Perio

Front 1

Gingival enlargement

Back 1

Marginal, Papillary, Diffuse, Discrete

Front 2

Drug induced gingival enlargement

Back 2

Painless
Usually does not bleed
Most severe in anterior sextants
Disappears when teeth are extracted
Recurs with surgical excision
Disappears within months of drug discontinuation

Front 3

Histopathology of drug induced enlargement

Back 3

Hyperplasia
Acanthosis
Elongated rete pegs
Increased fibroblasts and new blood vessels

Front 4

Dilantin

Back 4

Phenytoin - Anticonvulsant
- Not related to dosage after threashold
- Stimulates fibroblast-like cells and inactivates collagenase

Front 5

Cyclosporin

Back 5

Immunosupressant to prevent organ transplant injection by inhibiting T cells
- Plasma cells, abundant amorphous extracellular substance
- Overgrowth starts within 1-3 months of drug initiation

Front 6

Nifedipine

Back 6

Calcium channel blockers

Blocks intracellular mobilization of calcium to dilate coronary arteries and peripheral vasculature

Front 7

Benign gingival tumors

Back 7

Epulis - Benign tumor
Fibroma - Arise from gingival CT or PDL
Papilloma - Associated with HPV
Peripheral Giant cell Granuloma
Pyogenic granuloma - Chronic inflammatory, nonspecific enlargement

Front 8

Malignant gingival tumors

Back 8

Squamous cell carcinoma
Malignant Melanoma
Metastasis to gingiva

Front 9

Hereditary gingival fibromatosis

Back 9

Autosomal Dominant
May completely cover teeth
Delay eruption

-Onset common during eruption of permanent incisors, but may involve deciduous teeth
- Gingiva is firm and not retractable. Enlargement does not extend beyond mucogingival junction

Front 10

Treatment of gingival enlargement depends on what?

Back 10

Function of weather:
Fibrotic: From medication
Inflammation: From plaque

Front 11

Grades of gingival enlargement

Back 11

0 - No enlargement
1 - Confined to interdental papilla
2 - Papilla and marginal gingiva
3 - Covers 3/4 of crown

Front 12

Systemic diseases causing enlargement

Back 12

Pregnancy tumor - Hormones increase vascular permeability and exposure to prevotella intermedia.

Leukemia - Firable gingiva, bleeding

Wegener's granulomatosis - Granulomatous necrotizing lesions of respiratory tract

Vitamin C deficiency - Enlargement due to plaque. Extent of inflammation is exaggerated due to hemorrhage.

Front 13

Indications for Treatment of Gingival Overgrowth

Back 13

Aesthetics
Access for home care
Interference with speech, function, or tooth eruption

Front 14

Treatment of gingival enlargement

Back 14

Discontinue or change medication - Medical consult required

Plaque control
Perio surgery - Flap surgery, gingivectomy
Lasers
Maintain as is
Periodontal maintenance
Positive pressure appliance

Front 15

Adaptive capacity

Back 15

Ability of teeth and tissues of periodontium to adapt to forces acting on periodontium without injury

Front 16

Radiographic signs of occlusal trauma

Back 16

- Widened PDL space
- Bone loss (Furcation, vertical, circumferential)
- Root resorption

Front 17

Primary occlusal trauma definition and examples

Back 17

- Injury to healthy periodontium under excessive force. Usually reversible

High restoration
Shifting of teeth
Ortho

Front 18

Malocclusion and Perio

Back 18

- Does not necessarily produce trauma especially if periodontium can adapt to it
- Does not cause Gingivitis or Periodontitis

Front 19

Occlusal adjustment and reasons

Back 19

Reshaping of occlusal surfaces of teeth by grinding to create harmonious contacts
- Eliminate lateral interference and preserve supporting cusp tips
- Round teeth edges to reduce contact area during parafunction

Reduce mobility, muscle pain and dysfunction, and prevent development of abnormal wear patterns

Front 20

Occlusal indicators and diagnostic aids

Back 20

Marking paper
Floss
Wax recording
Direct inspection
Fremitus detection with direct finger pressure

Front 21

Sequence of Occlusal adjustment

Back 21

1) Preliminary recontouring & Emergencies
2) Elimination of centric interference
3) Elimination of eccentric interference in protrusive and lateral
4) Re-examination of centric
5) Smooth all surfaces except centric stops

Front 22

Preliminary reshaping

Back 22

Emergency adjustments
Marginal ridge relaitonship
Correct for abnormal occlusal wear and wear facets
Reshape for extruded teeth

Front 23

Hawley bite plane

Back 23

6 anterior teeth in contact with platform
- Stabilize tooth position and increases vertical dimension
- Reduces myospasm but can get supraeruption of unopposed teeth. So use short term

Front 24

Vesicle vs Bulla

Back 24

Vesicle - Small 2-5mm circumscribed, elevated lesion with a thin surface covering with accumulation of fluid.

