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113 Cards in this Set
- Front
- Back
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Chief Complaint & Caution
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Headline sentence containing patient identification & data, followed by main reason for visit
Add note if source and reliability are questionable |
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History of present illness & dimensions of symptoms
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Describe each presenting complaint & include dimesions of symptoms such as: LQCSATADA
Location - Where? Does it move Quality - What does it feel or look like. Chronology - onset, duration, frequency, evolution Severity - Does it interrupt activities or sleep Aggravating and alleviating factors Treatment - Self treated? Associated symptoms Disability & Adaptation - How it has affected you & those around you. How you managed. Attributions - What do you think caused it, what has it meant to you. |
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Past Medical history
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MPOMAHSETDH
Medical conditions or illnesses Past hospitalizations Operations or injuries Medications Allergies Habits - Smoking, Drugs Sexual Hx - Birth control Exposures Travel Diet Health maintenance - Regular eye, dental, physicals |
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Social History
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BWRFLRSM
Background Work Residence Family/relationships Leisure Religion Satisfaction/stress Medical costs |
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Family History
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Parents
Siblings Children General - Health problems that run in the family |
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Dental History
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PFLLFP
Past perio treatment Family history Last dental visit Last scaling Frequency of recall Problems with treatments? Home care - Toothbrush, floss, rinse |
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Three parts of perio probe
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Handle Shank Working end
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Probing depth vs Attachment level
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Probing depth - Gingival margin to deepest point reached by probe
Attachment level - Distance from fixed point like CEJ to deepest point. Not affected by position of gingival margin |
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Uses of PD probe(5)
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Estimate pocket depth & attachment loss
Quantify plaque Quantify gingival inflammation, recession & width Approximate configuration of bony defect Relationship of pocket depth to mucogingival junction |
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Factors affecting probing
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Morphology of root
Inflammation Depth of pocket Obstructions Force Angulation of probe Probe width Shape of probe tip Local factors Prior treatments Reproducibility Repeated probing |
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Nabor's probe
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Instrument used to detect layout and extent of furcations
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Modified Hamp Index
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Degrees
1: <3mm horizontal loss of attachment 2: >3mm horizontal loss of attachment but does not encompass total width of furcation 3: Horizontal through and through destruction of PD tissue 4: Visible through and through furcation |
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Glickman Classification
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Grade
I - Incipient or early when pocket is suprabony primarily affects soft tissue. No radio II - Has horizontal component with communicating furcas. May have vertical bone loss. Maybe radio III - Through and through with definite radio IV - Clinically visible furcation |
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Vertical classification
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Subclass
A: 1-3mm vertical depth B: 4-6mm C: >7mm Class A: Destruction up to 1/3 interradicular height Class B: 2/3 Class C: Into apical 1/3 |
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Automatic constant Force probe
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Precision of 0.1mm with a range of 10mm. Sterilizable with constant probing force & digital readout
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Tooth mobility
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Miller classification
0: No mobility 1: Perceptible mobility 2: <1mm facial-lingually but no apical movement 3: >1mm apical as well as lateral movement |
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Causes of tooth mobility (6)
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Attachment loss
Occlusal trauma Spread of inflammation PD surgery (Transient) Pregnancy Pathology in Jaws |
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Fremitus
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Palpable with visible movement of tooth when subjected to occlusal forces
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Normal height of crestal bone in relationship to CEJ
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1.5-2mm apical
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Fenestration vs Dehiscence
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Window vs complete opening with massive root exposure
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Exhostosis
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Benign growth of bone on top of bone
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Osseous Defects
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Suprabony - Horizontal bone loss with 0 walls
Infrabony - Vertical bone loss with 1,2, or 3 walls which affects only 1 tooth. Craters are 2 walls & affects 2 adjacent root surfaces similarl. Interradicular defects - With furcation involvement |
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Interradicular defects classifications
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Horizontal classification - I,II,III,IV
I - Less than 3mm horizontal attachment loss II - More than 3mm but not through and through III - Through and through IV - Clinically visible furcation Vertical classification Subclasses A,B,C A - Vertical bone loss of 3mm or less B - 4-6mm C- 7mm or more |
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Topography of Osseous defects
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Soft tissue pockets - Pseudo/gingival, suprabony & infrabony
Anatomic osseous defects - Horizontal vs vertical loss Remaining osseous walls |
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Hemiseptum
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Osseous defect with only proximal wall remaining
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When interproximal bone is more apical than bone on radicular surface
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Reverse Architecture
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Moat
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Circumferential bone loss with four remaining osseous walls
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Radiograph uses (7)
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Detects:
Boneloss Widened PDL space Crown to root ratio Shape of root to length of root trunk Root proximity Implant evaluation Pathologies |
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Radiographs in diagnosis of PD
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- Not a substitute but only supplement to clinical examination
- Earliest signs of PD must be detected clinically while radiograph is helpful in detecting existing disease |
