Perio Exam 1

Front 1

Periodontal Clinical Evaluation

Back 1

Visual: Gingival color, contour, texture and amt
Indices: Plaque and Bleeding
Probing
Furcation involvement
tooth mobility/occlusion

Front 2

Perio Diagnostic Information

Back 2

Patient Interview
Clinical Examination
Radiographic Examination
Specialized testing

Front 3

Fenestration

Back 3

hole in the bone

Front 4

Dehiscense

Back 4

if the bridge of bone is gone- v-shaped

Front 5

alveolar bone resorption and formation of periodontal defects

Back 5

necessary to open a flap to see what is going on here

Front 6

Hormonal Complications

Back 6

1. Pregnancy gingivitis
2. Birth control pill induced gingivitis
3. Puberty gingivitis
4. Gingivitis menstrualis & intermenstualis

Front 7

Pregnancy Gingivitis (Etiology)

Back 7

-Estrogen & progesterone show higher gingival concentrations (second major cause)
-Induce changes in vascular permeability & gingival fluid flow (gingival edema & increased inflammatory response to dental plaque)
-Steroid hormones can also stimulate the growth of certain periodontal pathogens (Prevotella intermedia)
-PLAQUE is the MAJOR cause of pregnancy gingivitis

Front 8

Pregnancy Gingivitis (Clinical appearance)

Back 8

1) Marginal enlargement
2) Tumorlike gingival enlargement

Front 9

Pregnancy Gingivitis (Marginal Enlargement)

Back 9

-Swollen, red gingiva with enlarged papillae, increased BOP
-Clinically present especially between 2nd & 8th months of pregnancy
-Treatment: meticulous oral hygiene throughout pregnancy

Front 10

Pregnancy Gingivitis (Tumorlike Gingival Enlargment)

Back 10

-Pregnancy Granuloma (variant of pyogenic granuloma) --> Not a neoplasm, but an INFLAMMATORY RESPONSE
-Benign, bright red, friable polypoid papule/nodule ranging from a few mm to several cm.
-Often bleeding, erosion, ulceration, & crusting
-Regressing lesions appear as soft fibroma
-Frequent along the maxillary mucosal surface
-Occurs in 5% of pregnancies (2nd or 3rd trimester)
-Granuloma grows rapidly to its maximum size over a few weeks
-High RECURRENCE rate
-Often REGRESSES after pregnancy
-Treatment: try to remove & closely monitor. Must be removed if impairing function

Front 11

Oral Contraceptives

Back 11

-Hormonal changes induced by contraceptives could cause increased gingivitis, also "pregnancy granuloma"
-Vascular permeability & exudation is increased by contraceptives containing progesterone

Front 12

Puberty Gingivitis

Back 12

-Varying HORMONE LEVELS promote gingival inflammatory & proliferative responses to local factor (plaque)
-Changes in the subgingival microbiotic
-Treatment: good oral hygiene

Front 13

Medicament-Elicited Overgrowth

Back 13

1. Phenytoin-induced gingival overgrowth
2. Nifedipine-induced gingival overgrowth
3. Cyclosporine-induced gingival overgrowth
4. Medicament combination (cyclosporine/nifedipine)

Front 14

Phenytoin (Dilantin)-Induced Gingival Overgrowth

Back 14

-Anticonvulsant --> used for treatment of epilepsy
-Gingival enlargement observed in 50% of pts --> occurs after a threshold level has been exceeded (not dose-dependent)
-Tends to occur in younger pts
-Etiology:
1. Genetically predetermined subpopulations of fibroblasts (increased collagen)
2. Inactivation (decrease) of collagenase (less destruction of collagen)
3. Plaque-induced inflammation

Front 15

Phenytoin-Induced Gingival Overgrowth (Therapy)

Back 15

-Adequate oral hygiene
-Plaque & calculus removal
-Once inflammation subsides, fibrous tissue can be excised (gingivectomy & gingivoplasty)
-High recurrence rate

Front 16

Radiographic Information for Diagnosing Periodontal Disease

Back 16

-presence, extent, distribution, and pattern of alveolar bone loss
-furcation invasions
-widening of periodontal ligament (PDL)
-calculus detection
-confounding tooth anatomy or restorative factors

Front 17

Panoramic Radiograph

Back 17

Not the best for perio because cannot really tell bone levels around tooth
lose detail
good for tooth position and assesing position of mandibular canal
cannot see caries around crowns

Front 18

Dihydropyridine (Nifedipine)-Induced Gingival Overgrowth

Back 18

-Calcium channel blocker --> reducing the influx of calcium ions into heart muscle
-Reduces the strength of contraction & vascular resistance
-Reduces oxygen consumption
-Both anti-anginal & anti-hypertensive effects

Front 19

Dihydropyridine-Induced Gingival Overgrowth (Therapy)

Back 19

-Adequate oral hygiene
-Plaque & calculus removal
-Gingivectomy & Gingivoplasty, as needed

Front 20

Cyclosporine-Induced Gingival Overgrowth

Back 20

Immunosuppressive agent (often organ transplant pts):
-Suppression of antibody formation against T-cell-dependent antigens
-Suppression of cell-mediated immunity
-Interference with production of cytokines
Side effects:
-Nephrotoxicity
-Hypertension
-Hypertrichosis

Front 21

Cyclosporine-Induced Gingival Overgrowth (Therapy)

Back 21

-Motivation, OHI
-Initial periodontal therapy
-Possible gingivectomy & gingivoplasty

Front 22

Types of Gingival Overgrowth (Tumors)