Bulla - Large vesicular type lesion ranging from 5mm to several cm. Covering may be tense or lax depending on fluid volume

Front 25

Dermatoses

Back 25

Lichen planus
Mucous membrane pemphigoid
Bullous pemphigoid
Pemphigus

Front 26

Lichen planus

Back 26

Unknown etiology with epithelial basal cells as primary target
- Involves langerhans cells, Tcells and Macrophages

Front 27

Cicatricial Pemphigoid

Back 27

Sub-basilar separation of epithelium from underlying connective tissue
- Females more
- Patchy erythema extending beyond mucogingival junction
- Ocular lesions often exhibit progressive scarring which can lead to blindness

Front 28

Pemphigus

Back 28

Acantholysis - Loss of intracellular connections and rounding of keratinocytes floating freely within blister fluid

Front 29

Erythema Multiforme

Back 29

Mucocutaneous disease with prodrome
- Fever, headache, malaise, nausea, vomiting and diarrhea

Front 30

Treatment of NUG

Back 30

First visit:
- Review history, H&N exam paying attention to nodes
- Topical anesthesia and remove SUPRAgingival calculus. Use in office antimicrobial agent if needed
- Rinse frequently with warm water/3%H2O2 and 0.12% chlorhexidine BID
- Pts with lymphadenopathy should get antibiotics and return in 1-2 days

Second:
- Usually improved condition
- Scaling and root planing and return in 3-4 days

Third:
- Should be symptom free
- Scaling and root planing repeated
- Discontinue peroxide but continue chlorhexidine
- Continue comprehensive treatment for perio

Front 31

Treatment of NUP

Back 31

Similar to treatment for NUG
- Be cautious using antibiotics in HIV pts to avoid opportunistic infection such as candidiasis
- Metronidazol is drug of choice
- Use prophy antifungal agent if antibiotic is used

Front 32

Localized vs Generalized Aggressive periodontitis

Back 32

Localized - Circumpubertal onset with robus antibody response.
- localized first molar and incisor presentation.
- Interproximal attachment loss on atleast two permanent teeth, one of which is a first molar
- No more than 2 teeth other than first molars and incisors

Generalized - Usually 30yrs or older with poor antibody response
- Pronounced episodic nature
- Generalized interproximal attachment loss affecting atleast 3 permanent teeth other than first molars and incisors

Front 33

Revaluation phase purpose and procedures

Back 33

Purpose - Determine whether additional periodontal procedures are required including the use of chemotherapeutics or surgery. 4weeks after Scaling/Root planing
Procedures:
- Preform periodontal clinical charting
- ID residual calculus, caries on roots, defective restorations

Front 34

Periodontal Surgery

Back 34

1) Osseous surgery - Modify bone altered by disease by reshaping or removal
2) Reconstructive (regenerative) surgery
3) Mucogingival surgery: Corrects defects in morphology or position of dentogingival junction
4) Reentry surgery: Improve, enhance and evaluate results
5) Implant surgery

Front 35

Classification of flaps

Back 35

Full thickness - All soft tissue including periostium

Partial thickness - Only epithelium and a layer of connective tissue. Periosteum remains attached and alveolar bone is not exposed

Positioned(Advanced) flaps - Flap that is moved apical, coronal, or lateral to original position. APF, CPF, LPF

Replaced (Repositioned) Flaps
- Replaced flap, Modified Widman flap, or Excisional new attachment procedures ENAP.

Front 36

Incisions

Back 36

Hoizontal incisions
Envelope flap - Directed along margin of gingival in a mesial or distal direction

Vertical or Oblique releasing incisions
- Only at line angles of teeth
- Extend ot mucogingival junction
- Should not be performed in center of papilla

Front 37

Flap process

Back 37

1) Internal bevel incision
- Remove pocket lining, and conserve uninvolved outer layer.