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Lamina Dura
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Thin radiopaque border adjacent to PDL
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Presence of widened PDL space
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Combined with fremitus could indicate occlusal trauma
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Crown to Root ratio
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Extra-alveolar to intraalveolar ratio of tooth not anatomic crown to root ratio
1:1 ratio is limit for favorable prognosis |
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Chronic & Aggressive Periodontitis classifications
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Extent: Localized ≤30% vs Generalized >30%
Severity Slight: 1-2mm or 0-25% bone loss Moderate: 3-4mm or 25-50% bone loss Severe: 5mm or >50% bone loss |
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Medications that induce overgrowth
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Dilantin
Cyclosporin Ca++ blockers |
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Factors determining PD diagnosis (5)
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- Age of onset
- Rate of progression - Presence or absence of clinically detectable inflammation - Extent and pattern of attachment loss - Signs & symptoms like pain, ulceration, plaque, calculus |
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Theories of PD disease progression
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Continuous paradigm - Localized sites show progressive loss of attachment over time
Random Burst - Activity is random with multiple bursts & extent varies with site Asynchronous multiple burst - Several sites exhibit bursts over finite period then prolonged inactivity. Other sites have no activity. |
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Etiology of PD
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Plaque & Host response
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Tooth accumulated materials
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Acquired pellicle
Food particles Plaque - Biofilm Calculus Materia alba |
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Mediators that determine events in Periodontitis
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Proinflammatory/Destructive
- IL-1B - IL-8 - TNF-a - Prostaglandin E (PGE) - Matrix Metalloproteinases (MMP) Anti-inflammatory/protective - IL-1ra - IL - 4 - IL - 10 - Transforming growthfactor B (TGF-B) - Tissue inhibitor of matrixmetalloproteinases (TIMPs) |
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Risk Factor vs indicator
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Risk Factor - Environmental, behavioral or biologic factor that directly increases probability of disease occuring. If removed, reduces that probability.
Risk Indicator - Probable contributing factor that has not yet been confirmed. |
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Risk factors associated with PD disease
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Diabetes
Smoking Red Complex - Troponema denticola, Porphyromonas gingivalis, Bacteroides forsythus |
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Risk indicators associated with PD
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Aging, Gender, genetic predispositions, systemic illnesses, stress, calculus, nutrition, home care
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Local contributing factors to PD disease (6)
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Anatomical factors
Iatrogenic factors Calculus Trauma Chemical injuries Caries |
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Prognosis & when determined
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Prediction to the progress, course, outcome of disease, & results of treatment
Determined after the diagnosis & before treatment plan |
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Criteria for successful prognosis (3)
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- Recognize, control or eliminate etiological factors
- Ability to correct damage - Patient's attitude |
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Factors affecting overall prognosis (5)
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Age
Medical status Risk factors: Smoking, Diabetes Rate of progression Patient cooperation & compliance |
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Factors involving individual prognosis (6)
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Percentage bone loss
Probing depth Mobility Distribution & type of bone loss - Revealed at time of surgery Root anatomy - More surface area better for PDL. Root concavities & palatal grooves Crown to root ratio - 2:1 is good |
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Furcation involvement factors (5)
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- With class III furcation, the most difficult problem & reason for failure is caries
- Maxillary 1st premolar with furcation involvement has poorest Px. - Mandibular more favorable than maxillary - Mandibular First molar more favorable than second due to external oblique ridge - Maxillary molars with buccal & mesial furca more favorable than molars with distal furca due to access |
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Characteristics of Hopeless teeth (4)
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Mobility of Class 3
Bone loss beyond apex Vertical fractures Non-restorability due to extensive caries |
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McGuire & Nunn's system for prognosis
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Good - Control of etiological factors & adequate PD support. Easy to maintain by patient
Fair - 25% attachment loss and/or class I furcation involvement Poor - 50% attachment loss with Class II furcations. Questionable - Greater than 50% attachment loss resulting in poor crown to root ratio. Mobility of 2 or greater with class II to III furcations. Close to root Hopeless - Inadequate attachment to maintain tooth. Extraction |
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Objectives of Periodontal Care (5)
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Remove etiologic factor
Maintainable pocket depths Create maintainable gingival & Osseous architecture Restore function & Esthetics Maintenance by patient & doctor |
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Advantages to shallow Pocket depths (4)
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Easier to clean
Less bleeding Less anaerobes Less possibility of disease progression |
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Treatment plans
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Initial preparation/therapy:
- Control inflammation - Remove Accretions - Control Etx - Substitute program of homecare Through - Oral hygiene instruction, Scaling & root planing, Operative, extraction of hopeless teeth Reevaluation or Presurgical evaluation - OH status - PD condition - Mobility - Need for PD surgery - Occlusal adjustment - Splinting Periodontal surgery: Sextant analysis -Specific area & Type of surgery required - Implants surgery Post surgical evaluation Fixed/Removable prosthodontics PD maintenence |
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Treatment plan Presentation
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- Describe pathogenesis & clinical findings
- Encourage questions - Discuss length of treatment & costs - Obtain informed consent |
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Goal of PD therapy
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To preserve dentition in a state of health, comfort & function with appropriate esthetics
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Clinical Parameters used to judge success of PD therapy (4)
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- Reduction in bleeding upon probing.
