Fall 2024 Midterm Flashcards
(158 cards)
1
Q
The __ classification system is an older system (1999) that was used in the development of a classification system for periodontal disease and conditions
A
Armitage
2
Q
What are the 2 advantages of the Armitage classification system
A
Comprehensive review of periodontology
Clinical attachment levels highlighted
3
Q
Patients under 25 must be evaluated for a differential diagnosis of
A
Molar/incisor pattern periodontitis
(aka: aggressive periodontitis; localized juvenile periodontitis)
4
Q
In people under 25 with molar/incisor pattern periodontitis, assess for localized bone loss associated with the __
A
first molar and incisor teeth
(also assess OH relative to disease)
5
Q
__ calculus is a frequent finding with chronic periodontitis
A
Subgingival calculus
6
Q
Chronic periodontitis has a slow to moderate rate of progression, but may have periods of __
A
rapid destruction
7
Q
What systemic disease is chronic periodontitis most often associated with
A
Diabetes mellitus and HIV
8
Q
Chronic periodontitis can be modified by factors other than systemic diseases such as __ and __
A
Cigarette smoking and emotional stress
9
Q
Whether chronic periodontitis is localized or generalized depends on the
A
percentage of sites affected (6 sites per tooth : mesial, buccal, lingual, distal ..)
10
Q
What classifies generalized chronic perio
A
> 30% of sites affected
On both anterior and posterior teeth
(Can also be defined as perio without a clear pattern of disease distribution of affected teeth)
11
Q
What classifies localized perio
A
<30% of sites affected
Usually only on posterior teeth - no anterior
12
Q
What is the exception to localized chronic perio
A
Aggressive incisor and molar pattern
13
Q
If a pattern exists with chronic perio, is it generalized or localized
A
Neither, descriptive terminology is more accurate
(Ex: chronic periodontitis localized to max. molars with severe lesions on the premolars)
14
Q
We do NOT use this classification system, but it can be seen in older chart note. Severity of clinical attachment loss and armitage system of diagnosis
Slight chronic perio =
Moderate chronic perio =
Severe chronic perio =
A
1-2 mm of attachment loss
3-4 mm of attachment loss
>5mm of attachment loss
15
Q
Disadvantages of Armitage
A
Time consuming
Inaccuracies from probing angles
Root length disregarded
Difficult to determine CEJ
Systemic disease and local factors ignored
Doesn’t account for pseudopockets
16
Q
CAL stands for
A
Calculated attachment loss
17
Q
Measurements taken for CAL are in relation to the
A
CEJ
18
Q
If the patient has gingivitis there is
A
NO attachment loss
The gingiva is inflamed; assume the negative reciprocal for pocket depth that are 1-3mm
(Do NOT need to enter this in the chart)
PIC in notes
19
Q
When there is gingivitis and theres a pseudo-pocket of 4+ mm (the probe did not contact the CEJ) what must you do
A
You MUST put the negative reciprocal into axium (cant leave it out of the chart like with 1-3mm depths on gingivitis). Failure to do so will indicate a true pocket
20
Q
Why is is important to chart correctly for gingivitis patients
A
Distinguishes prophys (D4341) from SRPs (D4342) or scaling with inflammation (D4346)
(Scaling with inflammation is used when theres no root to scale, or with younger patients that have sub gingival calculus and edema, or patients with associated pharmacologic effects)
21
Q
If the patent has chronic periodontitis (true pocket) with a gingival margin above the CEJ what do we chart for GM
A
Assume -2mm for the gingival margin measurement to account for the gingiva above the CEJ
(Does NOT contribute to the true pocket depth)
22
Q
Patients with sub-gingival calculus on enamel without CAL loss are __ for SRP
A
not appropriate
23
Q
When there is recession present, how is GM charted
A
with a positive number instead of a negative number to show the true attachment loss
(Pocket + GM = attachment loss)
24
Q
Exposure of the root surface by an apical shift in the position of the gingiva
A
Recession
25
With root exposure these 2 things shift apically
Junctional epithelium
Gingiva
26
The actual recession is measured as
from the CEJ to the level of attachment
(The level of the attached periodontal tissue, not directly visible but determined by probing)
27
Visible on clinical examination from the gingival margin to the CEJ
Apparent recession
(The level of the gingival margin or crest of the free gingiva that is seen by direct vision)
28
3mm PD or less place the __ in the GM or __
negative of that number
blank
29
Enter __ for GM for pseudo-pockets
negative numbers
30
Enter __ when the GM is at the CEJ
0
31
4mm or greater pocket with CAL place a __
negative 2 GM or blank (??)
