Written Paper Flashcards
4 components of the periodontium
Gingiva
Periodontal ligament
Alveolar bone
Cementum
4 features of healthy gingiva
Pink
Stippled in texture
Knife-edged margins
Scalloped profile
2 functions of gingiva
Attachment between oral mucous membrane and hard tissues
Protects the underlying periodontal tissues from invasion by bacteria
3 types of gingival epithelium
Junctional epithelium
Sulcular/crevicular epithelium
Oral gingival epithelium
5 features of junctional epithelium
Stratified squamous non keratinised epithelium
Forms attachment of gingiva to tooth by hemi-desmosomes and internal basal lamina
Epithelial attachment to enamel which terminates apically at cementum-enamel junction
Very high cell turnover
Permeable epithelium
3 features of crevicular epithelium
Stratified squamous non-keratinised epithelium
Lines gingival crevice, not attached to tooth surface
0.5-2 mm in depth
3 features of oral gingival epithelium
Stratified squamous, keratinised epithelium
Masticatory mucosa
Rete pegs interdigitate with dermal papillae of the underlying connective tissue
4 components of gingival connective tissue
Collagen fibres embedded in an extra cellular matrix
Fibroblasts
Many blood vessels
Nerve cells
2 functions of fibroblasts
Secrete all components of the extracellular matrix including collagen fibres
Responsible for degradation of the matrix through secretion of MMPs
What is the periodontal ligament
A specialised gomphosis fibrous attachment of the tooth to alveolar bone
What is alveolar bone
The component of the maxilla or mandible which surrounds and support the teeth
3 components of alveolar bone
Alveolar bone proper
Cancellous/spongy bone
Cortical plates
What is cementum
Calcified mesenchymal tissue that covers entire root surface
2 types of cementum
Cellular cementum
Acellular cementum
3 functions of cementum
Anchorage
Protection
Repair
8 plaque retentive factors
Calculus
Poor restoration margins
Tooth position/angulation
Developmental anomalies
Oral appliances
Xerostomia
Gingival enlargement
Incompetent lip posture
6 stages in classifying periodontal disease
Condition
Pattern
Stage
Grade
Stability
Risk factor profile
6 considerations for risk factor status
Smoking
Poorly-controlled diabetes
Family history
Poor plaque control
Subgingival deposits of calculus
Local factors: mouth-breathing, crowding
4 periodontal indices
O’Learys laque index
Periodontal pocket depths
Bleeding on probing
Miller’s mobility index
Choice of radiographs for generalised moderate/advanced periodontal disease
OPT plus anterior IOPAs
Choice of radiographs for generalised mild periodontal disease
Bite-wings plus anterior IOPAS
Choice of radiographs for localised advanced periodontal disease
Additional IOPA
3 methods of mechanical plaque control
Bass method of toothbrushing – intrasulcular
Interdental flossing
Interdental brushing
Method of chemical plaque control
Chlorhexidine mouthwash: 0.2% chlorhexidine gluconate, 10ml rinse (20mg)
Mechanical and hand-instrumentation methods of root surface debridement (RSD)
Mechanical: ultrasonic scalers, sonic scalers
Hand instrumentation: site-specific curettes, hoes
4 modes of action of mechanical scalers
Mechanical energy
Irrigation
Cavitation
Acoustic microstreaming
Features of piezo–electric ultrasonic scaler
Linear movements of tip
Vibrations caused by oscillations of quartz crystals in the handpiece
Features of magnetostrictive ultrasonic scaler
Eliptical movements of tip
Magnetic energy converted to mechanical energy to create vibrations
5 principles of ultrasonic instrumentation
0 -15 degrees to tooth
Insertion at gingival margin
“Exploring” pressure
Keep tip in motion
Bidirectional stroke
4 advantages of ultrasonic scaling
Irrigation with water clears the field of debris and blood
Allow quick removal of gross deposits
Less tiring for the operator
Can be used to remove overhanging margins on amalgam restorations
4 disadvantages of ultrasonic scaling
Generate contaminated aerosols
Water/aerosol can obscure vision
Can damage teeth and restorations
Cause significant sensitivity
What are the types of Graceys curettes and what surfaces of which teeth are they used for
1, 2: all surfaces of anterior teeth
5, 6: all surfaces of anterior teeth
11, 12: buccal, lingual, mesial surfaces of posterior teeth
13, 14: distal surface of posterior teeth
4 advantages of hand scaling
Hand instruments allows the operator tactile sensitivity
No aerosol is generated
May provide better access, especially deeper sites (>5mm)
