maxillary third molars most frequently affected
mandibular third and maxillary seconf molars are next most common areas
less frequent = maxillary first and mandibular second
what is strongly assocaited with cervical projections and enamel pearls?
presence of furcation involvement
- due to the fact that when present in their locations- prevents connective tissue attachment - so predisposed to periodontal breakdown in these areas – a contributing etiologic factor in tissue breakdown at furcation sites
furcation anatomy and location?
classification of perio disease?
extension of inflammation apically and horizontally
do NOT require special consideration in classification of periodontal diseases
tooth position
position or inclination can be factors that predispose the periodontium to plaque accumulation and subsequent inflammation
** if meticulous oral hygein and maintaing good oral health is essential if do not want the increased effect
root proximity? risk factor?
proximity of the roots of adjacent teeth is widely held as a risk factor for development of periodontal disease
impedes on professional and self-preforming plaque-removal – so enhances gingival inflammation
the volume of connective tissue and bone is reduced in these areas where root proximities are closer – so inflammtion can more easily cause destructive harm
no scientific evidence * but with ortho – showed no predisposition to more rapid peridontal breakdown
bony septum in root proximity?
the bony septum between the teeth are VERY NARROW or absent – inflammation spreading into this area may rapidly produce a deep pocket
open contacts? implication?
the contact provides for proper mastication and defelction of food AWAY from the interdental space – so when weak or absent - food impaction is likely
etiologic factors for open contacts?
occlusal wear, interproximal bone and attachment loss, supereruption of teeth, tooth abnormalities, and poor restoration of interproximal contacts
example of root abnormalities?
GROOVES
*palato-gingival
palato-gingival grooves
developmental abnormalities seen primarily in maxillary incisor teeth
usually begin on the crown near central fossa and extend apically for varying distances and directions
can IMPEDE the removal of plaque and allow plaque microorganisms access to the subgingival area – many instances periodontal attachment and bone loss can be seen at these sites
proximal root grooves
found on incisor and maxillary premolars –
associated with POORER PERIODONTAL HEALTH including loss of attachment and bone
*grooves can be on any tooth surface
restorative resorations or appliances
subgingival margin discrepancy for onlays, crowns, fillings, and ortho bands can negatively influence the health of adjacent gingival tissues
implications of restorations violating the biological width?
Reaction of periodontium?
can cause an inflammatory response that may result in loss of bone, connective tissue attachment, and migration of the epithelial attachment
Attempt in the periodontium to reestablish the normal dimensions of the dentogingival junction by a process of osseous resorption which leads to chronic inflammaiton and periodontitis
severity of marginal discrepancy time present?
the time it is present influences the amount of damage to the periodontium and the ability of patients to maintain the areas free of plaque correlates
effects of restorative material
hypersensativity reaction/ allergies common to some metals and acrylics which can cause damage to the periodontium from the hypersensativity reaction
crown fractures implications on perio disease?
fractures of the tooth crown have NOT been shown to pose a risk for development of periodontal disease, unless the fracture enhances plaque accumulation
root fractures implication
vertical root fracture exists = common spot for an accompanying periodontal lesion.
these lesions are often difficult to distinguish from other types of endodontic or periodontal lesions
definition of cemental tears and relationship to perio
areas of the root surface cementum that have become either completely or partially detached
perio lesion that develops is a result of the growth f oral or sulcular bacteria within the cervical portion of a fracture line or cemental tear
inflammation from this causes loss in structures of the periodontium (PDL, alveolar bone, cementum - connective tissues
external root resorption
problem for perio if it is located CORONALLY on the root. – get communication between oral environment and area of resoprtion and bacteria can penetrate
Mucogingival deformities and conditions around teeth are part of what category?