Back 22

1. Epulis
2. Idiopathic & hereditary fibrosis
3. Neoplasms (Benign/Malignant Tumors)

Front 23

Epulis (Benign Tumors)

Back 23

Generic term that clinically designates all discrete tumors & tumorlike masses of the gingiva

Front 24

Epulis (Types)

Back 24

1. Pyogenic granuloma
2. Giant cell epulis
3. Fibrous epulis

-Pyogenic granuloma & giant cell epulis can develop quickly; the fribrous epulis develops rather slowly
-Unknown etiology, possible marginal irritation

Front 25

Pyogenic Granuloma - Epulis

Back 25

-Localized, tumor-like bright red
-Usually seen in papillary area
-When probed, copious mix of blood & pus
-Treatment = simple EXCISION

Front 26

Giant cell Epulis

Back 26

-"Peripheral giant cell granuloma"
-Often resembles a pyogenic granuloma
-TREATMENT = Excision, Gingival flap, Tooth & root surfaces planned, Bone filed
-High recurrence rate (must scrape surface of bone to be sure no giant cell is left behind)

Front 27

Fibrous Epulis

Back 27

-Localized, fibrous, firm mass
-Treatment: SIMPLE EXCISION

Front 28

Periapical Radiograph

Back 28

a lot of detail great for bone loss

Front 29

prescense of alveolar bone loss
initial lesion

Back 29

loss of crestal lamina dura
funeling or widening of coronal periodontal ligament space

Front 30

Presence of alveolar bone loss
established lesion

Back 30

apical migration of the alveolar crest greater than 2mm from the cemento-enamel junction (CEJ)

Front 31

Slight alveolar bone loss

Back 31

apical migration of the alveolar crest within the coronal third of the root length

Front 32

moderate alveolar bone loss

Back 32

apical migration of the alveolar crest within the middle third of the root length

Front 33

severe alveolar bone loss

Back 33

apical migration of the alveolar crest within the apical third of the root length

Front 34

percent alveolar bone loss

Back 34

relative to root length
so if you have short length a couple of mm could mean 50% bone loss

Front 35

Root anatomy and alveolar bone support

Back 35

easier to treat and maintain a single rooted tooth than a multi rooted tooth
furcation involvements happen with multi rooted teeth (more difficult to clean and more challenging to treat)

Front 36

Radiographically radiolucency in the furcation area

Back 36

automatically place the patient in a more advanced bone loss category because the furcation is more difficult to treat and maintain

Front 37

Clinical Crown to Root Ratio

Back 37

don't know how much structure is left around a tooth, trace a straight line from incisal edge of crown to there the bone is
straight line from bone to apex

Front 38

level of the radiographic alveolar bone crest and its relation to the CEJ will correspond to the anatomic crest when

Back 38

-x-ray beam is directed perpendicular to the alveolar bone
-the film is positioned parallel to the long axis of the tooth

Front 39

Distribution of alveolar bone loss

Back 39

-generalized: homogeneous throughout the dentition
-localized: heterogeneous throughout the dentition and restricted to isolated teeth

Front 40

Pattern of alveolar bone loss

Back 40

horizontal and vertical

Front 41

Horizontal bone loss

Back 41

interproximal bone destruction which is parallel with the line intersecting adjacent CEJS

Front 42

Vertical bone loss

Back 42

interproximal bone destruction which is not parallel with the line intersecting adjacent CEJs
Intrabony or vertical osseous defect formation

Front 43

Furcation invasions

Back 43

-radiolucent lesion at the site of root divergence of a multi-rooted tooth
initial widening of furcation periodontal ligament space
furcation lesions classified clinicaly (e.g., class I, II and III) and not radiographically

Front 44

Calculus detection

Back 44

can be done radiographically

Front 45

Widening of periodontal ligament (PDL) space

Back 45

-coronal versus apical widening
-initial lesion (interproximal or furcal)
- sign of trauma from occlusion

Front 46

radiographic signs of trauma from occlusion

Back 46

widened PDL space
thickenining of lamina dura
root resorption (external
hypercementosis
root fracture
pulpal calcifications

Front 47

trauma from occlusion

Back 47

-may be a destructive cofactor in periodontitis
-primary: increased occlusal forces (parafunctional or iatrogenic) superimposed on a normal periodontium
-secondary: normal forces superimposed on a compromised or reduced periodontium

Front 48

Idiopathic & hereditary fibrosis

Back 48

1. Fibrosis (may be CT, bone, or both)
2. Exostosis (increased bulkiness at the apices)
3. Papilloma, gingival cysts

Treatment:
-Excision of soft tissue growth
-Osseous thickening may require osteoplasty
-Combination thereof

Recurrences are frequent

Front 49

Malignant Tumors

Back 49

1. Carcinoma (Most common)
2. Melanoma
-Sarcoma
-Oral carcinoma = 1-5% of all carcinomas
-Malignant tumors are VERY RARE in gingiva
-Gingiva might be site for metastases

Front 50

Malignant Tumors
(Therapy)

Back 50

-Clinical Diagnosis
-Biopsy & frozen-section diagnosis
-Radical surgical removal, Chemotherapy, & Radiotherapy

Front 51

Pemphigoid

Back 51

Mucous membrane pemphigoid --> Ag-Ab complexing occurs at the BASEMENT MEMBRANE & CT, followed by complement activation & subsequent leukocyte recruitment
-Epithelium comes off when rubbed with gauze (exposes CT & is painful)
-Ocular lesions (Symblepharon; Ankyloblepharon)
-Oral lesions (Desquamative gingivitis, Erythema, Ulceration, Vesiculation)

