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BDS5 > Perio > Flashcards

Perio Flashcards

1
Q

Describe regeneration cascade of bone

A

Inflammation; blood clot
Fibroplasia; granulation tissue
Mineralisation; woven bone
Remodelling; lamellar bone

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2
Q

What does bone regeneration depend on?

A

Signalling molecules

  • cytokines
  • prostaglandins, leukotrienes
  • growth factors
  • hormones
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3
Q

What is req. for successful bone regeneration?

A 
Cells: osteoprogenitor + inflammatory
Scaffold: blood clot
Blood supply 
Signalling molecules 
Mechanical stability
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4
Q

Define biomaterial

A

NIH: A substance or combination of substances, synthetic or natural, which can be used for any period of time, which augments or replaces partially/totally a lost tissue/organ/function in order to maintain/improve QoL

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5
Q

Define: biocompatible, biotolerable, bioinert, bioactive, biodegradable

A

Biocompatible: no toxic/immunological response when exposed to host
Biotolerable: way in which tolerated materials are separated from host tissue by formation of fibrous tissue
Bioinert: no chemical reaction + tolerated (doesn’t exist)
Bioactive: materials that can form chemical bonds w/ bone
- bone tissue connnects to material promoting coating by bone cells
Biodegradable: degrade/solubilise/absorb over T when in contact w/ body

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6
Q

Describe osteogenesis

A

New bone synthesis by donor cells derived from either host/graft material
Cells: mesenchymal stem cells, osteoblasts/cytes

Transplants: autologous iliac bone, marrow grafts

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7
Q

Describe osteoinduction

A

Bone formation by differentiation of local uncommitted connective tissues -> bone-forming cells under influence of 1/+ inducing agents
Moderated by:
- GFs: platelet derived factor, bone morphogenetic proteins
- interleukins
- fibroblast GF
- angiogenic factors: vascular endothelial GF

Transplants: demineralised bone matrix, autologous bone grafts

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8
Q

Describe osteoconduction

A

Implanted scaffold passively allows ingrowth of host capillaries, perivascular tissue + mesenchymal stem cells
Microscopically: similar structure to cancellous bone

Transplants: all

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9
Q

Ideal properties of bone graft material

A 
Osteogenic, osteoinductive, osteoconductive
Structurally similar to bone
Angiogenicity
Nontoxic, non-antigenic
Optimal mechanical properties
Readily + sufficiently available 
Resistant to infection 
Min. surgical procedure + min. post-op sequalea 
Predictable 
Completely replaced by host bone of same quantity + quality 
Cost effective
Easy to use + manipulate
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10
Q

Types of bone grafts

A

Autograft: same individual
Allograft: different individual, same species
Xenograft: different species
Alloplastic: synthetic

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11
Q

What factors may impact incorporation of graft?

A 
Vascularity 
Infection
Foreign material
Malnutrition 
Drugs/Systemic condition
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12
Q

Discuss autografts

A

IO/EO harvesting sites
Forms: particulated, bone blocks

Origin

  • intramembranous
  • endochondral
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13
Q

Differences b/w cancellous + cortical autograft

A

Cortical
- excellent structural integrity + mechanical properties
- limited osteoblasts/cytes + progenitor cells
— = low osteogenic/inductive potential
- slower to incorporate cf cancellous

Cancellous

  • high conc. osteoblasts/cytes = better osteogenic potential
  • large trabecular surface encourages revascularisation
  • little mechanical support
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14
Q

Dis/adv of autografts

A

Adv

  • gold standard: osteogenic/inductive/conductive
  • biocompatible

Disadv

  • 2 surgeries
  • inc. op T
  • limited quantity
  • donor site morbidity: infection, pain, cosmetic
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15
Q

Discuss allografts

A

Forms: cortical, cancellous, highly processed bone derivatives

Osteoinductive/conductive
Antigenicity risk red. by
- freezing
- radiation
- chemicals
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16
Q

Discuss different types of allografts

A

Fresh Bone

  • highly antigenic
  • limited T to test immunogenicity/diseases

Fresh-frozen Bone

  • less antigenic
  • stored -80°
  • preserves biomechanical properties
  • red. risk disease transmission; donor screening, aseptic processing

De/mineralised Freeze-Dried Bone

  • red. antigenic
  • protein alterations = red. mechanical properties
  • demineralised: inc. bone morphogenetic proteins = more osteoinductive potential
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17
Q

Dis/adv of allografts

A

Adv

  • unlimited quantity
  • no donor site morbidity
  • red. surgical T

Disadv

  • risk: rejection, disease
  • ethical + religious concerns
  • red. osteogenic/inductive properties
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18
Q

