Introduction Flashcards
1
Q
how many americans suffer from periodontitis
A
Two in FIVE
2
Q
—% Adults 30 years and older
A
42.2
3
Q
—% Severe Form
—% Mild to Moderate Form
A
7.8
34.4
4
Q
SKIPPED
Tx plans
Phase 1
(7)
A
*OHI with patient motivation
*Marijuana cessation
*Caries control
*Consult orthodontics for mandibular alignment
*Microbiological testing
*SRP 4 quadrants w/ antibiotic adjunctive therapy
*Re-evaluation after phase I
5
Q
SKIPPED
Tx plans
Phase 2
A
Osseous recontouring and Guided Tissue Regeneration
6
Q
SKIPPED
Tx plans
Phase 3
A
None
7
Q
Tx plans
Phase 4
(3)
A
*Periodontal maintenance 1x/month (first 6 months)
*Bimonthly until 12 months
*Then keep 3 months follow-up
8
Q
Court Dictated Role
(4)
A
Diagnose periodontal disease
Inform the patient of clinical findings
Refer patient to a Periodontist, or treat themselves
Treat to the current standard of care
9
Q
Dentist’s Responsibilities
Professional
Legal
Ethical
A
To diagnose disease,
inform the patient of
existing disease, and
to refer or offer
appropriate treatment
10
Q
Gingivitis
A
“Gingivitis is the inflammation of the
gingival tissues without loss of
connective tissue attachment.”
11
Q
Periodontitis
A
“Periodontitis is the inflammation of
the gingival tissues with apical
migration of junctional epithelium
with concomitant loss of connective
tissue attachment and bone.”
12
Q
Probing Depth
A
“Probing depth is the distance from
the soft tissue margin to the tip of
the periodontal probe.”
13
Q
Pockets are classified as
Shallow (—mm);
Moderate (—mm);
Severe (—mm)
A
1-3
4-6
≥ 7
14
Q
Clinical Attachment Level
A
“Clinical attachment level (CAL) is the
distance from the cementoenamel
junction (CEJ) to the tip of the
periodontal probe during normal
probing.”
15
Q
Chronic Periodontitis
Mild (Incipient):
Moderate:
Severe:
A
1-2 mm CAL
3-4 mm CAL
≥ 5mm CAL
16
Q
Chronic Periodontitis
Localized:
Generalized:
A
less than 30% teeth involved
more than 30% teeth involved
17
Q
Aggressive Periodontitis
Not classified as mild/moderate/severe
Assumed all aggressive cases are severe due to
the (2)
A
rate of destruction and/or the age of onset
18
Q
Aggressive Periodontitis
Localized:
Generalized:
A
1st molars and incisors
1st molars, incisors, and ≥ 3 other
teeth
19
Q
STAGING
Based upon
(2)
A
- Severity of the case
- Complexity of the case
management
20
Q
STAGING
Consider
(7)
A
- CAL
- Amount and % of bone loss
- PD
- Presence/extent of ridge
defects - Furcation involvement
- Tooth mobility
- Tooth loss due to periodontitis
21
Q
GRADING
Consider biologic features
(3)
A
- Rate of disease progression
- Risk of further advancement
- Potential threats to general
health (eg. smoking, diabetes)
22
Q
GRADING
Grade A, B, C
A
- A: low risk of progression
- B: moderate risk
- C: high risk
23
Q
Gingiva
Macroscopic (clinical features)
(4)
A
- Marginal Gingiva
- Gingival Sulcus
- Attached Gingiva
- Interdental Gingiva
24
Q
Gingiva
Microscopic
(2)
A
- Gingival Epithelium
- Gingival Connective Tissue
25
Marginal Gingiva
(4)
Unattached or free
Sulcus epithelium adjacent to tooth
About 1 mm in depth
Up to 3 mm still considered normal
26
In ---% of cases, marginal gingiva is demarcated from
the attached gingiva by a free gingival groove
50
27
Gingival Sulcus
(2)
Not attached to enamel or cementum
Bounded apically by the free gingival groove (50%
incidence) on the oral epithelium (if present)
28
If attachment loss occurs then referred to as a
PERIODONTAL POCKET
29
Attached Gingiva formula
KG – PD = attached gingiva
30
Attached Gingiva
(4)
Bordered apically by the mucogingival junction
Bound to underlying periosteum of alveolar bone
Firm, resilient
Varies in width: Maxillary and Mandibular
31
Interdental Gingiva
(3)
It occupies the embrasure
The interproximal space beneath the area of tooth
contact (Col)
Pyramidal or col shaped
32
Gingival Epithelium
* Predominately --- in nature
* As a (4) barrier
* To protect
cellular
mechanical/chemical/water/microbial
the deep structures while allowing for a
selective interchange with the oral environment.
