Perio - Dx Of Common Perio Conditions 1+2

Front 1

What are the 3 broad categories in perio dx?

Back 1

1. Gingival diseases
2. Various type of periodontitis
3. periodontal manifestations of systemic disease

Front 2

What details must be included along side a periodontal diagonosis?

Back 2

- case history
- evaluation of clinical signs and symptoms, parameters and tests
- general evaluation of patient

Front 3

What are the sequence of procedures for perio dx?

Back 3

1. Overall appraisal of patient
2. Med hx
3. Casts, clinical photos
4. Oral examination
5. Exam of teeth and implants
6. Exam of the periodontium
7. Intraoral radiograph survey

Front 4

What types of things are important to note in an oral examination when considering a perio diagnosis?

Back 4

- OH
- malodor
- oral cavity in general
- lymph nodes

Front 5

What types of things are important to note in an examination of teeth and implants when considering a perio diagnosis?

Back 5

- wear
- sensitivity
- mobility
- occlusion

Front 6

What types of things are important to note in an examination of periodontium when considering a perio diagnosis?

Back 6

- plaque
- calculus
- gingiva
- probing depths
- BOP
- KT/AG
- recession
- suppuration
- presence of abscess

Front 7

What is suppuration?

Back 7

to undergo formation of pus

Front 8

Name one very common disease that can have a large affect periodontal disease?

Back 8

diabetes

Front 9

What is gingivitis?

Back 9

inflamation of the gingiva (localized)

Front 10

What is periodontitis?

Back 10

Inflammation of the supporting tissues of the teeth (gingiva + supporting structures).

Usually a progressively destructive change leading to loss of bone and pdl. An extension of inflammation from gingiva into the bone and pdl.

Front 11

What are the 8 categories of peridontal disease from Armitage 1999?

Back 11

1. gingival disease
2. chronic periodontitis
3. aggressive periodontitis
4. periodontitis as a manifestation of systemic disease
5. necrotizing periodontal disease
6. abscesses of the periodontium
7. periodontitis associated with endodontic lesions
8. development of acquired deformities and conditions

Front 12

4 subtypes of dental plauqe induced gingival disease?

Back 12

gingivtis associated with ...
1. dental plaque only

or modified by ...
2. systemic factors
3. medications
4. malnutrition

Front 13

8 subtypes of non-plaque induced gingival lesions?

Back 13

-Gingival diseases of: 1. specific bacterial origin 2. viral origin 3. fungal origin
-Gingival lesions of 4. genetic origin
- 5. gingival manifestations of systemic conditions
- 6 traumatic lesions.
- 7. foreign body reactions
- 8. not otherwise specified (NOS)

Front 14

Classification criteria for gingival diseases?

Back 14

1. signs and symptoms
2. med and dental hx
3. clinical examination that involves extent, distributions and duration
4. physical description of lesions affecting gingiva
5. clinical attachment levels
6. radiographs

Front 15

List some universal features of gingival disease

Back 15

- s/s confined to gingiva, associated with stable attachment levels or on a reduced periodontium
- reversible if cause removed
- plaque initiates or exacerbates the severity of the lesion
- clinical signs of inflammation: edema, swelling, temperature change in the sulcus, colour change, BOP
- possible precursor to attachment loss

Front 16

Common clinical changes from gingival health to gingivitis

Back 16

- red/blue colour
- edematous or bulbous contour
- soft and edematous consitency
- bleeding on provocation
- gingival exudate significantly increased
- temps slightly increased to ~34ºC

Front 17

What is plaque induced gingivitis?

Back 17

inflammation of the gingiva from bacteria located at the gingival margin – can occur on a periodontium without AL or with AL and not progressing

Front 18

What is considered healthy probing depths?

Back 18

1-3mm

Front 19

Features of plaque induced gingivitis?

Back 19

1. plaque present at gingival margin
2. disease begins at the gingival margin
3. change in gingival colour, consistency and contour
4. gingival bleeding on probing
5. absence of attachment loss/bone loss
6. histological changes
7. increased sulcular temp/increase gingival exudate
8. reversible with plaque removal

Front 20

Describe the gingival margin and common findings in plaque induced ginvgitis

Back 20

- bacteria at dentogingival junction
- disease begins at GM (where the plaque is) but can advance into the periodontium
-may not be able to ID early, but common findings include: erythema, edema, bleeding, sensitivity, tenderness, enlargement(changes in marginal and papillary tissues)

Front 21

What can be an early sign of gingivitis?