Front 52

Pemphigoid
(Therapy)

Back 52

-Symptomatic therapy (pain control)
-In more involved cases, topical & systemic corticosteroid preparations might be indicated

-Optimal oral hygiene
-CT grafts

Front 53

Epidermolysis bullosa

Back 53

-Generalized desquamating condition of the skin & mucosa with associated scarring, contractures & dental defects
-Similar ot bullous & mucous membrane pemphigoid
-Oral: teeth exhibit delayed eruption & enamel hypoplasia with rapid caries development
-Immune reactivity at the basement membrane zone

Front 54

Pemphigus Vulgaris

Back 54

-Autoimmune bullous disorders that produce cutaneous & mucous membrane blisters
-More serious condition
-EPITHELIUM layer sloughs, leaving painful & expanded erosions (Not between the epithelium & the CT)
-Cell-to-cell adhesion structures are damaged by the action of circulating & in vivo binding of auto-antibodies to the pemphigus vulgaris antigens

Front 55

Pemphigus Vulgaris
(Therapy)

Back 55

-Immunosuppressive drugs & systemic corticosteroids
-Prognosis is relatively poor

Front 56

Lichen Planus

Back 56

-Skin & mucosal alterations
-Relatively frequent
-Morbidity: 0.2-1.9% of adult population
-Milky-white, pebbly, hyperkeratotic, net-like coatings (Atrophic, may subsequently erode)

Front 57

Types of Lichen Planus

Back 57

Reticular
Erosive
Patch
Atrophic
Bullous

Front 58

confounding tooth anatomy or restorative factors

Back 58

-root length
-root form (conical versus bulbous;dilacerations)
-root divergence and proximity
-crown:root ratio
-caries and/or restorative margin quality (open or overhanging restorations)

Front 59

limitations of radiogrphs

Back 59

- 2D images representing 3D anatomic structure
- do not show Perio pockets
- do not distingish between successfully treated and untreated cases
- do not record morphology/pattern of bony defects
- do not show the facial/labial or lingual/palatal of tooth
- no soft-to-hard-tissue relationships
- do not record tooth mobility

Front 60

Screening
radiographs needed

Back 60

four, posterior vertical bitewing radiographs

Front 61

comprehensive examination
radiographs needed

Back 61

full mouth series (>18 intraoral films); limited diagnostic information from panoramic films

Front 62

Recall
radiographs needed

Back 62

vertical bitewing radiographs or select periapical films
- frequency: depends on overall patient risk for progressive disease, but in general every 2-3 years or longer

Front 63

Lichen Planus
(Therapy)

Back 63

-No true causal therapy
-Monitoring
-Erosive forms might require local and/or systemic corticosteroids

Front 64

Erythema multiforme
(Etiology & Clinical appearance)

Back 64

Etiologic factors:
1. Herpes simplex infection
2. Mycoplasma infection
3. Drug reactions

Oral lesions --> multiple, large shallow, painful ulcers with an erythematous border (on buccal mucosa, tongue)

Front 65

Erythema multiforme
(Therapy)

Back 65

-Resolve spontaneously
-Mild: antihistamines, topical anesthetics
-Severe: corticosteroids

Front 66

Leukoplakia
(Pre-Cancerous Lesions)

Back 66

-White spots that cannot be classified as any other kind of lesion, unrelated, except for the use of tobacco (NOT a diagnosis)
-Smokers 3X mor elikely to exhibit leukoplakia
-Etiology unknown
-Secondary infection & malignant formation

Front 67

Leukoplakia
(Therapy)

Back 67

-Observation/monitoring
-Retinoids
-Surgery if malignancy suspected

Front 68

Erythroplakia

Back 68

-A CLINICAL term for a red patch of the oral mucosa
-Frequently caused by epithelial dysplasia, carcinoma in situ, or squamous cell carcinoma

-ALWAYS BIOPSY

Front 69

Diagnosis of Active or Progressive alveolar bone loss

Back 69

-requires two radiographic examinations separated in time but similar projection and angulations
-approximately 30% of bone mineral must be lost for visual detection
- computer-assisted digital radiography for increased sensitivity of detection

Front 70

Systemic Treatment

Back 70

medical consultation and pre-medication

Front 71

Acute Treatment

Back 71

emergency treatement of pain and/or infection

Front 72

Disease Control Phase

Back 72

Initial therapy (scaling and root planing, OHI, removal of caries, antimicrobial therapy, occlusal therapy, minor orthodontic movement, etc)

Front 73

Reevaluation of Initial Therapy

Back 73

(4-8 weeks after last quadrant of ScRP): probing depths, check for gingival inflammation

Front 74

jDefinitive Phase

Back 74

Surgical treatment- including placement of implants

Front 75

Reevalution of surgical phase

Back 75

6 wks-6 months after last surgery

Front 76

Restorative phase

Back 76

final restorations, fixed and/or removable appliances etc

Front 77

Maintanance phase

Back 77

(long term care q 3 mo or according to plaque control)

Front 78

preferred sequence of perio therapy

Back 78

emergency phase-->
non surgical phase -->
maintenance phase --> to either surgical or restorative

Front 79

explaining tx plan to pt

Back 79

be specific
avoid vague statements
begin your discussion on a positive note always
try to present the treatment plan entirely, as a unit, as much as possible

Front 80

doing nothing is not advisable

Back 80

periodontal diseases are infections with systemic implications
restorations cannot be done until perio is treated and maintained
perio may lead to tooth loss and bone loss and makes it difficult to replace teeth

