Unit 1

Question 1

What is periodontal disease classification based on?

Answer 1

mainly on clinical and radiographic appearance, as well as on the systemic health or disease states of the client

Question 2

What are the general signs and symptoms of gingivitis?

Answer 2

• often involve systemic conditions that then become complicated by secondary inflammation
• primary inflammatory response of gingival tissue to irritation induced by bacterial plaque
• pain and heat are not common features of gingivitis
• typical sulcus depth of 4mm or less
• does not cause periodontitis
• can occur on a periodontium with no attachment loss or on a periodontium wiht attachment loss that is not progressing

Question 3

What are the signs and symptoms of chronic periodontitis?

Answer 3

-similar to plaque induced gingivitis
-presence of clinically detectable attachment loss
-preceded by inflammation occurring in the surrounding gingival tissues though not all gingivitis leads to periodontitis
-

Question 4

What causes CAL?

Answer 4

inflammation from the gingiva expanding to the supporting periodontal tissues which leads to apical migration of the epithelial attachment

• also known as loss of attachment (LOA)
• eventually is associated with periodontal pockets and bone loss

Question 5

How are pockets formed in periodontitis?

Answer 5

• begins as gingivitis (affecting only gingival tissue)
• bacterial plaque and its products break down the intercellular substances and cells in epithelial layer allow bacterial irritants to penetrate into the connective tissue layer
• leading to inflammation and degeneration and necrosis of sulcular epithelium
• results in ulceration of the lateral pocket wall, exposur of the infllamed CT, bleeding and someteims suppuration
• leads to edema and pseudopocket
• LOA occurs when the lower junctional epithelium migrates along the root once the gingival fibers apical to it are destroyed by inflmammatory infiltrate
• the transformation of a sulcus ot a pocket creates an area where plaque removal becomes difficult and often impossible, leading to more inflammation, which enhances pocket formation and allows more plaque accumulation

Question 6

What two events happen for LOA?

Answer 6

• at the apical end of teh epithelial attachment, the junctional epithelium is able to migrate apically along the root by proliferation (producing new cells that attach to the root where collagen is destroyed) in the area apical to the pre-existing junctional epithelium
• at the coronal end of the epithelial attachemtn, the weight of theinflammatory cells within the junctional epithelium cause the cell of the upper section of the junctional epithelium to lose adhesion and to detach from the root resulting deepening of the sulcus/pocket

Question 7

What are perio pockets?

Answer 7

• chronic inflammatory lesions constantly undergoing repair: the balance between exudative and constructive changes determines the color, consistency and surface texture o the inner pocket wall and to a lesser extent the gingival surface
• if inflammatory and cellular exudate predominate, the tissue will be more red and red-blue, soft, spongy and friable with a smooth & shiny surface
• if there is a predominance of newly formed CT cells and fibers, the pocket wall is firmer and pinker, with less (or somewhat no) detectable bleeding

Question 8

What defines pathogenic bacteria?

Answer 8

-changes in microflora as periodontal disease advances include a transition from less pathogenic gram +, non motile, aerobic forms to more pathogenic/virulent forms of gram -, anerobic bacteria, some of which have motility as virulence factors (eg. spirochetes)

Question 9

Describe pathways of inflammation?

Answer 9

• inflammation follows the path of least resistance

- the pathway of the spread of inflammation affects the pattern of bone destruction

Question 10

What are the two pathways of inflammation?

Answer 10

1. interproximally
   - from the gingiva into bone, then into PDL = horizontal bone loss
   - from the gingiva directly into the PDL then into the bone = vertical bone loss
2. facial & lingual
   - from the gingiva along outer periosteum, then into the bone = horizontal bone loss
   - from the gingiva directly into PDL and then bone = vertical bone loss

Question 11

What are clinical features of chronic periodontitis?

Answer 11

• typically little or no signs/symptoms
• similar to gingivitis with little or no clinically visible features that would indicate loss of attachment within pocket
• may have BOP, exudate
• gingiva may be red/bluish-red/swollen/inflamed or fibrotic
• development of pocket or furcation
• pocket formation and loss most often found interproximally
• may have mobility as disease progresses
• supra/sub calc or plaque seen in varying amounts
• progression: slow onset; may have bursts of activity; longer periods of inactivity or linear progression
• increased LOA compared to previous probings

Question 12

What is a perio pocket as per slide??

Answer 12

• A pathologically deepened sulcus
• One of the most important clinical features of periodontitis leading to further destruction of supporting tissues
• Pockets create a protected plaque retentive site that is most often inaccessible to client’s self care

Question 13

What are three causes of an increase in depth of a sulcus?