- Reduction in probing depth & regain attachment - Occlusal stability - Aesthetic satisfaction |
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Biofilm
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An accumulation of microbial cella within a matrix to optomize use of available nutrients.
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Effects of plaque removal
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Retard calculus formation
Resolve gingival inflammation Plaque reorganizes supra and subgingivally within 24hrs. |
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Oral hygiene in Ex
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Can be considered a contributing factor or risk indicator
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Oral hygiene instructure
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Establish need in patient's mind
Motivate Instruct Reinfore |
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Oral Hygiene Evaluation
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Question current practices
Allow pt to demonstrate Examine dentition for plaque, calculus, stain |
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Toothbrush Bristle characteristics (3)
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-Rounded ends
-Bristle hardness is propotional to diameter squared & inversely proportional to length squared. - Made natural from hogs or artificial nylon |
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Dentrifice components
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Abrasives such as silicon, oxides, & Granular polyvinyl chlorides
Water Soap or detergent Flavoring Therapeutic agents such as flourides |
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Dentrifice abrasion precautions
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Powder is 5x more abrasive than paste & can be a problem for pts with root exposure.
Dentin abraded 25x faster than enamel & 35x for cementum. |
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Triclosan & pyrophosphate
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Triclosan - Anti-plaque
Crest - Anti-calculus |
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Potassium nitrate & peroxide
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Potassium nitrate - Desensitizing agent
Peroxide - Whitening agent |
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Dentrifice abrasives
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Phosphates
- Dicalcium phosphate dihydrate - Calcium pyrophosphate to reduce calcium ion availability & increase flouride ion Carbonates - Sodium bicarbonate - least abrasive - Calcium carbonate (Chalk) Silicas - Cleans and thickens toothpaste |
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Potential side effects of Tartar control toothpaste
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Perioral rash & bronchospasm
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Stannous flouride
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Antibacterial flouride good for plaque/gingivitis, caries, & sensitivity. However, requires stabilization
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Sodium Hexametaphosphate
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Advanced anticalculus and whitening agent
Higher molecular weight & greater tooth coverage Strong attraction to calcium hydroxyapetite |
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Mechanism of tooth sensitivity
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Dentinal tubules contain fluids from pulp that can transmit pain
- Cold fluids shrinks - Air evaporates fluid - Sweets cause osmotic movement Mechanoreceptors of pulpal nerves also attach to odontoblasts & protrude into the tubule |
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Causes of sensitivity (6)
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Acids from foods
Abrasions Restorative procedure Fracture Scaling/Root planing Bleaching agents |
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Ways of reducing sensitivity (4)
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Plugging or sealing tubules
Saliva for remineralization Burnishing Ions - such as Flouride, potassium nitrate, oxalate, Calcium phosphate |
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Key of toothbrushing
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Thoroughness & manipulative skills of brusher
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Indications for interdental aids
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Size of interdental space
Tooth misalignment Presence of furcation Orthodontic appliances Presence of fixed prosthesis |
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Gingival massage
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May produce epithelial thickening, keratinization & increased circulation but it is questionable of any of this will protect against microbes & other local irritants.
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Oral irrigation Devices advantages & disadvantages
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May remove debris around ortho & pros
May disrupt plaque Can be used to deliver chemotherapeutics - However, may cause transient bacteremia following irrigation |
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Plaque Score technique
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Use water soluble dye like Erythrosine
Record stainable plaque on all four surfaces of six preselected teeth 0 - No plaque 1 - film of plaque at free gingival margin 2 - Moderate accumulation within gingival crevice visible to naked eye 3 - Abundance of soft matter within gingival crevice Average score for tooth and mouth |
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Effects of medications on plaque
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Patients taking Anti-depressants & Anti-hypertensives had more plaque
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Epidemiology & Objectives (5)
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Study of distribution & determinants of diseases & application to control health problems
Objectives - Identify cause & risk factors - Identify extent of problem - Study history & prognosis - Evaluate existing & new preventative & therapeutic measures - Provide foundation to develop public policy & regulations |
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Incidence
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Number of new cases that occur during a specific time / Number of persons at risk of developing the disease during that time
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Prevalence
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Proportion of population that has the disease
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Case fatality rates
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Number of individuals dying during specified period of time after disease onset / number with the disease
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Criteria for causality (4)
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Strength of association
Biological plausibility Dose-response effect Temporality |
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Effects of smoking on PD
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Vasoconstriction to cause ischemia
Direct damage to macrophages & fibroblasts to delay wound healing Less bleeding due to tissue keratinization |
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Scaling & rationale
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Instrumentation of crown and root to remove plaque, calculus and stains
Calculus is a mechanical irritant, provides surface area for plaque & Interferes with plaque removal |
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Root planing
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Treatment procedure designed to remove cementum or surface dentin that is impregnated with calculus or contaminated with toxins or microbes. Some unavoidable soft tissue removal occurs.