Front 81

Herpetic Gingivostomatitis

Back 81

-Viral infection (HSV-1), contagious
-Painful
-Acute gingivitis with blister-like aphthae, erosive lesions on attached gingiva (oral mucosa, lips)
-Vesicles --> Ulcers (red, elevated, halo-like margin)
-Course of disease is 7-10 days

Front 82

Herpetic Gingivostomatitis
(Predisposing Factors)

Back 82

Mechanical trauma
Sun exposure
Inadequate diet
Hormonal disturbances
Stress

Front 83

Herpetic Gingivostomatitis
(Therapy)

Back 83

-Topical application of PALLIATIVE ointments, antimicrobial rinse
-Acyclovir systemically & topically
-In severe forms - antibiotic tx
-Often healing spontaneously within 1-2 weeks without any therapy

Front 84

Diabetes Mellitus
(Type I)

Back 84

-"Early-onset" - IDDM
-Accounts for ~10% of all diabetes cases
-Most common in youth
-Due to destruction of the insulin producing beta-cells via an autoimmune process in susceptible individuals
-Treatment by insulin injections

Front 85

Diabetes Mellitus
(Type II)

Back 85

-"Adult onset" - NIDDM
-Accounts for 90% of diabetes cases
-Milder form with GRADUAL onset
-Most patients are OBESE
-Results from combination of resistance to insulin & an insulin secretory defect
-May require exogenous insulin or oral hypoglycemic drugs during periods of stress for acute hyperglycemia
-May be seen in FAMILY AGGREGATION as an autosomal dominant trait

Front 86

Diabetes Mellitus
(Symptoms)

Back 86

Polyuria
Polyphagia
Polydypsia

Front 87

Diabetes Mellitus
(Complications)

Back 87

Retinopathy
Nephropathy
Neuropathy
Circulatory abnormalities

Front 88

How might Diabetes affect the Periodontium?

Back 88

-Vascular changes
-Impaired collagen metabolsim
-Advanced Glycation End-products (AGEs) formation
-Increased GCF glucose
-Impaired host defense

Front 89

Effect of Periodontal Treatment on Metabolic Control of Diabetes (Mechanical Treatment Only)

Back 89

-Treatment had NO EFFECT on level of Blood Glucose or HbA1c
-Treatment reduced Probing Depths & increased CAL. No effect on HbA1c or serum glucose.

Front 90

Effect of Periodontal Treatment on Metabolic Control of Diabetes (Mechanical Treatment AND Systemic Antibiotics)

Back 90

-Treatment reduced PD and HbA1c.
-These results support the hypothesis that anti-inflammatory therapy can help in metabolic control of diabetes

Front 91

Ascorbic acid (Vitamin C) deficiency

Back 91

-Marginal gingival enlargement
-Hemorrhage
-Collagen degeneration (Spontaneous tooth loss; Collagen fibers of the PDL may be defective - severe periodontal disease)
Edema of the gingival connective tissue
Presence of plaque results in exaggerated inflammation
Treatment = MOST symptoms are REVERSED by adequate dietary intake of ascorbic acid (EXCEPT the periodontal damage)

Front 92

Down Syndrome

Back 92

-Trisomy 21
-Periodontal destruction exceeds that explainable by local factors alone (Poor PMN chemotaxis & phagocytosis; Increased #s of P. intermedia)
-Deep periodontal pockets
-Generalized; severe bone loss in mand. anteriors
-High frenum attachment
-Recession

Front 93

Papillon-Lefevre Syndrome

Back 93

-Rare autosomal recessive dermatologic disease
-Severe periodontitis & hyperkeratosis (palms & soles of feet)
-Deciduous teeth are lost prematurely
-Permanent teeth ALWAYS periodontally involved)

Therapy:
-Aggressive treatment including extraction of deciduous teeth & some permanent teeth has shown some success in maintaining residual permanent teeth (Outcome of periodontal therapy is unpredictable)

Front 94

Chediak-Higashi Syndrome

Back 94

-Rare genetic disease, autosomal recessive trait
-Abnormalities in the cytoplasmic granules result in impaired killing of certain microorganisms
-Reduced functional capacity of the PMN

-Partial albinism, mild bleeding disorders, recurrent bacterial infections
-Aggressive periodontitis

Front 95

Genetically-elicited Systemic Syndromes

Back 95

Down Syndrome
Papillon-Lefevre Syndrome
Chediak-Higashi Syndrome

Front 96

Hematological Diseases

Back 96

Leukemia
Cyclic neutropenia
Agranulocytosis
Thrombocytopenia
Anemia

Front 97

Leukemia

Back 97

-Overproduction of WBCs; many appear in immature form in the blood
-Acute, subacute & chronic forms

Front 98

Leukemia (Clinical Features)

Back 98

-Acute form --> malaise, fever, lympahdenopathy, petechiae or ecchymoses of skin or mucous membranes
-GENERALIZED GINGIVAL ENLARGEMENT is a common feature, especially in acute form
-Infiltration of gingiva with leukemic cells is observed in acute leukemias, esp. monocytic
-Also Gingivitis, Gingival Bleeding, Oral Ulcerations, & Petechiae are common

Front 99

Neutropenia

Back 99

-A decrease in circulating NEUTROPHILS in the peripheral blood

-Patients often present with infections
-Oral mucosa should be examined for apthous ulcers, candidiasis, or forms of periodontal diseases

Front 100

Neutropenia
(Severity Categories)