Back 21

BOP

Front 22

AL and bone loss in plaque induced gingivitis?

Back 22

-no CT or bone loss on probing or x-ray analysis but AL (recession) may be present from past periodontitis
-clinical pictures can be alarming but no bone loss on x-rays

Front 23

Why may the gingiva look bluish in colour in plaque induced gingivitis?

Back 23

inflammation --> venous return has stopped --> venous stasis --> accumulation of deoxygenated blood makes gingiva look blue

Front 24

Why may the gingiva look red in colour in plaque induced gingivits?

Back 24

increased vascularizaation or decreased degree of epithelial attachment

Front 25

Where do changes in gingival colour, consistency and contour start in plaque induced gingivitis?

Back 25

start in the interdental papilla and gingival margin and spread to attached gingiva

Front 26

Describe the changes in consistency of the gingiva in plaque induced gingivitis?

Back 26

edematous (destructive changes) and fibrotic (reparative changes)

Front 27

Describe the histological changes that occur in plaque induced gingivitis (4)

Back 27

1. Proliferate basal and JE→ apical and lateral cell migration
2. vasculitis of BV’s adjacent to JE
3. Progressive destruction of collagen fibrils
4. progressive inflammatory/immune cellular infiltrate

Front 28

How is plaque induced gingivitis reversed?

Back 28

-remove the plaque with non-surgical debridement→ gingival swelling gone
(also consider local contributing factors )

Front 29

What are some local contriubting factors that may contribute modify or predisposed to plaque induced gingivitis?

Back 29

- calculus,
- tooth anatomic factors,
- dental restos,
- appliances,
- root fractures,
- cervical root resorption

Front 30

What does BOP indicate/predict?

Back 30

- indicates an inflammatory lesion in both epithelium and connective tissue
- may NOT be a diagnostic indicator for clinical attachment but IS an excellent NEGATIVE predictors for future attachment loss

Front 31

What is indicative of healthy bone levels?

Back 31

distance from CEJ to alveolar crest is within 2mm

Front 32

Time (days) for the 3 stages of gingivitis

Back 32

1. Initial lesion: 2-4 days
2. Early lesion: 4-7 days
3. Established lesion: 14-21 days (2-3 weeks)

Front 33

Describe the blood vessel changes during the 3 stages of gingivitis

Back 33

1. Vascular dilation/vasculitis
2. Vascular proliferation
3. Same as stage II plus venous return is impaired (blue colour)

Front 34

Describe the changes in the junctional and sulcular epithelium in the 3 stages of gingivitis

Back 34

1. Infiltration by PMNs
2. Same as stage I + rete peg formation and loss of coronal portion of JE
3. Same as II + more advanced JE is now pocket epithelium

Front 35

Describe the predominant immunce cells in the 3 stages of gingivitis

Back 35

1. PMNs
2. Lymphocytes
3. Plasma cells

Front 36

Describe the loss of collagen in the 3 stages of gingivitis

Back 36

1. perivascular loss
2. increased loss
3. continued loss

Front 37

Describe the common clinical findings in the 3 stages of gingivitis

Back 37

1. gingival fluid flow increases
2. erythema, BOP, colour change, size change, texture etc
3. Can remain stable for months OR become more active and convert into and Advanced lesion

Front 38

Gingivitis can be clinically categorized according to?

Back 38

Severity: mild(1-2mm CAL), moderate (304mm CAL), severe (>5mm CAL)
Extent/distribution: localized (<= 30% site affected) generalized (>30% sites affected)


Ex Generalized moderate plaque induced gingival disease/gingivitis

Front 39

Some common features of periodontitis?

Back 39

- inflammation (gingivitis)
- peridontal pocketing
- loss of alveolar bone (horizontal or angular)
- attachment loss

Other:
- recession
- presence of exudate and suppuration
- furcation involvement
- tooth migration
- tooth mobility

Front 40

What are some histopathological features of periodontitis?

Back 40

Periodontal Pocketing
Bone Loss
- PMN’s in JE and pocket E
- Inflammatory cell infiltrate with plasma cells, L0, M0 → activate Osteoclasts → bone loss

Front 41

What is considered to be a periodontal "pocket"?

Back 41

only sulci with probing depths 5mm or greater
- apical migration of the JE compared to the CEJ
- loss of collagen fibers subjacent to the pocket epithelium

Front 42

Predominant types of bacteria?

Back 42

Filaments, rods and coccoid organisms with gram-negative cell walls

Front 43

What are the histopathologic features of bluish/red gingiva?