33
Gingival Connective Tissue
* Composed primarily of
* Also known as
* The gingival fibers are arranged in --- groups
collagen fibers and
ground substances
“lamina propria”. It consists of
a papillary layer and a reticular layer.
3
34
3 different areas defined from the morphological
and functional characteristics
* Oral Epithelium
* Sulcular epithelium (~1 mm)
* Junctional Epithelium (~ 1mm)
35
* Oral Epithelium
(2)
* Keratinized stratified squamous epithelium
* Turnover of 30 days
36
* Oral Epithelium
(2)
* Keratinized stratified squamous epithelium
* Turnover of 30 days
37
* Sulcular epithelium (~1 mm)
(3)
* Unattached to enamel
* Non-keratinized stratified squamous epithelium
* Lacks stratum corneum and granulosum;
Langerhans cells
38
* Junctional Epithelium (~ 1mm)
(3)
* Attached by hemidesmosomes
* Non-keratinized stratified squamous epithelium
* High turnover rate (7-10 days)
39
Oral Epithelium
* Keratinized stratified squamous epithelium
(4)
* Stratum corneum
* Stratum granulosum
* Stratum spinosum
* Stratum basale
40
* Sulcular epithelium (~1 mm)
Importance
it is a semi-permeable membrane against
bacterial products passing into underlying tissue
41
Junctional Epithelium (~ 1mm)
* Attachment to the tooth surface via
hemidesmosomes and non-collagenous
proteins (proteoglycans & glysosaminoglycans)
42
Development of Gingival Sulcus
(4)
* Once the enamel is fully developed,
the ameloblasts (AB) reduce in height
and form “reduced enamel epithelium
(REE)” together with other cells.
* Oral epithelium (OE) and REE show
increased mitotic activity and form a
joint epithelial mass.
* When the tooth penetrates the oral
mucosa, the mass transforms into the
junction epithelium (JE).
* In the later phase of the process, all
cells of the REE were replaced by
that of JE.
43
Gingival Connective
Tissue
* ---% collagen fibers, ---%
fibroblasts, ---% matrix,
vessels and nerves.
60
5
35
44
Gingival Connective
Tissue
* ---% collagen fibers, ---%
fibroblasts, ---% matrix,
vessels and nerves.
60
5
35
45
The gingival fibers are
oriented with functions
(3)
* To brace the marginal gingiva against tooth
* To provide rigidity,
* To unite the marginal gingiva with the
cementum and adjacent attached gingiva
46
Gingivodental group
(Dentogingival)
Cementum → gingiva
47
Circular group
Around the tooth in the gingiva
48
Transeptal group
Connecting cementum of
two adjacent teeth
49
Fibers that are in
close proximity to the
alveolar crest
contribute to the
connective tissue
attachment
component of the
“Biologic Width”
50
Gingival Crevicular Fluid
Can be represented as either a
transudate
(healthy) or an exudate (inflamed) from the
gingival connective tissue and blood
vessels.
