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Perio Flashcards

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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
Ideal properties of membrane material
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
26
Compare properties of non/resorbable membranes
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
27
Types of resorbable membranes
Polymer Collagen - non-cross linked - cross linked
28
Discuss polymer membranes
Aliphatic polyesters Excellent biocompatibility + controllable biodegradation Low rigidity Drug encapsulating ability Degradation products may give inflammatory foreign body reaction
29
Discuss non/cross linked collagen membranes
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
What are bioactive factors?
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
What restorative problems are associated w/ perio?
``` High lip/smile line Recession + Black triangles Drifting + Rotation Mobility Occlusal stability + OE Crown prep onto dentine Able to produce aesthetic pros restoration? ```
32
Discuss aetiology + Mx of recession and black triangles
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
Discuss drifting + rotation of teeth
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
Discuss mobility
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
Discuss OE
``` Aetiology: loss of opposing tooth Freq.: 83% Inc. risk - post. > ant. - Mx. > Md ```
36
Discuss splinting teeth
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
Define mucogingival deformity
Deviation from normal dimension + morphology relationship b/w gingiva + alveolar mucosa
38
Types of mucogingival deformities
Lack of keratinised gingiva Dec. vestibular depth Aberrant frenum Gingival recession
39
Types of PD plastic surgery
``` Frenectomy Alveolar ridge preservation Crown lengthening Keratinised attached gingiva augmentation Ectopic tooth eruption Papilla regeneration ```
40
Causes of red. keratinised attached gingiva
Recession Pocketing Abnormal frenum pull
41
Define gingival recession
Apical shift of soft-tissue w/ respect to CEJ
42
Aetiology of recession
``` 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
Risk factors for recession
Root prominence / B displacement / rotation Thin gingiva + red. KAG Thin underlying bone High/excessive frenum pull
44
Cairo classification of recession
Interproximal CEJ visible; Proximal Attachment Loss I: N; N II: Y; < B attachment loss III: Y; > B attachment loss
45
Miller classification of recession
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
Three types of gingival phenotype
Thick flat Thick scalloped Thin scalloped
47
Compare three gingival phenotypes
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
Classification of cervical lesions
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
Significance of steps in Tx planning
Red. Tx stability + predictability
50
Indications for recession Tx
``` Cosmetic concern Tooth/teeth sensitivity Gingival sensitivity when brushing Root caries Progressively inc. recession defect ```
51
Success criteria for Tx recession
Gingival margin on CEJ (Class I/II) Inc. KAG POD<3mm; BOP=0% No hypersensitivity Good aesthetics (colour + contour match) Cost effective
52
How many recession defects will achieve 100% root coverage?
67% success rate
53
Describe healing of free gingival graft
Plasmatic circulation: 0-3d Revascularisation: 2-11d Remodelling: 11-42d
54
Most predictable Tx modality for recession defect
Coronally advanced flap + connective tissue graft
55
Difference between free gingival graft and connective tissue graft
``` FGG: depth 2-3mm - palate CTG: deeper than FGG, from CT layer (no epithelialised tissue) - palatal P/M - retromolar / edentulous ridge - palatal flap ```
56
Define perio-endo lesion
Combined lesion involving inflammation of lateral (PD) and PA tissues Inflammatory products found in varying degrees in both PD tissue + pulp
57
Pathways between pulp + PD tissue
Anatomical - apical foremen - lat + accessory canals - dentinal tubules Non-Physiological - iatrogenic root perforation; RCT, post + core - vertical root # - poor RCT - poor restorations
58
Classification of perio-endo lesions (Simon, Glick, Frank 1972)
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
In EPF 2017 classification of EPL what are the subgroups?
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
Types of external root resorption seen w/ EPL
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
What are the grades for EPL w/o root damage?
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
Define periodontal abscess
Localised accumulation of pus within gingival wall of PPD w/ express PD breakdown occurring during limited T period + easily detectable clinical symptoms
63
Importance of periodontal abscess
7-14% of dental emergencies Rapid destruction of PD tissue + risk factor for exfoliation Systemic consequences
64
Classification of PD abscess 2017
PD pt - acute exacerbation - post-Tx Non-PD pt - impaction - harmful habits - ortho - gingival enlargement - alteration to root surface
65
Subgroups of PD abscesses for PD pt
Acute exacerbation - unTx PD - non responsive to Tx - supportive PD therapy Post-Tx - post-scale - post-surgery - post-medications
66
Subgroups of PD abscesses for non-PD pt
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
Hx and clinical signs of PD abscess
Hx - pain - tender gingiva - swelling - elevated tooth Clinical - ovoid gingival elevation near root - suppuration - deep PPD - BOP - inc. mobility - systemic signs - PD
68
Prognosis of EPLs
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
General Mx EPL
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
How are true combined EPLs Tx’d
As 1ry endo, 2ry perio | Consider root amputation, hemisection or separation to save some tooth tissue
71
Tx iatrogenic EPL
Perforations: seal ASAP | Prognosis dependent on size, location, T of Dx + Tx and sealing ability of material

BDS5 (5 decks)

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