Back 43

venous stasis

Front 44

What are the histopathologic features of flacid gingiva?

Back 44

destruction of gingival fibers

Front 45

What are the histopathologic features of smooth/shiny surface gingiva?

Back 45

atrophy of eptihlium and edema

Front 46

What are the histopathologic features of pink and firm gingiva?

Back 46

fibrotic surface but inner pocket wall is still ulcerated

Front 47

What are the histopathologic features of BOP?

Back 47

increased vascularity and thinning/degeneration of epithelium

Front 48

What are the histopathologic features of pus at gingiva?

Back 48

suppurative inflammation of inner wall

Front 49

8 overall characteristics of chronic periodontitis?

Back 49

- most prevalent in adults
- amount of destruction is consistent with the presence of local factors
- sub-G calculus usually present
- association with variable microbiollogical patter
- slow to moderate rate of progression (but may have periods of rapid progression)
- host factors determine rate of progression of disease
- Classified by extent: localized vs generalized 30% cutoff and severity CAL: 1-2, 3-4, 5 or >
- Associated or modified by systemic disease
- modified by predisposing factors such as cigarette smoking or emotional stress

Front 50

Common clinical findings for chronic peiodontitis

Back 50

- gingival swelling
- redness
- plaque, calculus
- BOP
- gingival shrinkage (recession, flattened papilla)
- tooth migration
- attachment loss

Front 51

Gingival disease can be modified by systemic factors such as..

Back 51

- puberty
- pregnancy
- diabetes
- blood dyscarsias

Front 52

Gingival disease can be modified by some medications such as..

Back 52

- dilantin
- cyclosporin
- phenytoin

Front 53

Gingival disease can be modifed by malnutrition such as...

Back 53

ascorbic acid deficiency

Front 54

Gingival diseases can be of specific bacterial origin such as..

Back 54

Neisseria gonorrhea
Treponema pallidum

Front 55

Gingival disease can be of viral origin such as..

Back 55

HSV
Varicella-Zoster

Front 56

Gingival diseases can be of fungal origin such as..

Back 56

candidiasis

Front 57

Gingival diseases can be of genetic origin such as..

Back 57

herditary gingival fibromatosis

Front 58

Some gingival manifestations of systemic conditions include..

Back 58

- mucocutaneous disorders
- allergic reactions

Front 59

Relation between puberty and gingival health?

Back 59

- prevalence of gingivitis increases due to increase in production of sex hormones
- P.intermedia associated with puberty gingivitis
- increased bleeding tendancy
- histopathologically consistent with inflammatory hyperplasia

Front 60

Relation between pregnancy and gingival health?

Back 60

- pregnancy gingivitis occurs in 30-100% of pregnant women
- called "pregnancy tumour" or pyogenic granuloma
- anterior region and interproximal sites are mostly involved
- Clx: erythema, edema, hyperplasia, increased bleeding

Front 61

Relation between diabetes and gingival health?

Back 61

- hyperglycemia may be exacerbated bc of the altertions in the gingival response to plaque

Front 62

Relation between leukemia and gingival health?

Back 62

- Mainly in acute leukemias
- Change in colour, contour (bluish-red), increase in size (first in interdental papilla)
- Spontaneous bleeding or prolonged bleeding → early sign of leukemia
- Accumulation of abnormal WBC’s → not fibrotic =not hard = do not cut

Front 63

Development and severity of gingival enlargement in response to medications is ____________ and may be influences by uncontrolled plaque levels and elevated hormonal levels ( in case of oral contraceptives)

Back 63

Development and severity of gingival enlargement in response to medications is PATIENT-SPECIFIC and may be influences by uncontrolled plaque levels and elevated hormonal levels ( in case of oral contraceptives)

Front 64

Features of drug induced gingival enlargment

Back 64

1. Anterior and buccal gingival
2. Prevalence is 20-80%
3. Onset within 3months → change in gingival colour and enlargement in size first noticed in interdental papilla (has a puffy pebble like appearance)
4. BOP. No AL
5. Secondary inflammation is due to plaque
6. Phenytoin, cyclosporine A, CCB’s
7. Hyperplasia → ↑ fb’s → ↑ collagen=hard feel, therefore must cut

Front 65

3 main drugs that cause gingival overgrowth

Back 65

CCBs (eg nifedipine)
Cyclosporine A
Phenytoin

Front 66

How does ascorbic acid defiency lead to gingivitis?

Back 66

Ascorbic acid (vit c) required for collagen synthesis.