Back 100

MILD - with an ANC (Absolute Neutrophil Count) of 1000-1500 cells/mm3
MODERATE - with an ANC of 500-1000 cells/mm3
SEVERE - with an ANC of <500 cells/mm3
AGRANULOCYTOSIS - <100 cells per microliter (Very susceptible to infections)

Front 101

Cyclic Neutropenia
(Clinical Appearance)

Back 101

-Periodic neutropenia with subsequent infections, followed by peripheral neutrophil count recovery
-Infants or children
-Prognosis good with benign course

Front 102

Thrombocytopenia

Back 102

-Abnormal reduction in the number of circulating BLOOD PLATELETS

Etiology:
-Idiopathic
-Might develop secondary to a variety of systemic conditions, infections or medications

Oral Features:
-Mild to severe Gingival Hemorrhage, often unprovoked
-Petechiae or ecchymoses might be seen in oral mucosa

-Risk of periodontal surgery = Decreased blood clot formation

Front 103

Anemia

Back 103

-Abnormal reduction in circulating RED BLOOD CELLS

Clinical features - variety of manifestations depending on type of anemia:
-weakness, fatigability, dizziness, weight loss, pallor, shortness of breath, numbness & tingling of extremities

Oral Manifestations:
-Glossitis, atrophy of tongue papillae, burning sensation of tongue
-Gingival hemorrhage may occur

Front 104

Immune Deficiency

Back 104

HIV Infection:
-Fungal infections
-Bacterial infections
-Viral infections
-Neoplasms

CANDIDIASIS is the MOST COMMON oral lesion in HIV disease and has been found in ~90% of AIDS patients
-Pseudomembranous
-Erythematous
-Hyperplastic candidiasis
-Angular cheilitis

Front 105

Pseudomembranous candidiasis
(Therapy)

Back 105

-Removal of membrane
-Local & Systemic Antifungals

Fungal Infection in HIV

Front 106

Atrophic, Erythematous candidiasis
(Therapy)

Back 106

-Topical Chlorihexidine
-Antimycotic Diflucan

Fungal Infection in HIV

Front 107

Linear Gingival Erythema (LGE)
(Therapy)

Back 107

-Mechanical cleaning
-Iodine subG irrigation
-CHX rinses
-OHI

Fungal Infection in HIV
-Candida species?

Front 108

Necrotizing Ulcerative Gingivitis (NUG)
(Therapy)

Back 108

-Debridement
-CHX rinse
-Metronidazole, amoxicillin

Bacterial Infection in HIV

Front 109

Necrotizing Ulcerative Periodontitis (NUP)
(Therapy)

Back 109

Metronidazole: 250mg with 2 tabs taken immediately and then 1 tab 4X daily for 5-7 days

Bacterial Infection in HIV

Front 110

Herpetic Stomatitis
(Therapy)

Back 110

-Topical analgesics
-Systemic acyclovir
-Anti-inflammatory

Viral Infection in HIV

Front 111

Viral Infection in HIV

Back 111

Herpetic Stomatitis
Human Papilloma Virus

Front 112

Fungal Infection in HIV

Back 112

Pseudomembranous candidiasis
Atrophic, Erythematous candidiasis
Linear Gingival Erythema (LGE)

Front 113

Bacterial Infection in HIV

Back 113

Necrotizing Ulcerative Gingivitis
Necrotizing Ulcerative Periodontits

Front 114

Neoplasms in HIV

Back 114

Kaposi Sarcoma

Front 115

Kaposi Sarcoma

Back 115

-Angiosarcoma of endothelium of blood & lymph vessels
-Flat or exophytic
-Painless
-In 10-20% of ALL HIV cases (in the past; not as common today)

Front 116

Prognosis Definition

Back 116

act of foretelling the duration, course result and termination of a disease.
*depends on correctness/accuracy of diagnosis

Front 117

Short Term Prognosis

Back 117

Less than or equal to 5 years

Front 118

Long Term Prognosis

Back 118

Greater than 5 years

Front 119

Factors Affecting Prognosis of the Dentition

Back 119

Patient attitudes and Desires
Age
General Health
Control of Etiology
Strategic Teeth
Oral Hygiene
Economics
Operator Ability

Front 120

Factors Affecting Prognosis of an Individual Tooth

Back 120

Osseous support
Root anatomy
Crown-Root Ratio
Rate of Attachment loss
Mobility
Importance of tooth
Knowledge and skill of therapist

Front 121

Factors Affecting General Prognosis

Back 121

Systemic factors/health
Plaque (quantity and composition)
Calculus
Smoking
Iatrogenic Factors
Genetics
Occlusion?

Front 122

Evaluation Process Patient Factors

Back 122

Health
Behaviors
exposures
genetics

Front 123

Evaluation Oral Problem List

Back 123

decay
perio disease
recession
excessive gingival display
edentulism
trauma

Front 124

Evaluation Process

Back 124

Posterior dentition VS esthetic zone (esthetic risk)
gingival biotype (thin, thick)
Presence of inflammation
Crestal bone levels (perio disease, furcation involvement)

Front 125

Decision Making Process

Back 125

Can tooth/teeth be restored
Treatment Planning
Costs
Esthetic concerns
Compliance

Front 126

Is a smooth surface needed?