Answer 13

• Movement of gingival margin coronally as a result of edema or fibrosis; called a gingival pocket 9no migration of the JE)
• Apical migration of the JE
• Combination of 1 & 2

Question 14

Explain the difference between a gingival pocket and a perio pocket

Answer 14

• A gingival pocket is the result to gingival enlargement, without destruction of the underlying periodontal tissues; sulcus is deepened because of increased bulk of tissue
• Perio pocket occurs with the destruction of supporting tissues ( JE, PDL, and eventually bone)

Question 15

What are the two types of perio pockets?

Answer 15

• suprabony

- infrabony

Question 16

What is a suprabony pocket??

Answer 16

• Base of pocket coronal to alveolar bone

- Pattern of bone destruction is horizontal

Question 17

What is a infrabony pocket?

Answer 17

• Base of pocket apical to crest of alveolar bone – bone is adjacent to soft tissue wall
• Destruction pattern is vertical

Question 18

Why are some pockets not associated with clinically visible signs of inflammation?

Answer 18

• Tissue external to the pocket may be fibrotic
• The inflammation may be present at the base of a deepened sulcus and therefore occurring at a distance from the externally visible gingiva

Question 19

What are the two concepts of periods of perio disease?

Answer 19

• quiescence
• exacerbation

Periods of exacerbation and quiescence in bone destruction tend to coincide with the same periods in gingival inflammation as the tissues are intimately connected

Question 20

What is a quiescence period in perio disease?

Answer 20

• ↓ inflammatory response
• ↑ gram+ bacteria
• Tissue pinker, firmer, ↓bleeding

Question 21

What is an exacerbation period in perio disease?

Answer 21

• ↑ inflammatory response
• ↑ gram- bacteria
• Erythema, bleeding

Question 22

What is the response of bone to inflammation?

Answer 22

response of bone to inflammation includes bone formation as well as resorption; therefore, bone loss in perio disease occurs when resorption exceeds formation

Question 23

What are radiographical changes relating to perio disease?

Answer 23

• early lesions = fuzzy interseptal crestal bone
• mesial and distal ‘corners’ are usually affected presenting as wedge-shaped at crest of interprox bone
• reduced crestal eight and loss of lamina dura
• generalized if involves most teeth at same rate
• vertical=bone loss more rapid in one site
• widening of PDL, areas of root resorption and loss of lamina dura
• bone loss can extend to the apex of the root

Question 24

What do we need to remember about bone loss?

Answer 24

• it does not necessarily indicate a current inflammatory condition (disease activity) but reflects bone that has been already lost (past pathology)
• amount of bone loss is not necessarily correlated with pocket depth

Question 25

What do we know about patterns of bone loss?

Answer 25

• they correlate with pathways of inflammation
• local factors include: those that cause inflammation resulting in horizontal bone loss; those that alter the pathway of inflammation (occlusal trauma)
• amount of bone loss and patterns are also affected by features of the bone itself (bony defects: fenestrations - developmental, diastrations - canine)

Question 26

What are features of bone that affect the destructive pattern in periodontitis?

Answer 26

• thickness and width of crestal bone
• teeth that are close in proximity
• thickness and width of facial bone
• alignment of teeth
• root anatomy, position
• vertical or angular defects
• reversible architecture
• craters
• ledges
• bulbous contours (exostoses)

Question 27

Describe acute perio

Answer 27

• rapid onset
• marked - severe signs/symptoms
• short duration (either resolves or shifts to chronic)

Question 28

Describe chronic perio

Answer 28

• slow onset
• no (or mild) signs/symptoms
• long standing (may shift/revert to acute)

Question 29

What are some things to remember when considering perio disease?

Answer 29

• a client who presents with CAL does not necessarily presently have periodontitis
• a clietn with rolled margins, festoons, or blunted papillae does not necessarily currently have gingivitis if there are no current clinical signs of inflammation
• these are important distinctions because a major focus of clinical therapy is to get rid of inflammation

Therefore:

• determine if the present condition is healthy but altered from previous disease OR currently active with signs of inflammation visible on the surface gingiva or from within a diseased pocket (presence of bleeding or suppuration
• if there are signs of inflammation, the next step is to determine if the inflammatory condition represents gingivitis or periodontitis

Question 30

How is gingivitis classified?

Answer 30

• by severity of the inflammatory response as slight, moderate or severe
• the clinician should determine the severity based on mainly the severity noted in the redness and edema currently present and recorded in the gingival assessment

Question 31

How is periodontitis described?

Answer 31

• no nearly as straight forward as gingivitis
• is it periodontitis (active)
• the extent of the involvement (severity)

Clients must be informed of the presence and significance of all parameters associated with periodontitis

Question 32

What are the basic clinical measures for assessing for past or current chronic periodontitis?

