Perio.txt

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Perio.txt
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Perio Midterm
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Perio Midterm
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  1. Periodontum Components
    • 1. Gingiva
    • 2. PDL
    • 3. Cementum (sim to bone, unique to teeth)
    • 4. Alveolar bone (cortical and cancellous)
  2. Healthy gingiva
    pink, firm, stippled, knife edge margin, coronal to CEJ, 1-3mm sulcus depth
  3. Gingiva epithelium
    • KERITINIZED oral surface
    • non-keritinized-sulcus/pocket
    • Rete Pegs-> finger like projections to get nutrients
  4. Gingiva CT
    collagen from fibroblasts
  5. Junctional Epithelium
    • between tooth surface & soft tisse like nail cuticle
    • provide seal of soft tissues around teeth
    • about 1mm in health
    • SEMI-PERMEABLE Membrane function-allow PMN migration
    • Hemi-Desmossomes-cell to tooth
  6. PDL
    • Sharpey's Fibers=collagen
    • link cementum to tissue not bone
  7. Where is cementum cellular?
    • Apically
    • Acellular Coronally (by CEJ)
  8. What types of bacteria inhabit supragingival areas?
    • Gram positive, Aerobes
    • subgingival = G-, anaerobes
  9. Pathogenesis of PD
    • BACTERIAL PLAQUE
    • INDUCES AN
    • INFLAMMATORY RESPONSE
    • CLINICALLY MANIFESTED AS
    • GINGIVITIS AND PERIODONTITIS
  10. inflammation changes
    • hemodynamic
    • vascular permeability
    • cellular events
  11. clinical perio inflammation
    • color, volume, consistency, texture, BLEEDING
    • red, swollen, spongy, nonstippled
  12. pocket formation
    • swelling->increases coronal tissue->deeper pseudopocket->more plaque
    • apical migration of junctional epithelium->destruction of CT and bone
  13. What are the consequenses of inflammation
    • Collagenase destroys collagen
    • Prostaglandins destroy bone
    • NOT DIRECTLY BACTERIA
    • NOT NECROSIS (resorbed)
  14. Diagnostic PD tools
    • Visual (pink, scalloped, knife-edge, margin coronal to CEJ, stippled, firm)
    • Probe (<3mm, no bleeding)
    • Radiographs (CEJ-crest distance 2mm, intactlamina dura)
  15. Visual health
    • 1. pink
    • 2. scalloped, knife edge
    • 3. margin coronal to CEJ
    • 4. Stippled
    • 5. Firm
  16. Gingivitis visual
    red/blue, enlarged rolled margins, coronal to CE, soft and smooth
  17. Gingivitis Radiographs
    NO CHANGES = CEJ-crest 2mm, intact lamina dura
  18. Periodontitis Visual
    red/blue, enlarged rolled margins, coronal or receded, soft smooth
  19. Periodontitis probing
    >4mm and BLEEDING
  20. Periodontitis radiographic
    • CEJ-crest >=3mm
    • loss of lamina dura
    • radiolucencies
  21. Horizontal Bone Loss
    • bone levels recede somewhat equally on all areas of the tooth
    • gingiva and its attachment also recedes along with the bone, and the roots are exposed supragingivally
  22. Vertical Bone Loss
    • along one side of a root
    • tunnel defect
  23. Bone destruction in furcations
    • Grade I- incipient
    • Grade II- still bone closing furcation
    • Grade III - no bone in furcation, probe all the way through
  24. Systemic Factors of periodontitis
    • Diabetes Mellitus->2x 3x chance, same microflora->different response toimposed defenses
    • control of diabetes important
  25. Diabetic changes
    • exposure to hyperglycemia-glycation end products
    • thickened rigid vessels
    • compromised diapedisis, O2 diffusion, metabolic waste removal
    • PMN dysfunction-decreased chemotaxis
  26. PD behavior
    • smoking light 2x, heavy 7x overal 2.8x, not good for therapy and recurrence
    • more bacteria, less O2, impared PMN chemotaxis/phagocytosis, less Ab production, more TNF-alpha (bone resorption)
  27. Bacteria PD etiology
    • Plaque = Gingivitis
    • plaque is necessary but not sufficient for periodontitis
    • (depends on immune response)
  28. Gingivitis causes
    • plaque (w or w/o local contributers)
    • systemic
    • medication
    • malnutrition
    • non-plaque gingival lesions-viral, fungal, genetic, mucocutaneous