2) Crevicular incision
- Performed from base of pocket to crest of bone. Forms V-shaped wedge ending at crest of bone

3) Interdental incision
- Separates collar of gingiva which is remaining around the tooth

Front 38

Periodontal dressing

Back 38

Coe-Pak: Most widely used periodontal dressing. Only protects and prevents trauma

Tube 1 - Zinc oxide, oil for palsticity, gum for cohesiveness, and a fungicide
Tube 2 - Liquid coconut fatty acids thickened by resin, bacteriostatic agent
- Leave around surgical site for appx 1wk

Front 39

Gingivectomy vs Gingivoplasty and indications vs contraindications

Back 39

Gingivectomy - Excision of a portion of the gingiva. Usually performed to reduce soft tissue walls of a perio pocket
Gingivoplasty - Reshaping of gingiva

Indications:
- Suprabony pockets coronal to mucogingival junction
- No osseous defects that require surgery
- Gingival enlargements secondary to medications, disease

Contraindications:
- Inadequate attached gingiva
- Infrabony defects
- Aesthetic compromised

Front 40

Disadvantages of Gingivectomy

Back 40

- Limited application
- Post op pain
- May create inadequate attached gingiva, unesthetic results, altered phonetics, and exposed bone

Front 41

Closed gingival curettage

Back 41

Debriding soft tissue wall of periodontal pocket
- Not a justifiable application for chronic adult periodontisis. Root planing is identical

Front 42

Excisional new attachment procedure

Back 42

Removes epithelial pocket lining
- Improved visualization
- Minimal trauma
- Facilitates new attachment

- Difficult, possible marginal flap necrosis, and potential loss of attachment
- Also dated, and does NOT result in new attachment

Front 43

Modified Widman procedure

Back 43

Replaced flaps
- Allows visualization and access for debridement of root surfaces and osseous defects
- More useful in maxillary anterior region of esthetic concern

Front 44

Apically positioned flaps: without osseous resection

Back 44

Similar procedure to modified Widman except flap is elevated past mucogingival junction and flap is sutured at or slightly coronal to elveolar crest

- Potentially greater probing depth reduction

- Unesthetic root exposure, and more hypersensitivity

Front 45

Wall defects and treatment
Combination defects

Back 45

0 Wall:
Dehiscences
Fenestrations
Osseous surgery is NOT treatment of choice

1 Wall:
Hemiseptal defect - Proximal wall present
Ramp - Facial or lingual wall present
Can treat with osseous surgery

2 Wall:
Interdental crater
- Facial lingual walls present
- Can treat with osseous surgery

4 Wall:
Circumferencial or Moat
- Osseous surgery is not treatment of choice

Combination treatments:
- Coronal 1 and 2 wall defects treated by osseous surgery
- Apical part of combination treated by regeneration

Front 46

Osteoplasty vs Ostectomy

Back 46

Osteoplasty:
Nonsupporting bone is reshaped to achieve physiological contour

Ostectomy:
Radicular and interradicular supporting bone is removed to eliminate osseous defects

Front 47

Osseous resection technique

Back 47

Vertical grooving

Radicular blending

Flattening interproximal bone

Gradualizing marginal bone

Front 48

Establishing biological width

Back 48

Juncitonal epithelium - 0.97mm
CT attachment - 1.07mm
Biological width - 2.04mm

Average sulcus depth = 0.69mm

Front 49

Healing of osseous surgery

Back 49

2 phases
1) Day 4 - Appearance of osteoclasts in marrow and PDL causing resorption

2) Begins second week - deposition of osteoid by osteoblasts completed by 3rd month

3) Evidence of bone maturation and remodeling over 18months

Front 50

Violation of biologic width

Back 50

Chronic pain
Chronic gingival inflammation
Unpredictable loss of alveolar bone

Front 51

Indications and contraindications for crown lengthening

Back 51

Caries
Fracture below gingiva
Altered passive eruption
Root surface prep
Restorative requirements

Non-restorable tooth
Esthetic compromise
Furcation exposure
Compromise of adjacent teeth

Front 52

Supracrestal Fiberotomy

Back 52

Rapid extrusion and a fiber resection technique eliminated the need for osseous resection entirely

Front 53

Evaluation of sharpness

Back 53

Reflection of light - Dull edge reflects light while sharp edge does not

Tactile evaluation

Front 54

Types of sharpening stones

Back 54

- Made of abrasive crystals that are harder than instrument metal

Couarse stones: Larger crystals that cut faster and used for very dull instruments

Finer stones - Smaller crystals that cut slower and used for refining edge

Front 55

Two ways to use unmounted stones

Back 55

Stabilize stone - Move instrument
Stabilize instrument - Move stone

Front 56

Lubrication of stone during sharpening

Back 56

Decrease frictional heat
Minimize clogging
Facilitate movement

Front 57

Test for sharpness

Back 57

Light
Plastic stick
Suction tip