51
GCF
* The main route:
basement membrane ->
JE intercellular space-> sulcus
52
GCF
* The biochemical factors (cytokines,
enzymes, antibodies, etc.) in the GCF
could potentially serve as
diagnostic or
prognostic biomarkers.
53
GCF
* Functions:
(3)
* Cleanse materials
* Improve adhesion of the epithelium to
the tooth through plasma proteins
* Possesses antimicrobial properties
54
Correlation of Clinical and
Microscopic Features
(4)
* Color
* Contour
* Consistency
* Texture
55
* Color
* Coral pink, melanin (variable)
56
* Contour
(2)
* Scalloped or flattened outline
* Depends on location (ant./posterior)
57
* Consistency
* Firm and resilient
58
* Texture
* Stippling
59
Stippling
* Represents the
* Is a form of adaptive
* ~ ---% of population
microscopic depressions and elevations created by the connective tissue projections within the gingival tissue
specialization or reinforcement for function
40
60
The gene of the underlying ---
determines the covering epithelium
connective tissue
61
PDL
A complex vascular and
highly cellular connective
tissue that surrounds the
tooth root and connecting
to the alveolar bone
62
PDL
consists of (3)
* Periodontal fibers
* Cellular elements
* Ground substances
63
PDL Fibers
* Contains
(4)
Collagen I, III and IV
* Sharpey’s fibers
64
Sharpey’s fibers:
the terminal portions of
the collagen fibers embedded in the root cementum
and the bundle bone
65
PDL Fibers
(5)
* Alveolar crest
* Horizontal
* Oblique
* Apical
* Interradicular
66
PDL Fibers
* Alveolar crest
(2)
* Cementum → crest alveolar bone
* Prevents extrusion and lateral movements
67
PDL Fibers
* Horizontal
(2)
* Cementum → alveolar bone at 90º
* Opposes lateral forces
68
PDL Fibers
* Oblique
(3)
*Largest group
* Cementum → alveolar bone coronal direction
* Resists vertical masticatory forces
69
PDL Fibers
* Apical
(2)
* Cementum → apical alveolar bone
* Resists tipping
70
PDL Fibers
* Interradicular
(2)
* Cementum → furcation bone
* Resist luxation and tipping
71
PDL Cells
* Connective tissue cells
(3)
* Fibroblasts
* Cementoblasts
* Osteoblasts & osteoclasts
72
* Fibroblasts
(2)
* The most abundant one
* Synthesize and degrade intracellular collagens
73
* Epithelial cells of Malassez
* Remnants of Hertwig’s root sheath
74
* Immune system cells
* Neutrophils, lymphocytes, macrophages, etc.
75
* Nerve fibers
* Pain, pressure, tactile, stretch
76
Functions of PDL
(3)
* Physical functions
Formative and remodeling functions
Nutritional and sensory functions
77
* Physical functions
* Contain (2)
* Absorbs ---
* Suspensory mechanism attaching the ---
* Maintains --- in the relationship to the teeth
blood vessels & nerves
occlusal forces and transmits occlusal force to the bone
teeth to the bone
gingival tissue
78
* Formative and remodeling functions
* Cells could respond to occlusal force and participate in the formation
and resorption of cementum/bone/collagens
79
* Nutritional and sensory functions
(2)
* Supplies nutrients to cementum/bone/gingiva
* Transmits pressure and pain via trigeminal pathways
80
PDL Space
The normal width of PDL is approximately
0.2 mm
81
PDL Space
* --- functions can affect
PDL space
* Within physiologic limits, PDL
accommodates increased force
with an
* When the force exceeds the
adaptive capacity ->
Occlusal
increased width,
thickened fiber bundles, and
increased numbers of Sharpey’s
fibers.
trauma
from occlusion.