  29. Periodontitis classes
    • Clinical Attachment loss
    • mild <3mm CAL, moderate 3-4, severe >5
  30. Aggressive periodontitis
    • (formerly called early-onset periodontitis, which includes juvenile, prepubertal, and rapid-progress periodontitis)"
    • –  Rapid attachment loss and bone destruction"
    • –  Amount of microbial deposits inconsistent with severity of tissue destruction"
    • –  Familial aggregation
    • –  Frequently associated with A. actinomycetemcomitans
    • –  Localized affects molars and incisors"
    • –  Generalized affects molars, incisors, and at least 3 other teeth
  31. supragingival calculus
    • whitish/yellow, clay-like, easily removed(from smooth surfaces), secondarily stained,
    • lingual lower anterior (whartons duct-submandibular)
    • buccal max molars (stensen's duct-parotid)
    • by ducts because high Ca and PO4
    • Dry teeth to aid diagnosis
    • May look hypoplastic structure (but more opaque)
  32. subgingival
    • apical to gingival margin
    • brown to black
    • flint-like
    • harder, more adherent
    • even distrobution
    • sometimes requires surgery to diagnose
  33. calculus radiographs
    • doesn't always show in radiograph
    • even interproximal calculus is not radiographically evident, buccal and lingual hardly show
    • accretions-radioapacities attached to surfaces of the teeth
  34. Accretions
    radioapacities attached to surfaces of the teeth
  35. calculus composition
    • 70-90% inorganic salts
    • •  Calcium and phosphorus are the most
    • abundant elements
    • •  Ca/P ration ranges from 1.66 to >2
    • •  Inorganic weight: 40% Ca and 20% P
    • there is more calcium than phosphorus
    • •  Trace amounts of Mg, Na, CO
    • , fluorine and others
    • these other elements are present
    • in saliva as well, &
    • Hydroxyapatite (58%)
    • •  Magnesium whitlockite (21%); mainly
    • found in subgingival calculus
    • •  Octacalcium phosphate (21%)
    • •  Brushite (9%); mainly found in
    • supragingival calculus
  36. Calculus Organic Composition
    • •  Proteins
    • •  Carbohydrates
    • •  Lipids
    • •  Epithelial cells
    • •  Leukocytes
    • •  Microorganisms
  37. calculus microscopic
    • layered
    • crystal rods randomly oriented
    • calcified microorganisms
    • covered by unmineralized plaque
  38. plaque->calculus
    • plaque precedes, matrix
    • small crystals fom in the intermicrobial matrix
    • calcifies matrix and bacteria
    • minerals from saliva (supragingival) or crevicular fluid(subgingival)
    • rate 50% in 2 days, 60-90% in 12 days, varies (person, location)
    • max volume 10 weeks - 6 months
  39. attachement of calculus
    calcifies pellicle and can penetrate (cementum)
  40. calculus->PD
    • associated with PD
    • yet(sterile calculus) is compatible with cell attachment
    • problem is PLAQUE TRAP, irregular surface
  41. Scaling:
    • removalof plaque and calculus from all surfaces coronal to junctional epithelium
    • manual tools: sickle, curette, Gracey Curette
    • power=vibration to dislodge
    • surgery usually when >6mm pockets
  42. Root Planing:
    removal of plaque,caluclus and portions of cementum or dentin to produce a smooth hard clean surface
  43. Oral cavity colonization
    500 capable usually 150
  44. shedding
    bacteria adherence, non-shedding (no turnover)= teeth, prothesis and implants
  45. Biofilm composition
    • mainly bacteria
    • ECM
    • Some host: epithelial, PMNs, Macrophages
  46. Organic Matrix
    • Polysaccharides: integrity
    • proteins
    • lipid material
    • albumins (crevicular fluid)
    • glycoproteins (saliva pellicle incorporation)
  47. Plaque/Biofilm formation
    • Pellicle formation-organic material, salivary proteins, proline rich, statherin,amylase mucins, agglutinins
    • adhesion/attachment-G+ bacteria
    • colonization/maturation-
  48. Supragingival plaque bacteria
    • G+/-
    • cocci, rods, filaments, spirochetes
    • facultative, some anaerobes
    • firmly adherent
    • caries, gingivitis
  49. Subgingival plaque bacteria
    • G- (LPS)