Patients report less sensitivity and less discomfort during the procedure
3 disadvantages of hand scaling
Can cause more operator fatigue
Are more time consuming compared to ultrasonics
Are more difficult to use effectively
5A’s of smoking cessation
Ask
Assess
Advise
Assist
Arrange
4 host defence mechanisms against periodontal disease pathogens
Saliva
Epithelial barrier
Inflammatory response
Immune response
2 functions of inflammation
Isolate, neutralise and remove cause
Initiate healing and repair
Red complex organisms
Porphyromonas Gingivalis
Treponema Denticola
Tannerella Forsythia
2 Porphyromonas gingivalis virulence factors
Production of proteases
Polysaccharide capsule
2 Tannerella forsythia virulence factors
Production of trypsin-like proteases Production of glycosidase enzymes
Treponema denticola virulence factor
Production of potent hydrolytic enzymes including collagenases and proteases
3 patients who would benefit from being prescribed high fluoride toothpaste
High caries risk
Xerostomia
Orthodontic appliances
2 concentrations of high fluoride toothpaste
2800ppm
5000ppm
Describe the Bass technique of toothbrushing
45 ̊ angle to the tooth surface
Bristles below the gum margin
Circular motion
Firm yet gentle pressure
At least 2 minutes
Concentration of the active ingredient in Chlorhexidine mouthwash
0.2% chlorhexidine gluconate
3 important properties of Chlorhexidine mouthwash
Antibacterial
Antiseptic
Substantivity
3 possible side effects of Chlorhexidine mouthwash
Staining
Altered taste sensation
Hypersensitivity
4 signs of inflamed gingiva
Red colour
Bleeding on brushing/probing
Bad breath
Receding gingiva
4 areas early plaque formation occurs faster in
Lower jaw
Molar areas
Buccal tooth surfaces
Interdental regions
5 bacterial pathogens associated with periodontal disease
Porphyromonas Gingivalis
Tannerella Forsythia
Treponema Denticola
Fusobacterium Nucleatum
Prevotella Intermedia
Define the periodontium
Supporting apparatus of the tooth
Describe the variation in width of attached gingiva
Wider in incisor regions
Narrower over canines and 1st premolars
Describe the role of collagen fibres in withstanding occlusal loading during tooth function
Capable of remodelling and stretching during occlusal loads whilst maintaining their overall structure
Describe the role of GAGs in withstanding occlusal loading during tooth function
Bind water and act as a hydraulic cushion to allow the PDL to resist compressive forces
4 antibacterial effects of saliva
Washing effects
Inhibition of attachment of bacteria (sIgA)
Killing bacteria by peroxidase system
Killing bacteria by lysozyme, lactoferrin, histatins
3 causes of xerostomia
Drug-induced: antihypertensives, antidepressants
Head and neck radiation
Salivary disease
6 methods of bacterial pathogenic synergy in periodontal disease
Bacterial signalling relays information about the biofilm environment
Bacterial gene transfer
Co-adhesion between bacteria allows organisation of the biofilm architecture
Protection provided by extracellular polymeric matrix and other bacteria
Provision of essential nutrients
Adherence to the enamel pedicle to resist the removal forces of GCF
Describe how to measure probing pocket depth
Gingival margin – base of pocket
Describe how to measure clinical attachment loss
Cementum-enamel junction – base of pocket
When does clinical attachment loss > probing pocket depth
Gingival recession
When does probing pocket depth > clinical attachment loss
Gingival swelling
Define Miller’s index score 0
No, or physiological movement
Define Miller’s index score 1
Buccal-lingual movement <1 mm
Define Miller’s index score 2
Buccal-lingual movement ≥1mm
Define Miller’s index score 3
Buccal-lingual movement ≥1mm and vertical movement
Describe Miller’s index
Used to assess the mobility of teeth by using the ends of a dental instrument e.g mirror
3 things accurate probing depends on
Probing force
Probe placement
Probe angulation
4 potential problems that may affect your ability to complete an accurate probing record
False pocketing
Subgingival calculus
Overcrowding
Orthodontic appliances
Define gingivitis
Inflammatory response of the marginal gingiva, reversible condition
Define periodontitis
Inflammatory condition resulting in the irreversible loss of the tooth supporting structures, periodontal ligament and alveolar bone
5 features of supra-gingival calculus
Attached to tooth
Creamy-yellow
Brittle
Easily removed from tooth
Visible