Back 126

-Soft tissue healing response
-Junctional epithelium readpts to root surface after SRP in uneven root surfaces
-Ultrasonic instrumentation is considered the best instrument for SRP in furcation areas

Front 127

Ultrasonic

Back 127

2 Types:
-Magnetostrictive --> elliptic vibration
-Piezoelectric --> linear vibration

-Vibrations are produced by a metal core, which can change dimension in an electromagnetic field with an operating frequency between 25,000 & 45,000 cycles/sec (Hz)
-Heat is produced during use & needs a coolant
-Sonic & piezoelectric generate less heat than Magenetostrictive
-Water cools frictional heat only & helps flush away debris

Front 128

Ultrasonic
(Advantages)

Back 128

-Reduction of time & fatigue
-All aspects of the tip work
-Uses water for cooling & lavage
-Improved access to areas such as furcations

-TF 10 (Black) for heavy calculus removal
-Slim-line (Green) for finishing & access

Front 129

Sonic

Back 129

-Sonic is AIR driven & vibrations are generated mechanically
-Vibrations of 2,000-6,500 cycles/sec (Hz)

-Some sonic scalers shown to be as effective for calculus removal as the ultrasonic
-Sonic scaler caused less root surface roughness than the ultrasonic

Front 130

Laser Instruments

Back 130

-Lack of evidence that this technology offers true advantage when compared to traditional methods

Front 131

Factors to Consider in Determining a Prognosis

Back 131

Overall clinical factors
Systemic and Environmental factors
Local Factors
Prosthetic and Restorative Factors

Front 132

Air Polishing

Back 132

-Air-powered slurry of warm water & sodium bicarbonate
-Ideal for extrinsic stain removal & soft deposits
-Tooth structure can be lost & gingival tissue injury can occur if improperly used
-Other powder: aluminum trihydroxide
-Recommend a pre-procedural rinse with 0.12% chlorhexidine gluconate to minimize the microbial content aerosol
-High-speed evacuation should always be used

Front 133

Overall Clinical Factors

Back 133

Patient age
disease severity
plaque control
patient compliance

Front 134

Systemic and Environmental Factors

Back 134

Smoking
Systemic disease or condition
Genetic Factors

Front 135

Air Polishing
(Contraindications)

Back 135

Respiratory illness
Hypertension
Sodium restricted diets (due to sodium bicarbonate)
Medications affecting electrolyte balance

Front 136

Local Factors

Back 136

Plaque and calculus
Subgingival restorations
Anatomic Factors

Front 137

Anatomic Factors

Back 137

Short, Tapered roots
Cervical enamel projections
Enamel pearls
Bifurcation ridges
Root concavity
Developmental grooves
Root Proximity
Furcation involvement

Front 138

Prosthetic and Restorative Factors

Back 138

Abutment selection
Caries
Non-vital teeth
Root resorption

Front 139

Perioscopy
(Periodontal Endoscope)

Back 139

-Statistically significant improvement in calculus removal during SRP, which was most evident in deeper PD sites
-Another study found no significant improvement in calculus removal in multirooted molar teeth

Front 140

Clinical Outcome of SRP Treatment

Back 140

1. Gingival Recession
2. Reduction of PD & slight gain in CAL
3. Reduced BOP
4. Radiographic bone fill

Front 141

Excellent Prognosis

Back 141

No bone loss
Excellent gingival condition
Good patient cooperation
No systemic or environmental factors

Front 142

What causes Reduction of Probing Depth?

Back 142

1. Shrinkage of swollen tissue (no more inflammation)
2. Long Junctional Epithelium formation no longer allows deep probe penetration

Front 143

Good Prognosis

Back 143

One or more of the following:
Adequate remaining bone support
Adequate possibilites to control etiologic factors and maintainable dentition
Adequate pt cooperation
No systemic or environmental factors
Systemic factors if present are well controlled

Front 144

Fair Prognosis

Back 144

One or more of the following:
Less than adequate remaining bone support
Some tooth mobility
Grade I furcation
Adequate maintenance possible
Acceptable pt cooperation
Presence of systemic or environmental factors

Front 145

Poor Prognosis

Back 145

One or more of the following:
moderate to advanced bone loss
tooth mobility
Grade I, II furcation involvements
Difficult to maintain areas
Doubtful pt cooperation
Presence of systemic or environmental factors

Front 146

Questionable Prognosis

Back 146

One or more of the following:
Advanced bone loss
Tooth Mobility
Grade II, III furcation
Inaccessible areas
Presence of systemic or environmental factors

Front 147

Hopeless Prognosis

Back 147

One or More of the following conditions:
Advanced bone loss
Non-maintainable areas
Extractions indicated
Presence of uncontrolled systemic or environmental factors

Front 148

Plaque and Oral Hygeine

Back 148

Qualitative VS Quantitative
Periodic Removal/Disruption
Habits

Front 149

Root Anatomy & Furcation Involvement

Back 149

Increased root separation = increased area for attachment
Less favorable short and long term if furcation is exposed
Difficult area for patient to keep clean
Difficult to treat periodontally

Front 150

Crown to root ratio

Back 150

increased crown to root ratio=decreased prognosis

Front 151

Restorations/ Structural Anomalies

Back 151

Iatrogenic: Overhangs, biologic width Violations
Developmental: root proximity, enamel pearls, enamel projections

Front 152

Rate of Bone Loss

Back 152

Variable, influenced by local hygiene, tooth anatomy, iatrogenic factors
Increased rate of bone loss = decreased prognosis

Front 153

Etiology of Mobility

Back 153

Loss of attachment
Inflammation
Occlusal Trauma
Increased mobility=decreased prognosis

Front 154

Importance of Tooth

Back 154

Prognosis of strategic teeth linked to restorative potential and periodontal support

Front 155

How long does it take a healthy individual to develop Gingivitis?

Back 155

~15-21 days

Front 156

How long does it take for an individual to get back to good oral health?