Category VIII - Development or Inherited Conditions (part B)
mucogingival
a term used to describe that portion of the oral mucosa that covers the alveolar process including the gingiva (keratinized) and the adjacent alveolar mucosa
mucogingival deformity definition and implications
departure from the normal dimension and morphology of the interrelationship between gingiva and alveolar mucosa – deformity can be associated with a deformity in the underlying bone
implications on pt. esthetics and function and can be congenital, developmental, or acquired defects
clinical appearance of the gingiva and thickness requirements exist?
previously it was believed that there had to be a certain width of attached gingiva for proper health - but today it is thought that there is no absolute minimum is required as long as hygeine practice is adequate
average thickness = 1.41mm
perio ‘biotypes’ and what is the major factor that determines which
- thin/scalloped
- thick/flat
these refer to the actual consistency / thickness of he gingiva tissue and underlying bone as well as the forms of the surrounding tissues
shape of tooth is major determining factor
triangular shaped tooth what perio biotype/form?
square tooth?
which is more susceptible to gingival recession?
which is more susceptible to periodontal pocketing?
trinagular – thin scalloped form
square – thick/flat form
*THIN TISSUE TYPE = more susceptible to gingival recession (especially on the anterior teeth)
**THICK TISSUE TYPE= more susceptible to perio pocketing
defintion of gingival recession
location of the gingival margin apical to the cemento-enamel junciton
commonly seen on the buccal or lingual surfaces, but can be interproximal as well
mucogingival therapy
non-surgical and surgical correction of defects in morphology, position, and/or amount of soft tissue and underlying bone
periodontal plastic surgery
surgical procedures performed to prevent or correct anatomical, developmental, traumatical or plaque disease-induced defects of the gingiva, alveolar mucosa, or bone
biological width compromised of? refers to?
this is the optimal distance between the free gingival margin to the osseous crest of bone, which with normal conditions should be 3MM
all is kerainized tissue
non-attached /free gingiva = SULCUS
EPITHELIAL ATTACHMENT - junctional epithelium (1mm) is second part
CONNECTIVE TISSUE ATTACHEMNT (1-2mm)
proper width between CEJ and bone?
1mm – should always be this for proper gingival attachment – and this is altered when there is attachment loss
non -attached space aka
called in health?
called in disease?
Measures?
less than equal to 3,, dimensions w/ sulcular epithelium
SULCUS = health
clinical X = 1.8
POCKET = DISEASE
if greater than or equal to 3mm
Mucogingival deformities and conditions on edentulous ridges is part of what category?
Category VIII– Development or Inherited Conditions breakdown
third part of this category
Trauma from Occlusion is part of what category?
Category VIII– Development or Inherited Conditions breakdown
fourth part of this category
force is known as what type of quantity? definition
VECTOR quantity- associated with an interaction
push or pull acting upon an object as a result f its interaction with another object
*a force is an interaction that causes acceleration / or change
SI units is Newtons
A force has? (4 components)
- Duration
- Intensity/ Magnitude
- Frequency
- Direction
can also thing about distribution – like how many teeth are receiving the force
occlusal trauma
during function, OCCLUSAL FORCES are generated and transmitted to the attachement apparatus (PDL, bone, cementum) of the teeth which are capable of dissipating these forces
traumatogenic occlusion>
forces are generated with EXCESSIVE duration, intensity, frequency or direction that exceed the adaptive capacity of the supporting structures of the teeth and pt’s can experience constant pain or discomfort upon biting
primary occlusal trauma
an injury resulting from application of excessive occlusal forces acting upon a tooth or teeth with normal periodontal support
Under excessive occlusal load bt otherwise healthy intact periodontium so NO LOSS OF GINGIVAL CONNECTIVE TISSUE OR APICAL MIGRATION OF EPITHELIAL ATTACHMENT
NO POCKET
NO CA LOSS
secondary occlusal trauma
effect of excessive OR NORMAL occlusal forced causing an injury to the attachment apparatus of a tooth or teeth with REDUCED PERIODONTAL SUPPORT
PRESENTS WITH INCREASING MOBILITY WITH BONE LOSS – with alreay reduced periodontal attachment levels and apical migration
remaining periodontium is no longer able to support the tooth without the presence of mobility, migration, or fremitus under normal occlusal loads
radiographic changes consistent with occlusal trauma
- widening of the crestal portion of the PDL space
- irregular widening of the entire PDL space
- if periodontitits – vertical or angular bone resoprtion and radiolucencies in furcation areas
more extreme cases = resorption of alveolar bone or root resorption can be demonstrated
funneling of crestal PDL space is radiographic sign of?
occlusal trauma
widening of PDL is radigraphic sign of?
occlusal trauma
occlusal trauma implication on periodontal disease?
does not cause any CAL or initiate gingivitis or convert gingivitits to periodontitis BUT OCCLUSION MAY PLAY A SECONDARY ROLE IN THE PROGRESSION OF PERIODONTAL DISEASE