5 features of sub-gingival calculus
Attached to root surfaces
Brown/Black
Very hard
Tenacious
Detected by gentle probing/ radiograph
6 clinical presentations of periodontitis
Formation of periodontal pockets
Bleeding on probing
Gingival inflammation
Drifting of teeth
Tooth mobility
Gingival recession
Radiographic presentation of periodontitis
Loss of alveolar bone - >1.5mm apical to CEJ
Classify the pattern of periodontitis
Localised: ≤ 30% teeth involved
Generalised: > 30% teeth involved
Molar-incisor distribution: only molar and incisor teeth involved
Classify the staging of periodontitis
Stage I : < 15% or < 2mm attachment loss from CEJ
Stage II : coronal third of the root
Stage III : middle third of the root
Stage IV : apical third of the root
Classify the grading of periodontitis
Grade A: < 0.5
Grade B: 0.5-1
Grade C: > 1
Classify the current disease status of periodontitis
Stable: BoP<10%; PPD≤4mm, no BoP at 4mm sites
Remission: BoP≥10%; PPD≤4mm; no BoP at 4mm sites
Unstable: PPD≥5mm or PPD≥4mm with BoP
3 types of hand scalers
Gracey curettes
Periodontal hoes
Sickle scaler
2 types of mechanical scalers
UItrasonic scalers
Sonic scalers
2 types of ultra-sonic scalers
Piezo-electric
Magnetostrictive
3 histological changes following successful non-surgical therapy
Decreased vasodilation and number of inflammatory cells
Remodelling of alveolar bone
Deposition of collagen fibres
5 clinical changes following successful non-surgical therapy
Decreased inflammation and swelling
Decreased redness
Decreased bleeding
Decreased probing depths
Reduction in subgingival calculus
4 important factors for successful non-surgical treatment
High standard of plaque control
Smoking cessation
Good quality root surface debridement
Good quality restorative treatment
Features of alveolar bone proper
Consists of thin lamella of bone that surrounds the root of the tooth
Gives attachment to the principal fibres of the periodontal ligament
Perforated due to ingress of vessels/nerves
Features of cancellous/spongy bone
Surrounds the alveolar bone proper and gives support to the socket
Widely spaced concentric or tranverse lamella enclosing the marrow spaces
Features of cortical plates
Forms the outer and inner plates of the alveolar bone
Cells responsible for alveolar bone resorption
Osteoclasts
Cells responsible for alveolar bone deposition
Osteoblasts
Features of cementum
It is avascular and not innervated
Formed slowly throughout life
Thicker at root apices
Resistant to resorption
Features of cellular cementum
Contains cementocytes in lacunae which resorb cementum
Communicate with each other through a network of canaliculi
Features of acellular cementum
Forms a thin surface layer which is often confined to cervical portions of the root
Cementoblasts are found on its surface
Define hypercementosis
Excessive deposition of cementum usually at apical area of roots
Features of inflammatory response
Rapid
Relatively non-specific
Cellular exudate of inflammatory response
Neutrophils
Macrophages
2 disorders which affect inflammatory response in periodontal disease
Leucocyte adhesion deficiency
Cyclic neutropenia
Features of adaptive immune response
Exhibits memory
Highly specific
Histology of healthy gingiva
Few neutrophils migrating through JE
Histopathology of early lesion (4-7 days)
Increased neutrophil migration
Macrophage and lymphocytic infiltrate
Localised collagen degradation
Localised fibroblast degeneration
Histopathology of established lesion (14-21 days)
Neutrophils walling off plaque
Increased lymphocytic infiltrate
60-70% collagen destruction
Lateral proliferation of JE with micro-ulceration
Histopathology of periodontitis
Apical migration of JE
Loss of periodontal ligament attachment
Loss of alveolar bone
Micro-ulceration of JE
When do you get false pocket formation
Gingivitis
5 stages of development of a plaque biofilm on a clean tooth surface
- The pellicle derived from saliva forms on a clean tooth surface
- Initially gram-positive cocci predominate in oral biofilms
- After a few hours the plaque bulk increases by bacterial division
- As plaque matures, gram positive bacteria are gradually replaced by gram negative species
- Gram negative filamentous forms such as fusiforms and spirochaetes appear in the later stages of plaque maturation
Composition of dental plaque
80-90% water
Composition of calculus
70-80% inorganic salts
Bacteria found in supra-gingival plaque
Mostly gram positive, aerobic bacteria
Bacterial composition of sub-gingival plaque