32
Causes of Recession
Patient self-care ( hard/incorrect brushing, abrasive dentifrice/toothpaste, hard brush)
Anatomical (eruption patterns, position of the tooth within the alveolus)
33
Fenestration vs dehiscence
(both are anatomical predispositions to recession)
Fenestration = window of bone loss exposing root
Dehiscence= alveolar bone loss and complete root exposure
34
Know how to identify
Early recession
Stillman cleft
palatal recession
McCall Festoon
Localized recession
Stillman cleft = narrow shaped triangular recession on buccal
McCall Festoon= scalloped GM that protrudes or buldges out near the tooth
Look at PIC
35
Gingival phenotype
Prob visible = thin, < or at 1 mm
Probe not visible = thick, >1mm
36
Recession Type I (RT1)
Gingival recession with no loss of interproximal attachment
Inter-proximal CEJ is not clinically detectable at both mesial and distal aspects of the tooth
37
Recession Type 2 (RT2)
Gingival recession WITH loss of interproximal attachment
The amount of interproximal attachment loss (from the interproximal CEJ to the depth of the pocket) is less than or equal to the buccal attachment loss (from buccal CEJ to the apical end of the buccal pocket)
38
Recession Type 3 (RT3)
Gingival recession associated WITH loss of interproximal attachment
The amount of interproximal attachment (from the interproximal CEJ to the apical end of the pocket) is HIGHEr than the buccal attachment loss
39
Miller Class 1 recession
Recession is NOT to the MGJ
NO interproximal bone or papilla loss
100% coverage possible with bone graft (B/c interproximal coverage offers a blood supply)
PIC
40
Miller Class 2 recession
Recession past the MGJ
NO interproximal bone or papilla loss
100% coverage possible with bone graft (B/c interproximal coverage offers a blood supply)
Possibility of root coverage
PIC
41
Miller Class 3 recession
Recession past the MGJ
Interproximal bone or papilla loss
Malposition
Partial coverage
PIC
42
Miller Class 4 recession
Recession past the MGJ
Severe interproximal bone or papilla loss
Malposition
NO coverage
PIC
43
Why might the free gingival margin be at the level of the CEJ
Previous Perio
Recession
Attrition with age
Malposition of teeth
44
If the embrasure space between 2 teeth is NOT filled with gingival tissue/papilla = black triangle, this indicates
GM at the CEJ
45
When the GM is at the CEJ what do we chart for GM
0
46
What do we use to find a furcation
Nabers probe
47
Class I furcation
A depression that does not catch the probe
48
Class II furcation
A furcation deep enough to catch the probe but not contiguous with other furcation on the same tooth
49
Class III furcation
Bone loss through and through but covered with gingival tissue
50
Class IV furcation
Bone loss through and through and directly exposed to the oral environment, the gingival margin is apical to the entrance of the furcation
51
How do you approach maximally molars for feeling furcations
Since there are 3 roots (palatal) of maxillary molars, you should treat each root as a separate tooth (feel mesial and distal aspects of the root)
(same for 2 roots
52
When entering furcations into axium, place number in the __ box only
middle
(Except on the lingual of max molars where you have a palatal root, then you would put it mesial or distal)
53
What is an anatomical anomaly that can be felt when feeling for furcations
enamel pearls
54
This is a marker of disease activity and must be noted in the chart
BOP
Bleeding on Probing
55
Measures actual positives correctly identified (% of population which has a condition)
Sensitivity
56
Measures the actual negatives correctly identified (% of population which does not have a condition)
Specificity
57
BOP has high __ and low __
Specificity
Sensitivity
58
__ is the degree of looseness of a tooth when we move it. It is due to __ or is prior to perio treatment due to __
Mobility
inflammation and/or bone loss
trauma
59
Two ways we evaluate a tooth for mobility
Incisal - apical
buccal- lingual
60
Grades of mobility 0-3
0= within physiological limits
1= less than 1 mm BL/MD direction
2 = 1mm or more in BL/MD direction
3 = exceeding 1 mm and depressible (up/down) in an occluso-apical direction
61
The movement of teeth during function or parafunction
Functional mobility
62
__ can often be detected earlier than bidigital tooth mobility and has been associated in the presence of inflammation, with increased bone and attachment loss (pocket formation)
Fremitus
63
The index finger is placed on the labial surface of the tooth or teeth and the patient is asked to grind in later and protrusive movements. Any movement seen or felt is termed __
Fremitus (displacement of a tooth from the bite)
64
Attached gingiva measurement
Measure from GM to MGJ outside of the pocket, and then subtract the pocket depth
PIC
(also look at pic of calculating in axium)
65
Recession enter the __ in the GM
Positive number
66
3mm or less PD enter the GM as the __
negative of the PD (or leave blank)
67
Pseudopockets place the __ in the GM
negative of the PD
68
IF periodontitis, then 4 PD or greater a __ GM
negative 2 (always give -2 when >/= 4mm)
69
__ GM when the FGM is at the CEJ
0
70
What to do if you cannot probe
Inform faculty
Radiographs - extractions ?