Back 156

~7-10 days

Front 157

Initial Periodontal Therapy

Back 157

-Patient education & motivation
-OHI/daily antimicrobials
-Scaling & root planing combined or not combined with antimicrobials
-Removal of additional retention factors for plaque (i.e.restoration overhangs, ill-fitting crowns, etc)
-Minor restorative work
-Extraction of hopeless teeth

Front 158

Criteria for Periodontal Surgery

Back 158

Gingivitis & Slight Periodontitis = No Surgery; OHI & ScRP
Moderate Periodontitis = OHI & ScRP; Surgery (?)
Severe Periodontitis = OHI & ScRP; Surgery

Front 159

Mechanical Plaque Control

Back 159

-BEST APPROACH for the prevention & treatment of Gingivitis
-Prevention of gingivitis requires only METICULOUS removal of plaque every 48 hours
-No more than 60% of the overall plaque is removed at each episode of oral hygiene
-the MAIN benefit of 2X/day oral hygiene is the CHEMICAL ACTION of the DENTIFRICE
-Studies show that gingival health improves with up to 2X/day brushing, but not more frequently

Front 160

Mechanical Plaque Control
(Toothbrush Design)

Back 160

-Long contoured handle performed better than short & flattened
-Small head size is best
-Arrangement & height of filaments do no matter. High filament density is more effective.

Front 161

Powered Toothbrushes

Back 161

-Higher compliance (62% of participants in on study showed continued daily use for 36 months)
-May removed 84% of the plaque in 2 minutes & 93% in 6 minutes
-In a study, Plaque & Gingivitis reduction were only shown in Rotation oscillation brushes (OralB)

Front 162

Clinical Studies on Oral Hygiene

Back 162

-Lack of reinforcement of oral hygiene over time increased poor compliance
-2-10% of the population floss regularly & effectively
-A substantial part of the population never floss at all
-Patient's average brushing time is 37 seconds
-Only 10% of the population floss daily
-Only 20% of the patients regularly perform acceptable flossing

Front 163

Irrigation Devices

Back 163

-1,200 pulsations/minute with pressure of 55-90 psi reduces bleeding & gingivitis
-Many patients think this is a substitute for flossing (it is NOT)
-Does NOT removed Plaque

Front 164

Dentifrice
(ADA Approval)

Back 164

An agent with antiplaque activity must have demonstrated a significant benefit on gingival health in randomized controlled studies of at least 6 months duration to receive approval by the ADA

Front 165

Dentifrices
(Main Components)

Back 165

-Mild abrasiveness --> to remove debris & residual surface stains (ex: calcium carbonate, dehydrated silica gels, hydrated aluminum oxides, magnesium carbonate, phosphate salts & silicates)
-Fluoride --> to remineralized tooth (All ADA-Accepted toothpastes contain fluoride)
-Humectants --> to prevent water loss (ex: glycerol, propylene, glycol & sorbitol)
-Flavoring agents
-Thickening agents --> to stabilize the formula
-Detergents --> to create foaming action

Front 166

Antimicrobial Mouthrinses

Back 166

-Biofilm cannot be suppressed by mechanical methods only (for most pts)
-Evidence supports the adjunctive use of mouthrinses on a daily basis

Front 167

Meta-Analysis

Back 167

Systematic review of literature to evaluate the efficacy of antigingivitis & antiplaque products in 6 months trials

Front 168

Meta-Analysis for Dentifrices

Back 168

-17 studies support antiplaque, antigingivitis effects of dentifrices containing 0.30% triclosan & 2.0% gantrez copolymer
-No evidence of efficacy for triclosan with either soluble pyrophosphate or zinc citrate
-Stannous fluoride has a marginal clinical significance as an antiplaque agent, but is both clinically & statistically significant as an antigingivitis agent

Front 169

Meta-Analysis for Mouthrinses

Back 169

-21 studies support essential oils as efficacious mouthrinses
-7 studies support a strong antiplaque, antigingivitis effect for 0.12% Chlorhexidine
-Results for cetylpyridinium chloride vary & depend on the product's formula

Front 170

Scaling

Back 170

Instrumentation of crowns & root surfaces of the teeth to remove plaque, calculus & stains from these surfaces

Front 171

Root Planing

Back 171

A treatment procedure designed to remove cementum or surface dentin that is rough, impregnated with calculus, or contaminated wiht toxins & microorganisms

Front 172

Scaling & Root Planing: Rationale

Back 172

-Smooth surfaces are easier to clean & maintain
-Less potential to accumulate plaque & calculus
-To eliminate biologically-incompatible cementum/dentin (cementum-bound endotoxin)
-To make root surfaces biologically compatible for healing & long-term care

Front 173

Removal of Calculus

Back 173

-Sites with PD>5mm have consistently shown remaining calculus after "closed" ScRP
-Surgically treated sites have shown improved efficacy of ScRP

Front 174

Other Factors of Calculus Removal

Back 174

Root Anatomy:
-Single-rooted vs. multirooted
-Concavities
-Tooth furrows

Skill of the operatore
-Experience becomes more relevant in deep PD>6mm sites

Time allowed:
-Hand instruments: 6-8 min/tooth
-Ultrasonic instruments: 4-6 min/tooth

Front 175

Ultrasonic & Sonic Scalers

Back 175

-Outcome: uneven root surface
-Supplement with hand instrumentation for smoother surface
-4-7mm pockets responded equally well to ultrasonic vs. hand instruments

Front 176

Results After ScRP
If Initial Probing Depth <3mm
(Non-Molar Sites)

Back 176

Probing Depth Reduction = 0.5mm

Attachment Change = -0.5mm

Front 177

Results After ScRP
If Initial Probing Depth 3-6mm
(Non-Molar Sites)