When lacking, gingiva may appear bright red, swollen and there is bleeding

Front 67

Gingival diseases of bacterial origin are especially a result of ?

Back 67

STDs such as Ghonnorrhea and Syphilis

Front 68

What is streptococcal gingivitis?

Back 68

a rare infection that may be acute and present with fever, malaise, red and swollen gingiva with increased bleeding

Front 69

What are the most common viruses the cause gingival diseases?

Back 69

Herpesviruses 1 and 2
Frequently related to reactivation of a latent virus esp due to reduced immune function

HSV1 more common, mainly contracted by children >adults→ get primary herpetic gingivostomatitis

Front 70

Tx of gingival disease of viral origin?

Back 70

topical and/or sytemic antiviral drugs

NB by the time patient presents, it is ofter too late for these drugs to take effect

Front 71

Relationship between Varicella-Zoster virus and gingival disease

Back 71

VZV (chickenpox in children and Shingles in adults)
o Small ulcers on tongue, palate, gingiva→ dormant in DRG → reactivate as herpes zoster along nerve segment with vesicles usually on gingiva that pop and become ulcerated
o Dx = obvious: unilateral lesions associated with severe pain

Front 72

What is the most common fungus to cause gingival disease?

Back 72

candidiasis

more frequently in immunocompromised inv and those with normal flora distributed by the long term use of broad specture abx

presents as: white patches on gingiva, tongue or oral mucous membrane that can be removed with a gauze and leaves behing red/bleeding surfac

Front 73

What is the most common gingival disease of genetic origin?

Back 73

Hereditary gingival fibromatosis

Gingival enlargment may completly cover the teeth

May be associated with other syndromes

Front 74

What are some systemic conditions that can cause mucocutaneous disorders

Back 74

Lichen Planus
Benign mucous membrane
Pemphigoid

Front 75

Which allergies are commonly associate with gingival manifestations?

Back 75

allergies to:
restorative materials
toothpastes
mouthwashes
chewing gum
foods

Front 76

What is a common presentation of systemic conditions with gingival manifestation?

Back 76

desquamative lesions
±
ulceration of gingiva

Front 77

Examples of traumatic lesions associated with gingival disease

Back 77

- patient finger nails
- toothbrush trauma (ulceration and recession)
- iatrogenic trauma (ortho applicance)
- minor burns (food/drinks)

Front 78

The clinical feature that distniguished periodontitis from gingivitis is presence of ________________________

Back 78

clinically detectable attachment loss

Front 79

Primary (common) features of aggressive periodontitis

Back 79

- otherwise healthy ptn
- rapid attachment loss and bone destruction
- familial aggregation

Front 80

Secondary features of aggressive periodontitis

Back 80

- amount of microbial deposits are inconsistant with the severity of periodontal tissue destruction
- ↑proportions of A.a.
- abnormalities in phagocyte funtion
- hyper-responsive macrophage phenotype, including ↑levels of PGE2 and ILB
- Progression of attachment loss and bone loss may be self arresting

Front 81

Where is aggressive periodontitis usually localized to?

Back 81

central incisors and first molars

Front 82

Clinical characteristics of localized aggressive periodontitis

Back 82

1. circumpubertal onset of disease
2. localized 1st molar/incisor presentation with interproximal attachment loss on at least 2 permanent teeth, one of which is a 1st molar and involving no more than 2 teeth other than the 1st molar and incisors
3. usually patients <30YO
4. generalized interproximaly attachment loss affecting at least 3 permanent teeth other than 1st molar and incisors
5. Periods of advanced destruction followed by stages of quiescence of variable length

Front 83

3 types of periodontitis as a manifestation of systemic disease

Back 83

1. Associated with hematological disorders (eg leukemia)
2. Associated with genetic disorders
3. Not otherwise specified (NOS)

Front 84

Types of genetic disorders that may be associated with periodontitis?

Back 84

Cyclic neutropenia
Papillon-Lefevre syndrome
LAD

Front 85

How to distinguish periodontitis as a MANIFESTATION of sys disease from aggressive and chronic periodontitis MODIFIED by systemic disease?

Back 85

When systemic conditions is a major predisposing factor and other local factors such as plaque are not that evidence = periodontitis as a MANIFESTATION of systemic disease

Front 86

What is cyclic neutropenia?

Back 86

form of neutropenia that tends to occur every three weeks and lasting 3-6 days at a time, due to changing rates of cell production by the bone marrow.