    • rods, spirochetes
    • anaerobes
    • loosely adherent, motile
    • gingivitis, periodontitis
  50. Which virulence factor is important for PD?
    • LPS (from gram-negative bacteria)
    • Aggregatibacter actinomycetemcomitans (leukotoxin)
    • P. gingivalis (LPS endotoxin)
    • T. forsythia (trypsin)
  51. specific plaque hypothesis
    microorganisms vary in pathogenic potential
  52. Ecologic Plaque Hypothesis
    • unified non-specific/specific
    • BOTH TOTAL AMOUNT AND COMPOSITION matter
    • Perturbations to host response may alter plaqu-induced host-response
  53. Socransky
    • 1. Association:high numbers diseased sites
    • 2. Elimination: remission of disease
    • 3. Host Response: specific pathogen
    • 4. Virulence Factors: properties that damage host tissue
    • 5. Animal Studies: putative pathogen to function in producing disease in animal model
  54. Caries
    • S. mutans, Lactobacilus
    • Saccharolytic, fermentation
    • compared to proteolytic (PD disease)
  55. Periodontal Disease
    • Many bacteria(different than caries) P. gingivalis, T. denticola, T. forsythia. A.a
    • PROTEOLYTIC
    • Host Response
    • Decrease Microbial load
  56. Periodontal Health
    • Homeostasis
    • bacteria alone not sufficient
    • Endogenous disease
    • complex interplay of biofilm and Host immune response
  57. Biologic Gradient
    • Gingivitis = REVERSIBLE
    • Periodontitis = IRREVERSIBLE
  58. Scales Type
    • Ordinal=ranking on severity
    • Ratio = intervals between points are equal, absolute 0
  59. PMA (Papillary-Marginal Attachment Index)
    • Massler & Schour
    • Gingivitis
    • VISUAL
    • Mirror & blunt end of probe
    • FACIAL surfaces of anterior teeth
    • Assess location & extent of gingivitis
    • Papillary & Marginal (PM) Units assessed on scale of 0 - 5
    •  0 = No inflammation
    •  1 = Mild engorgement
    •  2 = Obvious swelling, bleeding on pressure (blunt end of probe) “palpation”
    •  3 = Excessive swelling, spontaneous bleeding
    •  4 = Necrotic papilla
    •  5 = Atrophy (loss) of Papilla [Margin presents recession with margin below CEJ for Marginal unit]
    • Attached Gingiva (A) Unit assessed on scale of 0 - 3
    •  0 = Normal pink with stippling
    •  1 = Slight engorgement (swelling)
    •  2 = Obvious swelling with pocket formation
    •  3 = Advanced periodontitis with obvious pocket present
    • Scores totaled divided by number of units to get PMA index
    • modifications of the criteria served as basis of all succeeding indices of GINGIVITIS.
  60. PI (Periodontal Index)
    • Russell
    • •  Estimate DEEPER PERIODONTAL disease than PMA Index
    • •  VISUAL exam of gingival tissue circumscribing each tooth as the scoring unit for all of the teeth present
    • •  ONLY a mouth mirror is used (NO PROBE)
    • •  ALL TEETH present are scored
    • PI Index
    •   0 = No inflammation present
    •   1 = Mild gingivitis present
    •   2 = Moderate gingivitis circumscribes entire tooth
    •   6 = Gingivitis with Pocket Present - distortion of gingival margin due to gross calculus
    •   8 = Advanced Destruction with Loss of Function - tooth is mobile or depressible
    • Summed/total teeth scored
    • more data assembled using PI that any other index
    • distribution of PD worldwide
    • UNDERESTIMATES -> no probe (especially when prevalence is low)
    • ONLY non-invasive index
  61. PDI (Periodontal Disease Index)
    • Ramfjord
    • PRESENCE & SEVERITY
    • VISUAL exam & INDIRECT using mirror & calibrated probe
    • Gingivitis scored 0-3
    • Attachment Level 4-6 (in 3mm increments)
    • measured at mid-facial and mesial facial
    • 6 Index Ramfjord Teeth: 3, 9, 12, 19, 25, 28
    • scores totals and averaged
    • Calculus (0-3) and Plaque (0-3 with disclosing soln) assessed separately
    • formed the basis of how we CLINICALLY MEASURE LOSS OF ATTACHMENT (AL)
    • PD (pocket or probe depth) = measured from edge of the Free Gingival Margin (FGM) to base of
    • gingival sulcus/pocket
    • Gingival Recession (GR) = distance
    • from Free Gingival Margin to CEJ
    • –  If GM coronal to CEJ, positive number –  If GM apical to CEJ, negative number
    • Attachment Loss (AL) is the difference between PD and GR
    • •  Attachment Loss (AL) = PD - (±GR)
  62. Extent & Severity Index
    • NIDCR
    • •  Because PD is site specific, NIDCR developed biphasic method of presenting data (not a true index)
    • •  (Extent, Severity)
    • •  (% of sites with AL, mm of AL)
  63. OHI-S (Simplified Oral Hygiene Index)
    • Greene and Vermillion
    • •  Developed as simple way to quantitate oral cleanliness
    • •  Based on surface area of tooth covered by plaque and calculus
    • •  Scoring unit is facial surface from mesial to distal contact
    • •  Assumption that dirtier the mouth the greater the surface area of the tooth covered by plaque
    • Based on VISUAL exam using mouth mirror and dental explorer on six tooth surfaces
    • •  OHI-S = Debris Index (DI-S) plus Calculus Index (CI-S)
    • DI-S of OHI-S
    •   0 = No debris or stain
    •   1 = Debris covering one-third of tooth surface
    •   2 = Debris covering more than one-third, less than two-thirds
    •   3 = Debris covering more than two-thirds
    • CI-S of OHI-S
    •   0 = No calculus present
    •   1 = Supragingival calculus covering more than one-third of surface
    •   2 = Supragingival calculus covering more that one-third but less than two-thirds OR flecks of Subgingival calculus
    •   3 = Supragingival calculus covering more than two- thirds OR continuous band of Subgingival calculus (M to D)
    • SIGNIFICACE of OHI-S is that, like the PI, it has been used extensively throughout the world and the U.S.