Back 177

Probing Depth Reduction = 1.0 - 1.5mm

Attachment Change = -0.5/+0.5mm

Front 178

Results After ScRP
If Initial Probing Depth 7-10+mm
(Non-Molar Sites)

Back 178

Probing Depth Reduction = 2.5 - 5.0mm

Attachment Change = +0.5/+2.0mm

Front 179

Full-Mouth Disinfection (FMD)

Back 179

-Moretti says is does NOT work to add FMD

Front 180

Systemic Antibiotics in Periodontics

Back 180

-For common forms of gingivitis & periodontitis, ScRP should always be carried out before antibiotics are administered
-Development of resistant bacterial strains is a major concern in medicine

Front 181

Systemic Antibiotics in Periodontics
(Main Indications)

Back 181

Refractory Cases (no response to tx)
Aggressive Periodontitis
Medical conditions (i.e. Diabetes)
Acute periodontal infections (abscess, NUG/NUP)
Periodontal Regeneration Surgeries
Implant Dentistry
Post-surgical infections

Front 182

Selection of Antibiotics

Back 182

-Travels easily to infection site
-Concentration in GCF, gingiva & bone
-Minimal side effects
-Research showing efficacy
-Microbiological Culture & Sensitivity Test?

Front 183

Penicillin

Back 183

Bactericidal

Front 184

Tetracycline

Back 184

Bacteriostatic

Front 185

Minocycline

Back 185

Bacteriostatic

Front 186

Doxycycline

Back 186

Bacteriostatic

Front 187

Metronidazole

Back 187

Bactericidal

Front 188

Clindamycin

Back 188

Usually Bacteriostatis

Bactericidal in high doses

Front 189

Ciprofloxacin

Back 189

Bactericidal

Front 190

Azithromycin

Back 190

Bacteriostatic

Front 191

Combination Therapy
(Advantages)

Back 191

-Broadens antimicrobial range of the therapeutic regimen of a single antibiotic
-Prevents emergence of resistant bacteria through overlapping antimicrobial mechanisms
-Lowers the dose of individual antibiotics by exploiting possible synergy between 2 drugs

Front 192

Combination Therapy
(Disadvantages)

Back 192

-May increase adverse reactions
-Potential for antagonist drug interactions with improperly selected antibiotics

Front 193

Combination Therapy

Back 193

-DO NOT combine bactericidal with bacteriostatic (cancels the effects of both)
-Most common = Amoxicillin + Metronidazole
-Augmentin + Doxycyclin (Must be used SEQUENTIAL)
-Ciprofloxacin - Metronidazole

Front 194

Conclusions on Systemic Antibiotics

Back 194

-In periodontics, systemic antibiotics should be an exception rather than the rule
-If indicated, they should be used as adjuncts to mechanical therapy
-They should not be used in cases of poor plaque control
-Evidence has shown that they offer little, it any, adjunctive effect on smokers
-Considered especially in refractory & aggressive cases of periodontitis (also in acute conditions & some medical situations)
-Current trend favoring combined antibiotic therapy

Front 195

Topical Antimicrobial Agents

Back 195

-Pathogens may be unreachable (furcation, dentin tubules, biofilm, deep vertical defects)
-Local delivery (Pocket irrigation, drug ointment/gel, prolonged release)

-The average patient MAY have PD REDUCED 1mm
-No significant change in CAL; BOP reduced 50% on average

-Up to the clinician if they want to use these products

Front 196

Subgingival Irrigation

Back 196

-Washed out rapidly by the GCF
-Half-life of a non-binding drug is 1 minute
-Levels don't reach the MIC (Minimal Inhibitory Concentration) for oral microorganisms

-Chlorhexidine & tetracycline (high substantivity)

Front 197

Supragingival Irrigation

Back 197

Will not reach deeper parts of the pocket

Front 198

Local Delivery Devices should

Back 198

-Establish a drug reservoir
-Have effective concentration
-Be active for prolonged period of time
-UNC SOD uses "Arestin"

Front 199

Periodontium Pro-Inflammatory Mediators

Back 199

IL-1Beta
IL-6
TNF-alpha
PGE2
MMPs

Front 200

Host Modulators

Back 200

-NSAIDs
-Bisphosphonates?
-Statins?
-Low-Dose Doxycycline

Front 201

Periodontium Natural Enzyme Inhibitors

Back 201

TGF-Beta
IL-4
IL-10
IL-12
TIMPs

Front 202

Pathogenesis of Periodontal Disease
(Smokers)

Back 202

Chronic Overproduction of Tissue Destructive Enzymes (Bone Loss, Deeper Pockets are Greatly Affected)

-Studies show smokers have less favorable response to traditional modes of periodontal therapy
-Smoking INCREASES levels of pro-inflammatory mediators; INCREASE release of DESTRUCTIVE COLLAGENASE
-Periostat DECREASES pro-inflammatory mediators & collagenase

Front 203

What is the ONLY drug available to help PREVENT periodontitis?

Back 203

PERIOSTAT (Doxycycline Hyclate)

Front 204

How does PERIOSTAT work?

Back 204

Subantimicrobial agent - Does not reach the Minimal Inhibitory Concentration in the blood to kill bacteria.
A small amount of the drug changes the immune response of MMPs & alters the disease progression to help reduce the rate of destruction of the periodontium

-Should be taken 2X/day for 3-9 months (very costly)
-Studies show statistically significant improvement with respect to PD reductions & gains in CAL when compared to ScRP alone.