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Goals & objectives of scaling & root planing
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Decrease bacterial load
Create a smooth hard cementum surface free of calculus & toxins Produce tooth surface that is biocompatible with sulcular epithelium Decrease inflammation, pocket depths & gain attachment |
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Endotoxin characteristics
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Can penetrate up to 12 microns beneath cemental surface & attracts inflammatory cells, cytokines, stimulates bone resorption etc.
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Root modification
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Scaling & root planing may create a smear layer of irregular dentin surface & rinsing will not remove it. Less endotoxin
Cervical cementum may be removed in 1-4 strokes |
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Pathogenic bacteria in scaling & root planing
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Effective against motile rods & spirochetes
Ineffective against invasive Porphyromonas gingivalis & Actinobacillis Actinomycetemcomitans |
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Scaling & root planing factors to consider (4)
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Severity of PD disease
Inflammation, bleeding, suppuration Tissue contour, tone & architecture |
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Reduced pocket depths after scaling/root planing due to, & time
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Recession of gingiva
Gain in attachment level Inability to probe a pocket due to close adaptation of gingiva to tooth Healing in 4-6 weeks & 9-12 months for maturation of periodontium |
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Advantages of calculus removal prior to surgery
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Decreased inflammation to make tissue easier to incise & reflect
Decrease amount of time flap needs to be open Possibly eliminate surgery altogether |
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Critical probing depth
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2.9mm scaling
4.2mm surgery 5.5mm osseous surgery |
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Patient operator position 2&4
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Patient:
Supine with feet leveled during maxillary Back of chair raised 30-40 degrees for mandibular Operator: Height of chair should be at elbow height Right handed between 8-1 Left between 11-4 Feet flat & back straight |
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Ergodynamics
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Hips slightly higher than knees by 5-15 edegrees
Position knees under patient Feet firmly on floor |
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Anatomy of an instrument
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Terminal shank between blade & first bend
Functional shank extend from working end to the shank bend closest to handle. Working end - face, cutting edge, back, toe |
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Instrument handle factors
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Weight: Hollow handle increases tactile transfer & decreased muscle fatigue
Diameter: Larger handle maximizes control & reduces fatigue Serration: Smooth handle decreases control & increases fatigue |
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Balanced instrument
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Working end centered on line running through long axis of handle
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The Sickle
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Used for supragingival calculus for anterior teeth
Anterior sickle scaler - blade & shank in same plane Posterior sickle scaler - angulated shank |
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The hoe
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Similar action to chisel with pull stroke.
Sharp corners & limited application with subgingival calculus |
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The chisel
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Push stroke for mandibular anterior proximal
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The File
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Miniature series of hoes on a single blade
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The Curette uses, shape & strokes
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For supra and subgingival scaling & root planing.
Spoon shaped Push/pull strokes |
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Gracey Curettes
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Specific
1/2,3/4,5/6 - Anterior teeth 7/8,9/10 - Facial & lingual of posterior teeth 11/12 - Mesial of posterior 13/14 - Distal of posterior |
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Columbias
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More universal
2R2L for anterior 4R4L for posterior 13/14 used for anything |
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Gracey vs Universal curette
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Gracey
Facial surface is 60-70 degrees to shank Site specific One cutting edge Universal Facial surface is 90 degrees to shank Non-site specific Two cutting edges |
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Instrument activation
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Adapt blade to tooth surface
Close blade Insert blade to base of pocket Opel blade to establish cutting edge lock fingers on curette Apply fulcrum pressure & lateral pressure on tooth Move instrument apical and coronal push pull |
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Fulcrums(5)
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Built-up fulcrum
Split fulcrum Cross arch fulcrum Opposite arch fulcrom Extraoral fulcrum |
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Polishing
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To remove supragingival plaque & stain with prophy paste.
Can remove up to 5 microns of enamel Ribbed cup causes more heat |
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Prophy jet
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Very effective in removing stain
Uses sodium bicarbonate However, can abrade epithelium |
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Root conditioning
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Citric acid
Tetracycline Ethylenediaminetetraacetic Acid (EDTA) May help to remove smear layer caused by scaling/root planing |