82
Cementum
* A specialized mineralized tissue
(2)
* Inorganic content (45-50%) is mainly hydroxyapatite, < bone/dentin/enamel
* Organic matrix (50-55%) is mainly composed of type I and type III collagen
83
Cementum
* Contains no blood or lymph vessels, no nerves,
and grows by continuing deposition
* It’s different from ---
* The highest rate of formation is in the ---regions
* The greatest thickness is in ---
bone
apical
apical third and the furcation areas
84
Two main types of cementum
* Acellular (primary)
* Cellular (secondary)
* Found in coronal portion of root
* Found in apical portion of root
85
Two major sources of collagen fibers
* Sharpey’s fiber
* Fibers that belong to cementum matrix
86
* Sharpey’s fiber
* extrinsic - from fibroblasts
87
* Fibers that belong to cementum matrix
* Intrinsic - from cementoblasts
88
Functions of Cementum
(4)
* Attaches the principal PDL
fibers to the root (main function)
* Contributes to the process
of repair after damage to
the root surfaces
* Adjusts the tooth position
to new requirements* It compensates for tooth eruption
* Protects dental pulp/dentin
89
CEJ
Gap between enamel
and cementum
5-10%
90
CEJ
End-to-end
30%
91
CEJ
Cementum
overlapping enamel
60-65%
92
Exposed Cementum
(4)
* Rough surface texture facilitates plaque adherence
* Porosities facilitate attachment of calculus
* Porosities facilitate absorption of bacterial enzymes
(i.e. endotoxin)
* Smear layer inhibits attachment of connective tissue
93
Alveolar Process
* The portion of the maxilla and mandible that
forms
and supports the tooth sockets.
94
Alveolar Process
* The portion of the maxilla and mandible that forms
and supports the tooth sockets.
* A tooth dependent structure:
It forms when the tooth erupts and disappears
gradually after tooth extraction
95
Alveolar Process
* Contains blood or lymph vessels, and attachment
of PDL fibers (Sharpey’s fibers)
(2)
* Nerves are not in the bone but in the periosteum
* Vascular pathways from gingiva into supporting alveolar bone
96
Alveolar Process
Shape
Depends on interdental
distance, tooth contours, root
contours
* Anterior:
* Posterior:
Scalloped
Flattened Scallop
97
Distance from CEJ in health
* 1 to 1.5 mm
* 1.5-2 mm in adult (taking into
account the biologic width
concept)
98
Alveolar Process
Components
(3)
* External plate: cortical bone
* Inner socket wall: thin cortical
bone
* Spongy bone: cancellous
trabeculae
99
* Inner socket wall: thin cortical
bone
(3)
* Alveolar bone proper
* Bundle bone
* Lamina dura:radiographic term
100
*Basal bone is located --- but unrelated to the teeth.
apically
101
Cancellous bone is
found predominately in the
interdental & interradicular areas
(less in facially/lingually)
102
In adult humans, more cancellous
bone in the --- than in the
---.
maxilla, mandible
103
Usually in the mandible, there is
thicker cortical bone and ---
cancellous bone.
less
104
Alveolar Process
* Thin --- cortical
plates overlying root surfaces
facial and lingual
105
Alveolar Process
* Lack of cancellous bone (so no
progenitor cells) overlying many
--- root surfaces
facial
106
Alveolar Process
* Increased
fibrosis and lipid cell
content in marrow spaces (results
in a decrease in progenitor cells)
in adults > 40 years old
107
* Dehiscence:
lack of bone on
the facial/lingual of the tooth
but with interproximal bone
108
Fenestration:
lack of bone
on the facial/lingual of the
tooth resembling a “window”
109
* Predisposing factors:
prominent root
contours, malposition and roots with labial
protrusion in combination of thin bony plate
110
Periosteum
(2)
* The periosteum is a fibrous sheath that lines the outer surface of bone.
* Bundles of periosteal collagen fibers penetrate the bone, binding the
periosteum to the bone.
111
Periosteum
Composed of two layers:
Fibrous layer: a dense, fibrous,
vascular layer
Osteogenic layer: a loose
connective tissue inner layer,
containing osteoprogenitor cells.