Plan an SRP if appropriate ( obtain quad by quad) - complete chart on last SRP
NEVER full mouth debridement (can blow and abcess)
71
3 major components of a periodontal examination
Diagnosis (ID)
Treatment plan (plan of action)
Prognosis (expected therapy)
72
The new classification system is based on an __ model
oncology (stage and grade)
73
Severity and extent of disease
Stage
74
Complexity assessment (CAL and Radiographic bone loss) - reflects what you have to treat
Stage
75
Estimates of future risks, rate of progression, response to therapy and systemic implications.
Grade
76
Reflects the prognosis
Grade
77
The severity of the periodontal diagnosis will be based on the __
most severe tooth
78
Periodontal health and gingival health= clinical gingival health on an __ or __ periodontium
intact
reduced (stable periodontitis or non-stable periodontist patient)
79
Gingivitis is __ induced and mediated by __ or __ risk factors. Can also have __ gingival enlargement
dental biofilm
systemic or local
drug-induced
80
Can also have gingival disease that are __
non-dental biofilm induced
(Genetic/developmental disorders, infections, immune conditions, reactive process neoplasms, endocrine, nutritional and metabolic diseases, traumatic lesions, gingival pigmentation)
81
3 forms of periodontitis
Necrotizing periodontal disease (dead tissue)
Periodontitis as manifestation of systemic diseases
Periodontitis (stages and grades)
82
Other conditions affecting the periodontium
Systemic diseases or conditions affecting perio supporting tissue
Other perio conditions (abscess, lesions)
Mucogingival deformities and conditions around teeth
Traumatic occlusal forces
Prostheses and tooth-related factors that predispose to plaque induced gingival/perio
83
How to stage and grade periodontitis is based on the __ World workshop on the classification of periodontal and peri-implant disease
2017
84
The new staging a grading system of periodontal disease is __, but not __
simple, but not simplistic
(incorporates presence and control of risk factors in the diagnosis, highlights patient response to treatment, eliminates overlap of former disease categories, strives for more diagnostic precision)
85
The new disease classification system uses clinical attachment loss primarily at __ sites but may also include __ sites
interdental
buccal/oral
86
The apical migration of the attachment apparatus, measured as the distance from the CEJ to the base of the periodontal pocket/sulcus
Clinical Attachment Loss
87
Periodontitis definition based on CAL
Interdental CAL detected at >= 2 non-adjacent teeth OR buccal or oral (lingual) CAL >= 3 with pocketing >3mm is detectable at >=2 teeth
(Clinical judgement should be used; if there is an excessively large CAL on 1 tooth this can still be considered periodontitis)
88
An observed CAL cannot be ascribed to non-periodontitis-related causes. These are all things that cause a fake CAL
Gingival Recession of traumatic origin
Dental caries extending in the cervical area of the tooth
Presence of CAL on the distal aspect of a second molar and associated with malposition or extraction of a third molar
An endodontic lesion draining through the marginal periodontium
The occurrence of a vertical root fracture from endo treatment
89
The stage reflects the severity of disease at the __ and is expressed through __ and __
most affected area
attachment and bone loss
90
This reflects the tooth loss that has occurred as a result of periodontitis and the anticipated complexity of treatment required
Stage
91
How many stages can be assigned to a patient
Only one, stage is patient based not tooth-based
92
3 categories of staging
Severity
Complexity
Extent and distribution
93
What is included in the severity of staging
Interdental CAL
RBL
Tooth loss due to periodontitis
94
What is included in the complexity of periodontitis staging
Probing depths
type of bone loss
furcation involvement
ridge defects
masticatory disfunction
occlusal trauma
bite collapse, drifting, flaring
95
What does extent and distribution mean in the staging of periodontitis
extent describes the % of teeth affected by the severity level that defines that stage
Localized or generalized
Molar-incisor pattern of distribution
96
What are the interdental cals for stages I-IV