    • •  Contributed to our understanding of how plaque and calculus are involved in the etiology of periodontal disease
    • Strongly correlated with PI, r = 0.69-0.81
    • •  Supports clinical impressions of Russell that active periodontal disease is rarely found in the absence of plaque and/or calculus.
    • •  85 % to 90 % of your patients will have plaque related disease
  64. GI (Gingival Index)
    • Löe & Silness
    • –  Developed to assess the severity of gingival inflammation
    • –  Uses a mouth mirror and blunt end of a periodontal probe to “palpate “ the gingival tissues
    • –  Gingival inflammation is measured on a scale of 0 to 3 on four scoring units of a tooth
    • (Mesial, mid Facial, Distal and the entire Lingual surface as one scoring unit) - only anterior teeth, but can be ALL)
    •   0 = Normal gingiva
    •   1 = Mild inflammation, color change, slight edema, NO bleeding
    •   2 = Moderate inflammation, redness, edema, glazing, bleeding on palpation* of sulcus
    •   3 = Severe inflammation, marked redness and edema, tendency for spontaneous bleeding on palpation*
    • Probe parallel to long axis
    • *Palpation = probe is swept along inner wall of sulcus from mesial to distal
    • contact using only 2 mm of the probe tip •  Advantage - easy to use because more
    • than one sign of inflammation, color change and bleeding
    • •  Disadvantage - donʼt know which sign you are measuring
    • •  “Purist” point of view, measure color change separately and bleeding
    • separately
  65. MGI (Modified Gingival Index)
    • Lobene
    • •  MGI uses ONLY the color change criteria of the GI and excludes the bleeding criteria.
    • •  Use only a mouth mirror to assess color change at four sites per tooth
    • •  Usually done on all teeth, but can be limited to index teeth
  66. PlI (Plaque Index)
    • Silness & Löe
    • •  Parallel Index to the GI •  Developed to examine “thickness” of
    • plaque at only the gingival one-third of a tooth
    • •  Assesses plaque on a scale of 0 to 3 at four sites per tooth from mesial to distal contact using a periodontal probe
    • •  Probe is drawn horizontally along the inner lining of the gingival sulcus
    • •  Can be limited to anterior teeth, but usually done on all teeth especially since it is well suited to clinical trials
    • of plaque reducing agents
    • •  Since no DISCLOSING dye is used,
    • index requires an experienced examiner because of the subjective
    • nature of measuring undisclosed plaque.
    •   0 = No plaque is visible on tip of periodontal probe after it is sweep along gingival sulcus.
    •   1 = Plaque is visible on tip of periodontal probe after it is sweep along gingival sulcus.
    •   2 = Moderate plaque is visible at gingival tooth interphase with naked eye.
    •   3 = Abundant plaque is obviously visible at gingival third of tooth surface.
  67. MBI & PI
    • •  In the clinic, use dichotomous indices (presence or absence) to measure gingivitis and plaque on the facial and
    • lingual surfaces of all teeth in a quadrant
    • •  MARGINAL Bleeding Index (MBI) is used to assess gingivitis with a periodontal
    • probe at six sites per tooth
  68. PI (Plaque Index)
    • •  PI index is used to assess plaque at six sites per tooth using a disclosing dye
    • •  We’ll have demonstrations on both, during this Summer Quarter after you’ve had your periodontal instrumentation course and understand how to use the periodontal probe. This is done on EVERY patient that you will treat in the clinic!
  69. PERIODONTITIS: PROBING
    • •  Depth: > 4mm
    • •  Bleeding
  70. Severe Periodontitis
    • 2 or more interproximal sites with ≥ 6 mm CAL and
    • 1 or more interproximal sites with ≥ 5 mm PD
  71. Moderate Periodontitis
    2 or more interproximal sites with ≥ 4 mm clinical CAL OR 2 or more interproximal sites with PD ≥ 5 mm
  72. TOTAL Periodontitis
    • Severe + Moderate
    • *CDC/AAP definition. Sites not on same tooth
    • Severe Periodontitis
    • 2 or more interproximal sites with ≥ 6 mm CAL and
    • 1 or more interproximal sites with ≥ 5 mm PD
    • Moderate Periodontitis
    • 2 or more interproximal sites with ≥ 4 mm clinical CAL OR 2 or more interproximal sites with PD ≥ 5 mm

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