Discuss xenografts

A

Processed to make less antigenic + prevent infection -> lose osteogenic/inductive potential

Forms: particulated, bone blocks
Sources: bovine, porcine, equine, natural coral

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19
Q

Discuss demineralised bovine bone mineral

A

Xenograft

Bovine bone processed to natural bone w/o organic component
HA skeleton retains microporous/macroporous structure of cortical/cancellous bone
Chemical + physically similar to human mineral matrix
V low resorption rate
Safety: proteins removed, 100% crystalline HA

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20
Q

Dis/adv of xenografts

A

Adv

  • similar structure, chemistry, porosity cf human bone
  • unlimited quantity
  • short surgical T
  • no donor site morbidity

Disadv

  • may remain in defect for years
  • mainly osteoconductive
  • ethical + religious concerns
  • risk disease
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21
Q

Discuss alloplastic grafts

A

Variety textures, sizes, shapes
Forms: crystalline, amorphous
Non/resorbable

Materials

  • calcium sulphate/phosphate
  • polymers
  • synthetic HA
  • bioactive glasses
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22
Q

Dis/adv of alloplastic grafts

A

Adv

  • no disease transmission
  • short surgical T
  • no donor site morbidity
  • unlimited quantity
  • biocompatible

Disadv

  • only osteoconductive
  • remain in defect for years
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23
Q

Why are membranes req. for bone regeneration?

A

Prevent ingrowth of epithelial cells thus allowing time for bone + PDL to re-establish

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24
Q

Principles for successful bone regeneration

A 
PASS
Primary wound closure
- membrane must not be exposed
- red. mechanical + infection insult 
- red. epithelialisation + collagen contraction

Angiogenesis

Space Creation + Maintenance

  • bone substitutes for space maintenance
  • autograft gold standard to avoid collapse of membrane

Stability of wound

  • initial adhesion of blood clot to defect + wound stabilisation crucial
  • acts as scaffold rich in growth factors
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25
Q

Ideal properties of membrane material

A

Biocompatible
Biological activity; actively promote bone regeneration
Easy handling
Space making + maintaining
Cell occlusion/porosity: prevent down growth of tissue but allow nutrients through
Biodegradable: no 2nd surgery
Red. complications

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26
Q

Compare properties of non/resorbable membranes

A

Non-resorbable

  • biocompatible
  • biologically active
  • space making + maintaining
  • cell occlusion/porosity
  • poor handling
  • req. 2nd surgery
  • if exposed will become infected

Resorbable

  • biocompatible
  • biologically active
  • easy handling
  • cell occlusion/porosity
  • less infection risk
  • no 2nd surgery
  • poor mechanical properties; req. bone graft
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27
Q

Types of resorbable membranes

A

Polymer
Collagen
- non-cross linked
- cross linked

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28
Q

Discuss polymer membranes

A

Aliphatic polyesters
Excellent biocompatibility + controllable biodegradation
Low rigidity
Drug encapsulating ability

Degradation products may give inflammatory foreign body reaction

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29
Q

Discuss non/cross linked collagen membranes

A

Non-cross linked

  • T1 + 3 collagen
  • good vascularisation, biodegrade w/o foreign body reaction
  • lack space maintaining properties + poor mechanical strength
  • degradation T caries; 4d-6wk

Cross-linked

  • glutaraldehyde most common chemical cross linker
  • prolongs degradation T + enhance tensile strength
  • indirect relationship b/w level of cross linking and tissue integration + neoangiogenesis
30
Q

What are bioactive factors?

A

Natural mediators of tissue repair capable of eliciting a response from a living tissue/organism/cell

  • osteoblasts differentiation
  • angiogenesis

Growth factors
Enamel matrix derivatives
Autologous platelet concentrations

31
Q

What restorative problems are associated w/ perio?