Stage I = 1-2mm
Stage II = 3-4 mm
Stage III = >=5mm
Stage IV= >=5mm
97
Stage I-IV of RBL
Stage I = coronal third
Stage II = coronal third
Stage III = extending to middle third of root and beyond
Stage IV = extending to middle third of root and beyond
98
Stage I-IV of tooth loss
No tooth loss - stage I and II
<=4 teeth = stage III
>=5 teeth = Stage IV
99
Mostly horizontal bone loss
Stage I and II
100
Max probing depths for stage I -stage IV
Stage I = <=4mm
Stage II = >5mm
Stage III = >6mm
101
If less than 20 teeth remaining
Stage IV
102
If depth all 4 but patient is grade A its probably __ so do a __ not an SRP
pseudopockets
4346
103
Only stage and grade with
active perio
104
These patients show periodontitis of mild to moderate severity and have not lost any teeth due to disease
Stage I and II patients
105
These are more complex cases, they require more advanced periodontal treatment, extent of tooth loss requires extensive rehabilitation in
Stage III and IV patients
106
__ is the most accurate parameter for staging, we will use __ for staging if we don't have this
Inter-proximal CAL
RBL
107
Vertical bone loss >= 3 mm
automatic stage III
108
Furcation involvement of class II or class III
automatic stage III
109
These cases we send to grad perio
Stage III and IV
110
This allows the clinician to incorporate individual patient factors into the diagnosis, which are crucial to comprehensive case management
Grade
111
What three things does grade describe
observed/inferred progression rate
risk for further deterioration due to environmental factors (smoking) and co-morbidities (diabetes)
Risk that disease/treatment may adversely affect general health
112
Grading is based on 3 fundamental principles
Not all individuals are equally susceptible to periodontitis
Multiple factors interact to influence the clinical phenotypes
Some cases require more intensive control of the biofilm and inflammation
113
Grade A-C
Rate of progression
Grade A = slow
Grade B = moderate
Grace C = rapid
114
Assume grade __ until clinical or medical history provide evidence of more rapid or slower progression or risk factors increase the probability of more rapid progression
B
115
Usually a patient who is grade C is
over responding
116
What are the 2 grade modifiers
Smoking and diabetes
117
smoking grade A vs B vs C
A = doesnt smoke
B = < 10 cigs a day
C = > 10 cigs a day (more than 1/2 a pack)
118
Diabetes grade A vs B vs C
A = no diabetes
B = HbA1c < 7% (horizontal bone loss)
C = HbA1c >7% (vertical bone loss)
119
To establish the grade/ rate of progression you need direct evidence of progression by __
RBL or CAL over 5 years
120
Indirect evidence of grade
% bone loss / age
- IF % bone loss is more than their age = Grade C
- If around 1/2 = Grade B
Biofilm deposits or level of destruction
121
Revision of the Grade upwards is possible if the __ increases or the risk profile of the patient deteriorates
% bone loss / age ratio
122
3 steps to staging and grading a patients
Step 1 : Case overview (screening - probing depths, full mouth radiographs, missing teeth)
Step 2 : establish stage
Step 3 : establish grade
123
15% root length
>30% root length
Grade B
Grade C
124
Peri-implant diseases
Diagnostic aids
Visual inspection
Probing (plastic)
X-rays (at time of placement and 1 yr after abutment connection)
125
Absence of erythema, BOP, swelling and suppuration (discharge of pus) with implant
NO bone loss <2 mm
Peri-implant health
126
Not possible to define a range of probing depths compatible with health for an implant due to
NO long junctional epithelium attachment to implant
127
Main characteristic = BOP with gentle probing of an implant
Erythema, swelling/inflammation and or suppuration may be present
Peri-implant mucositis
128
Absence of additional bone loss beyond initial bone remodeling
<2mm of bone loss
Peri-implant mucositis
129
Peri-implant mucositis etiological factor =
plaque
130
Plaque associated pathological condition
Characterized by inflammation of the peri-implant mucosa and subsequent progressive bone loss
Clinical signs of inflammation, increased probing depths, and or mucosal recession in addition to loss of supportive bone
Peri-implantitis
131
Peri-implantitis in the absences of previous examination
PD at 1 year postload