Front 87

Presentation of necrotizing periodontal diseases

Back 87

- ulcerate and necrotic papillary and margina gingiva covered by yellowish white or greyish slough or pseudomembrane,
- blunting and cratering of papilla,
- bleeding,
- pain,
- malodorous breath
- may be accompanied by fever, malaise, lymphadenopathy

Front 88

What are the two forms of necrotizing periodontal diseases

Back 88

NUG and NUP

Front 89

What is NUG?

Back 89

Necrotizing Ulcerative Gingivitis
aka Vincents disease, fusospirochetal gingivitis, acute necrotizing ulcerative gingivitis (ANUG)

Front 90

Bacteria associated with gingival lesions in NUG

Back 90

fusiform bacteria
- P. intermeida

spirochetes

Front 91

What 3 specific linical characteristics must be present to diagnose NUG?

Back 91

PAIN
INTERDENTAL GINGIVAL NECROSIS
BLEEDING

Front 92

Describe the pain in NUG

Back 92

- usually rapid onset
- quality is intense and results in ptn seeking tx

Front 93

Describe the interdental gingival necrosis in NUG

Back 93

self limited to the interdental and marginal gingiva
- causes blunting of papilla

Front 94

Describe the bleeding in NUG

Back 94

- gingival bleeding in NUGoccurs with little or no provocation

Front 95

What may form secondary to diagnostic features of NUG?

Back 95

Malodorous breath
Pseudomembranous formation

Front 96

What is NUP?

Back 96

An infectoin characterized by necrosis of gingival tissue, PDL and alveolar bone.
- most commonly observed in individuals with systemic conditions incl. but not limited to: HIV, malnutrition and immunosuppresion

Front 97

Features of NUP

Back 97

- very similar clinical and etiological factors as NUG but also has CAL, and BL
-immune dysfunction predisposes to both NUG and NUP

Front 98

3 types of abscesses of the peridontinum

Back 98

1. gingival - localzied to marginal gingiva and interdental papilla
2. periodontal - localized to tissues adjacent to the periodontal pocket
3. pericoronal - localized to tissues surrounding crown of partially erupted tooth

Front 99

Features of gingival abscess?

Back 99

-local, painful, expanding lesion of the marginal gingiva and interdental papilla in previously disease free area
-usually from introduction of foreign substance into gingiva
-in 24-48 hours, its fluctuant and pointed with surface orifice
-may rupture spont→ pulpal hypersensitivity

Front 100

Features of periodontal abscess?

Back 100

= local accumulation of pus within the gingival wall or a periodontal pocket → collagen destruction and loss of alveolar bone
-calculus often present, associated with deep and tortuous pockets, furcations and infrabony defects
- lesions may be acute or chronic

Front 101

Features of peicoronal absesses?

Back 101

-pus in the overlying gingival flap around the crown of a tooth that has not fully erupted (mand 3rd molars)
-red and swollen flap
-infection can spread to the oropharyngeal area and medially to the base of the tongue and involve the regional lymph node
-patients have history of pericoronitits and have dysphagia

Front 102

Features of combined periodontic-endodontic lesions

Back 102

= where endo and perio problems are present in the same situation
-classification is not dependant on initial etiology, either can develop independently

Front 103

Do you treat endo or perio problems first?

Back 103

ENDO always

In all cases of perio associated with endo lesions, the endo infection should be controlled before beginning definitive management of perio lesion, esp when regenerative or bone-grafting techniques are planned.

Front 104

4 types of development or aquired deformities and conditions of the periodontium

Back 104

1. localized tooth related factors that modify or predispose to plaque induced gingival disease/periodontitis
2. mucogingival deformities and conditions around the teeth
3. mucogingival deformities and conditions on edentulous ridges
4. occlusal trauma

Front 105

Examples of localized tooth related factors that modify or predispose to plaque induced gingival disease/periodontitis

Back 105

- tooth anatomic factors
- dental restorations/applicances
- root fractures

Front 106

Examples of mucogingival deformities and conditions around the teeth

Back 106

- recession
- lack of keratinized gingiva
- decrease vestibular depth
- abberant frenum
- gingival excess

Front 107

Examples of occlusal trauma affecting periodontium

Back 107

occlusal forces cause injury to attachment apparatus
- primary occlusal trauma: excessive occlusal forces on a tooth with normal support
-secondary occlusal trauma: normal or excessive forces on a tooth with inadequate support (on a reduced periodontium)
-see fremitus (mvt of tooth with fxn), attrition, linea alba, crenated tongue, wide PDL space, migration of teeth