Gram negative rods and spirochetes, anaerobic bacteria
Describe the ecological plaque hypothesis for the development of periodontal disease
Organisms associated with disease may be found at healthy sites but at levels that are too low to be clinically relevant
Disease occurs as a result of a shift in the balance of the resident microflora due to a change in the local environmental conditions
The amount of dental plaque and the specific microbial composition of the plaque contribute to the transition from health to disease
The destruction in periodontal disease is the outcome of interactions between the host and the microbial challenge
Important message of the Ecological plaque hypothesis
Periodontal disease can be prevented, not only be targeting the putative pathogens, but also by interfering with the environmental factors which drive the changes in the balance of microflora
Calculation to determine plaque score
Number of surfaces exhibiting plaque divided by the number of available surfaces x 100
2 probes for measuring periodontal disease
Williams probe
WHO probe
Light probing force
20-25g
Features of WHO probe
Ball end is 0.5mm in diameter
First black band is found at 3.5mm to 5.5mm
5 things radiographic periodontal assessment allow us to determine
Bone loss: severity, pattern
Presence of sub-gingival calculus
Restoration margins
Presence of furcation
Peri-apical radiolucencies
4 components of periodontal disease prevention
OHI
Diet advice
Smoking cessation advice
Medication advice
What does non-surgical management of periodontal disease involve
Removal and control of plaque bacteria and their products
Removal of plaque-retentive factors
Uses for a WHO probe
Detect developing periodontal pockets
Measure the depths of the pockets and any loss of attachment to periodontal structures
Detect calculus and measure furcation involvement
Describe BPE 0 score
Pockets <3.5mm (black band entirely visible)
No calculus/overhangs, no bleeding on probing
Describe BPE 1 score
Pockets <3.5mm (black band entirely visible)
No calculus/overhangs, bleeding on probing
Describe BPE score 2
Pockets <3.5mm (black band entirely visible)
Supra or subgingival calculus/overhangs
Describe BPE score 3
Probing depth 3.5-5.5mm (black band partially visible)
Indicating pocket of 4-5mm
Describe BPE score 4
Probing depth >5.5mm (black band disappears)
Indicating a pocket of 6mm or more
Describe * BPE
Furcation involvement
Management of BPE score 0
No need for periodontal treatment
Management of BPE score 1
OHI
Management of BPE score 2
OHI
Removal of plaque retentive factors
Management of BPE score 3
OHI
Removal of plaque retentive factors
Root surface debrivement if required
Management of BPE score 4
OHI
Removal of plaque retentive factors
Root surface debridement
Referral to specialist if indicated
Define chemotaxis
The movement of an organism in response to a chemical stimulus
Define cytokine
Small protein produced mainly by macrophages that facilitate cell-cell communication via paracrine/autocrine signalling
Define phagocytosis
Process initiated by innate immune response, where pathogens are engulfed, neutralised and degraded
Recall for periodontal review
6/8 weeks
Define cross infection
Transmission of a pathogenic organism from one person to another
6 measures to prevent cross infection control
Dress code
PPE
Hand hygiene
Zoning
Decontamination
Segregation of waste
How will Amiodipine therapy affect treatment
Calcium channel blocker
Risk of gingival overgrowth
Increased risk of gingivitis and periodontitis therefore need to emphasise good OHI
How will Warfarin therapy affect treatment
Anticoagulant
Increased bleeding time
Need to check INR is below 4.0
How is stage of periodontal disease determined
Extent of interproximal bone loss recorded in the site with the most bone loss
How is grade of periodontal disease determined
Percentage bone loss at worst site divided by patients age
3 effects of protease release
Collagen breakdown
Extracellular matrix breakdown
Loss of attachment
2 effects of IL-1, IL-6 and prostaglandins activation
Osteoclast activation
Bone loss
6 cells found in periodontal ligament
Fibroblasts
Osteoblasts
Cementoblasts
Osteoclasts
Nerve cells
Vascular cells
Define virulence factors
Microbial determinants of pathogens that mediate host damage
6 surface associated virulence factors
Adhesion pili
Capsule
Adhesins
LPS
Flagella
Surface proteins
3 secreted virulence factors
Exotoxin
Enzymes
Iron binding proteins