Answer 32

• presence of inflammation (indicated disease activity)
• probing depth (PD)
• clinical attachment loss (CAL) - indicator of past loss
• radiographic assessment of bone loss

Question 33

How do we assess for the presence of inflammation?

Answer 33

• the most reliable sign is bleeding/suppuration
• redness and edema are also important indicators
• inflammation is indicative of current disease activity
• will not indicate resulting destruction of the attachment apparatus
• presence of active perio (inflammation of the perio attachment apparatus) should be based on presence of clinical signs of inflammation or a reasonable assumption that inflammation is likely present in a deep pocket combined with evidence of loss of attachment

Question 34

what is the significance of inflammation?

Answer 34

• it is the key pathological process that underlies periodontitis (it is the pathophysiological process that initiates and perpetuates perio tissue destruction)
• self care and other interventions such as debridement are aimed at eliminating the cause and contributing factors of inflammation to bring tissues to health, stabilize attachment and bone levels and further attachment loss

Question 35

What is the significance of pseudo pockets

Answer 35

• need to be distinguished from periodontal pockets
• factoring (estimating) in the amount of probe depth resulting from edematous or fibrotic enlargement at a particular site

Question 36

What is the significance of the depth of perio pockets?

Answer 36

• comparison of probing depths are not as reliable as a measure of disease progression as comparison of subsequent CAL measurements because the level of the gingiva margin can change independent of the attachment level
• the soft tissue forming a perio pocket is the area that ‘houses’ the main inflammatory tissue component associated with periodontitis, and covers the diseased portion of the exposed root
• pockets act as a protected area for accumulation and proliferation of pathogenic gram-negative bacteria and subgingival calculus
• probe depths are used in calculating clinical attachment levels that may include measurements of recession and the factoring in of depths from pseudo pocketing

Question 37

What is the key goal to periodontal therapy?

Answer 37

-to eliminate the soft tissue inflammation and reduce the pocket to a shallow, maintainable depth (generally 3mm or less)

Question 38

How are pockets classified?

Answer 38

• based on how the AAP formerly classified periodontitis
• mild/slight = 1-2 mm deeper than what is considered normal (4-5mm probings)
• moderate = 3-4 mm deeper than considered normal (6-7mm probings)
• severe = CAL of >5mm = probe depths of 8-9

Question 39

What is clinical attachment loss (CAL)?

Answer 39

• a measure of accumulated past disease at a site rather than current activity
• determined by measuring the distance from CEJ to the base of the sulcus/pocket (level of attachment of epithelial attachment to the root)
• not a measure of condition of the surrounding soft tissue (absence or presence or severity of inflammation in the surrounding soft tissue, nor is CAL a reflection of the condition of the exposed roots)
• CAL does not necessarily equate to probing depths

Question 40

What is the significance of CAL as a measurement of Periodontitis?

Answer 40

-identifies the level of the most coronal attachment of the periodontium to the tooth and helps determine crown root ratio and remaining support
-gives a measure of accumulated loss of soft tissue attachment to the root
-is the criterion to determine disease progression - a change in CAL of 2-3mm is considered the standard measure of disease activity/progression
-more accurate than probing as CEJ is a fixed point of measure
-the mere presence of CAL does not necessarily designate the perio condition as periodontitis (for client presenting with an area of minimal inflammation, shallow probing depth and CAL (that included visible recession) that is stable - the period could be described as plaque-induced gingivitis on a periodontium with (slt/mod/severe) attachment loss that is not progressing whereas presentation of CAL with no inflammation and shallow probe depths are considered healthy)
-currently AAP sub classification of chronic perio is solely based on severity of CAL
=mild/slight - CAL of 1-2mm
=moderate - CAL of 3-4mm
=severe - CAL of >5mm

Question 41

What is the significance of bone loss in perio?

Answer 41

• loss of perio attachment eventually leads to bone loss
• like CAL, assessment of bone levels is a measure of accumulated past loss of bone height and not necessarily an indicator of current disease activity
• represents loss of support for the tooth
• eventually leads to mobility and tooth loss
• sites involved are for each probe site (approximately 168 probing sites therefore for generalized would need >50 sites)
• clients can have different levels of disease in different areas of the mouth (gingivitis in anteriors and most posteriors with perio in only two molars)

Question 42

What can we assume in clients who have deep perio pockets?

Answer 42

• that there is probably inflammation occurring at the base of the pocket even if there is no clinical signs present on the outer surface of the gingiva or observable BOP
• the inflammation may not be clinically visible because it is occurring at the base of the pocket rather than on the outer gingival surface and although bleeding is present it has not reached the surface gingiva where it becomes clinically visible