In absence of exam:
PD >= 6 mm
BOP
BL >= 3 mm
132
Conditions following the normal healing process of tooth loss that leads to diminished dimensions of the alveolar process/ridge, resulting in both hard- and soft tissue deficiencies
Peri-implant soft and hard tissue deficiencies
133
Your assessment of the expected outcomes of suggested treatment
Prognosis
134
KWOK, Caton Et Al 2007
Guidelines for prognosis
135
The periodontal status of the tooth can be stabilized with comprehensive periodontal treatment and maintenance
Future loss of the periodontal supporting tissues is unlikely if these conditions are met
Favorable prognosis
136
The periodontal status of the tooth is influenced by local and/or systemic factors that may or may not be able to be controlled
The periodontium can be stabilized with comprehensive treatment and maintenance if these factors are controlled; otherwise, future periodontal breakdown may occur
EX: High HbA1c that is being treated, or quitting smoking, changing meds
Questionable Prognosis
137
The periodontal status of the tooth is influenced by local and/or systemic factors that cannot be controlled
Periodontal breakdown is likely to occur even with comprehensive periodontal treatment and maintenance
EX: not quitting smoking, uncontrolled diabetes, patients who are developmentally challenged and are unable to brush teeth
Unfavorable Prognosis
138
Tooth must be extracted
Hopeless prognosis
139
The only evidence based prognosis scheme for molars with furcations
Miller prognosis
140
These teeth have the worst miller prognosis
Max 2nd molars
Automatically mark as 2
141
With miller prognosis, numbers are plugged in to get __ year and __ year perio prognosis (which is helpful in informing patients of likelihood of success/failure of crowns, abutments etc. from a perio health standpoint)
15 year
30 year
Helps Legally if a tooth fails
DOES not help if tooth id carious (must do E&E)
142
Ideally want a miller score of
below 5
143
May have minimal recession without pre-existing active periodontal disease
Health
144
A healthy state in a patient with previously diagnosed periodontal disease (attachment loss)
Stability
145
4 categories of periodontal health
Pristine Periodontal Health
Clinical Periodontal Health
Periodontal Disease Stability
Periodontal Disease Remission/Control
146
Denotes the absence of pocket depths >3mm, attachment loss, BOP <10%, clinical erythema,edema or pus
Pristine Periodontal Health
147
Can contain attachment loss die to recession, BP <10%, no edema, erythema, or pus. NO pocket depth of clinical importance. Absence of minimal levels of clinical inflammation. Normal osseous support
Clinical Periodontal Health
148
Absence of inflammation and infection. Reducing predisposing factors
Control modifying factos
On a reduced periodontium (over brushing, trauma, ortho)
Periodontal disease stability
149
Goal of periodontitis patients
Periodontal disease stability
150
Cannot fully control modifying/predisposing factors. Decreased inflammation, improvement in clinical parameters, stabilization of disease progression to low disease activity, may be an acceptable alternative therapeutic goal in long standing periodontal disease
Periodontal disease remission/control
151
Preferred term for gingivitis
inflammation of reduced periodontium
152
Diagnosis sequence for chronic periodontitis
Generalized or localized
stage or grade
chronic periodontitis at end
EX: generalized stage I Grade B chronic periodontitis
153
D0180
Dental examination
- will not charge patient
- updated annually
- liquid stain for plaque index
- Diagnosis, TX, prognosis
- probing is an invasive procedure
154
D1330
Oral hygiene instructions
ALL competencies MUST have an approved plaque index entered in axium
155
D1110
Dental Prophylaxis
- usually on gingivitis cases
- recall every 6 m
- remove plaque calculus and staining
- do not polish calculus
156
D4341 and or D4342
Scaling and Root planing
- MUST have attachment loss documented
- PD >4mm
- MUST anesthetized
- 1 quad at a time
- Dont polish
157
D4346
Scaling for gingivitis/ in presence of inflammation
- subgingival calc no bone loss
- anesthesia when/where indicated
- re-eval 4-6 wks
158
D4910
Perio maintenance
Limited SRP w/ anesthesia is part of the code