A 
High lip/smile line
Recession + Black triangles
Drifting + Rotation 
Mobility 
Occlusal stability + OE
Crown prep onto dentine
Able to produce aesthetic pros restoration?
32
Q

Discuss aetiology + Mx of recession and black triangles

A

Aetiology

  • gingival recession post-inflammation/restoration/surgery
  • inc. risk: triangular teeth, thin gingival biotype
  • inc. embrasure space, inc. risk imp locking + tearing

My: make aware before occur

  • accept
  • comp additions/crowns; move contacts apical, teeth more square
  • gingival veneers; poor compliance
  • long pontics when replacing teeth
33
Q

Discuss drifting + rotation of teeth

A

Aetiology: loss of PD support

Problem

  • loss of pros space
  • may make bridge/denture path challenging

Mx

  • ortho: if PD stable
  • XLA: move out arch or lip/tongue balance
34
Q

Discuss mobility

A

Aetiology: loss of PD support

1ry trauma from occlusion: overloading on intact periodontium
2ry trauma: overloading on red. periodontium

Problems

  • challenge for conventional imps
  • accuracy of CoCr framework
35
Q

Discuss OE

A 
Aetiology: loss of opposing tooth 
Freq.: 83%
Inc. risk
- post. > ant.
- Mx. > Md
36
Q

Discuss splinting teeth

A

Indications

  • improve pt comfort + function
  • prevent drifting
  • temp. during PD regenerative surgery

Materials

  • ortho wire
  • fibre-reinforced comp
  • comp: freq. repair + maintenance
  • cast metal

Close maintenance req.; debonds freq.

37
Q

Define mucogingival deformity

A

Deviation from normal dimension + morphology relationship b/w gingiva + alveolar mucosa

38
Q

Types of mucogingival deformities

A

Lack of keratinised gingiva
Dec. vestibular depth
Aberrant frenum
Gingival recession

39
Q

Types of PD plastic surgery

A 
Frenectomy
Alveolar ridge preservation 
Crown lengthening 
Keratinised attached gingiva augmentation 
Ectopic tooth eruption 
Papilla regeneration
40
Q

Causes of red. keratinised attached gingiva

A

Recession
Pocketing
Abnormal frenum pull

41
Q

Define gingival recession

A

Apical shift of soft-tissue w/ respect to CEJ

42
Q

Aetiology of recession

A 
Mechanical: brushing, self inflicted trauma 
Plaque induced inflammation 
PD: post-Tx
Iatrogenic
- ortho: 5-12% within 12/12
- tongue piercings
- overhangs 
- clasps
- suboptimal crown margins
43
Q

Risk factors for recession

A

Root prominence / B displacement / rotation
Thin gingiva + red. KAG
Thin underlying bone
High/excessive frenum pull

44
Q

Cairo classification of recession

A

Interproximal CEJ visible; Proximal Attachment Loss
I: N; N
II: Y; < B attachment loss
III: Y; > B attachment loss

45
Q

Miller classification of recession

A

Recession; Proximal Bone Loss; Root Coverage
I: < mucogingival junction; N; 100%
II: >/= mucogingival junction; N; 100%
III: >/= mucogingival junction; Y or displacement; partial
IV: >/= mucogingival junction; Severe; 0%

46
Q

Three types of gingival phenotype

A

Thick flat
Thick scalloped
Thin scalloped

47
Q

Compare three gingival phenotypes

A

Thick flat

  • thick fibrotic gingiva
  • thick alveolar bone
  • square teeth
  • large contact points
  • pronounced cervical convexity
  • broad zone KT

Thick scalloped

  • thick fibrotic gingiva
  • slender teeth
  • pronounced gingival scalloping
  • narrower zone KT

Thin scalloped: probe visible through crevice

  • thin gingiva
  • thin alveolar bone
  • slender teeth
  • contact points coronal
  • subtle cervical convexity
  • narrow zone KT
48
Q

Classification of cervical lesions

A

CEJ A -: CEJ detectable w/o step
CEJ A +: CEJ detectable w/ step

CEJ B -: CEJ detectable w/o step
CEJ B +: CEJ detectable w/ step

49
Q

Significance of steps in Tx planning

A

Red. Tx stability + predictability

50
Q

Indications for recession Tx

A 
Cosmetic concern 
Tooth/teeth sensitivity 
Gingival sensitivity when brushing 
Root caries
Progressively inc. recession defect
51
Q

Success criteria for Tx recession

A

Gingival margin on CEJ (Class I/II)
Inc. KAG
POD<3mm; BOP=0%

No hypersensitivity
Good aesthetics (colour + contour match)
Cost effective

52
Q

How many recession defects will achieve 100% root coverage?

A

67% success rate

53
Q

Describe healing of free gingival graft

A

Plasmatic circulation: 0-3d
Revascularisation: 2-11d
Remodelling: 11-42d

54
Q

Most predictable Tx modality for recession defect

A

Coronally advanced flap + connective tissue graft

55
Q

Difference between free gingival graft and connective tissue graft

A 
FGG: depth 2-3mm
- palate 
CTG: deeper than FGG, from CT layer (no epithelialised tissue)
- palatal P/M
- retromolar / edentulous ridge 
- palatal flap
56
Q

Define perio-endo lesion

A

Combined lesion involving inflammation of lateral (PD) and PA tissues
Inflammatory products found in varying degrees in both PD tissue + pulp

57
Q

Pathways between pulp + PD tissue

A

Anatomical

  • apical foremen
  • lat + accessory canals
  • dentinal tubules

Non-Physiological

  • iatrogenic root perforation; RCT, post + core
  • vertical root #
  • poor RCT
  • poor restorations
58
Q

Classification of perio-endo lesions (Simon, Glick, Frank 1972)

A

1ry endo: inflammatory process in PD tissues resulting from noxious agents present in RC

1ry perio: inflammatory process in pulpal tissues resulting from accumulation of plaque on root surfaces

True-combined: PD + endo developing independently + progress concurrently which meet and merge at point along root surface

Iatrogenic: usually endo lesions prod. by Tx modality

59
Q

In EPF 2017 classification of EPL what are the subgroups?

A

EPL w/ Root Damage: often painful

  • root #
  • root perforation
  • external root resorption

EPL w/o Root Damage

  • PD pt: usually asymptomatic
  • non-PD pt
60
Q

Types of external root resorption seen w/ EPL

A

Progressive inflammatory
- Tx: removal of inflamed pulp + RCT

Invasive (non-inflammatory)
- Tx: complete removal/inactivation of resorptive tissues

Replacement (non-inflammatory)

  • poor prognosis
  • osteoclast/blast activity resorb root + replace w/ bone
61
Q

What are the grades for EPL w/o root damage?

A

For both non/PD pts
Grade 1: narrow, deep pocket, 1 surface
Grade 2: wide, deep pocket, 1 surface
Grade 3: deep pocket, >1 surface

62
Q

Define periodontal abscess

A

Localised accumulation of pus within gingival wall of PPD w/ express PD breakdown occurring during limited T period + easily detectable clinical symptoms

63
Q

Importance of periodontal abscess

A

7-14% of dental emergencies
Rapid destruction of PD tissue + risk factor for exfoliation
Systemic consequences

64
Q

Classification of PD abscess 2017

A

PD pt

  • acute exacerbation
  • post-Tx

Non-PD pt

  • impaction
  • harmful habits
  • ortho
  • gingival enlargement
  • alteration to root surface
65
Q

Subgroups of PD abscesses for PD pt

A

Acute exacerbation

  • unTx PD
  • non responsive to Tx
  • supportive PD therapy

Post-Tx

  • post-scale
  • post-surgery
  • post-medications
66
Q

Subgroups of PD abscesses for non-PD pt

A

Impaction: floss, toothpick, ortho elastic, popcorn, rubber dam
Harmful habits: nail/wire biting, clenching
Orthodontic: forces, X-bite
Gingival enlargement
Alteration to root surface
- severe anatomic alteration: invaginated, dens evaginates, odontodysplasia
- minor anatomic: cemental tear, enamel pearls, grooves
- iatrogenic: perforation
- severe root damage: fissure, #, cracked tooth syndrome
- external root resorption

67
Q

Hx and clinical signs of PD abscess

A

Hx

  • pain
  • tender gingiva
  • swelling
  • elevated tooth

Clinical

  • ovoid gingival elevation near root
  • suppuration
  • deep PPD
  • BOP
  • inc. mobility
  • systemic signs
  • PD
68
Q

Prognosis of EPLs

A

Generally poor
> perio = worse
> T = worse

1ry endo: better cf 1ry perio
- worse w/ 2ry perio 
1ry perio: poor
- worse w/ apical involvement 
True combined
- poor/hopeless 
- dependent on efficacy of perio Tx
69
Q

General Mx EPL

A

Acute symptoms: pain, swelling, pus
Re-evaluate
Endo Tx
- inhibits PD contamination
- Ca(OH)2: bactericidal, proteolytic, anti-inflammatory = favour repair
- obturation good healing prognosis
Perio Tx
- remove noxious stimuli + allows 2ry remineralisation of dentine tubules = pulpal hypersensitivity resolves
- pulpal inflammation irreversible: RCT -> perio Tx
Review 4-6/12: healing PPD + bony repair

70
Q

How are true combined EPLs Tx’d

A

As 1ry endo, 2ry perio

Consider root amputation, hemisection or separation to save some tooth tissue

71
Q

Tx iatrogenic EPL

A

Perforations: seal ASAP

Prognosis dependent on size, location, T of Dx + Tx and sealing ability of material

BDS5 (5 decks)

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