Perio Midterm Flashcards
1
Q
How many stages and grades are assigned to each perio pt?
A
1 stage + 1 grade
2
Q
What is the severity of perio diagnosis based on?
A
Most severe tooth
3
Q
Your assessment of expected outcomes of suggested tx modalities
A
Prognosis
4
Q
What are the different prognoses?
A
Favorable
Questionable
Unfavorable
Hopeless
5
Q
Which prognosis?
Perio status of the tooth can be stabilized with comprehensive periodontal tx and maintenance.
A
Favorable
6
Q
Which prognosis?
Future loss of the periodontal supporting tissues is unlikely if these conditions are met
A
Favorable
7
Q
Which prognosis?
Perio status of the tooth is influenced by local and/or systemic factors that may or may not be able to be controlled.
A
Questionable
8
Q
Which prognosis?
The periodontium can be stabilized with comprehensive treatment and periodontal maintenance if these factors are controlled; otherwise, future periodontal
breakdown may occur
A
Questionable
9
Q
Which prognosis?
Periodo status of the tooth is influenced by local and/or systemic factors that cannot be controlled
A
Unfavorable
10
Q
Which prognosis?
Periodontal breakdown is likely to occur even with comprehensive periodontal tx and maintenance
A
Unfavorable
11
Q
Which prognosis?
Tooth must be extracted
A
Hopeless
12
Q
What is the only evidence based prognosis scheme for molars with furcations?
A
Miller prognosis
13
Q
What is the goal for Miller prognosis?
A
Score of < 5
14
Q
What are the 4 categories of perio health?
A
Pristine perio health
Clinical perio health
Perio disease stability
Perio disease remission/control
15
Q
Which category of perio health?
Absence of pocket depth > 3mm
(exception = most distal molar)
A
Pristine perio health
16
Q
Which category of perio health?
Absence of attachment loss
A
Pristine perio health
17
Q
Which category of perio health?
BOP < 10%
A
Pristine perio health
Clinical perio health
18
Q
Which category of perio health?
Absence of clinical erythema, edema, pus
A
Pristine perio health
Clinical perio health
19
Q
Which catgeory of perio health?
Can contain attachment loss due to recession
A
Clinical perio health
20
Q
Which category of perio health?
No pocket depths of clinical importance (pseudopockets)
A
Clinical perio health
21
Q
Which category of perio health?
Absence of minimal levels of clinical inflammation
A
Clinical perio health
22
Q
Which category of perio health?
Normal osseous support
A
Clinical perio health
23
Q
Which category of perio health?
Absence of inflammation and infection, but reduced periodontium
A
Perio disease stability
24
Q
Which category of perio health?
Goal of perio patients
A
Perio disease stability
25
Which category of perio health?
Reducing predisposing factors and controlling modifying factors
Perio disease stability
26
Which category of perio health?
Cannot fully control modifying and predisposing factors
Perio disease remission/control
27
Which category of perio health?
Decreased inflammation and improvement in clinical parameters
Perio disease remission/control
28
Which category of perio health?
Stabilization of disease progression to low disease activity
Perio disease remission/control
29
Which category of perio health?
May be an acceptable alternative therapeutic goal in long-standing disease
Perio disease remission/control
30
Minimal recession without pre-existing active perio disease (ex: brushing too hard, ortho, etc)
Health
31
Denotes a healthy state in a patient with a previously diagnosed perio disease (attachment loss)
Stability
32
For patients with reduced periodontium
for any reason (recession, crown
lengthening procedure, or history of
periodontal therapy), as long as PDs
are ≤3 mm, the diagnosis is _____________
Gingivitis/inflammation on a reduced periodontium
33
For patients with a history of periodontitis, PDs ≥4 mm with BOP (at the same sites) indicate _______________
Recurrence of disease
34
Describe Step 1: initial case overview to assess disease
Full mouth PDs
Full mouth X-Rays
Missing teeth
Mild-moderate perio is usually Stage I or II
Severe-very severe perio is usually Stage III or IV
35
Describe Step 2: establish stage (for mild-moderate perio)
Confirm CAL
Rule out non-perio causes of CAL
Determine max CAL or radiographic bone loss (RBL)
Confirm RBL patterns
36
Describe Step 2: establish stage (for moderate-severe perio)
Determine max CAL or RBL
Confirm RBL patterns
Assess tooth loss due to perio
Evaluate case complexity factors
37
Describe Step 3: establish grade
Calculate RBL (% of root length x 100) divided by age
Assess risk factors
Measure response to SRP & plaque control
Assess expected rate of bone loss
Conduct detailed risk assessment
Account for medical/systemic inflammatory considerations
38
Root length, CAL, and CP for Stage I chronic perio
Root length = 15%
CAL = 1-2
CP = slight
39
Root length, CAL, and CP for Stage III or IV chronic perio
Root length = >30%
CAL = >5mm
CP = severe
40
PDs and gingival margin enteries are required for ____ sites and _____ teeth present at time of evaluation
all; all
41
If you have a PD of 3mm or less, what do you put in the GM?
Negative reciprocal, or blank
42
If you have a PD of 4mm or greater with CAL, what do you put in the GM?
-2 or blank
43
What do you enter when you see recession?
Positive numbers
44
What do you enter when you see pseudo-pockets?
Negative numbers
45
What do you enter when gingival margin is at the CEJ?
0
46
Go through the diagnosis sequence for chronic perio
Start with generalized or localized
Enter stage and grade
Enter chronic perio at end
(Ex: Generalized Stage I Grade B chronic perio)
47
Probing is considered what type of procedure?
Invasive
(premed, other consults may be necessary)
48
How often must a dental exam be updated (D0180)?
Anually
49
What code is used for a dental exam?
D0180
50
What must you use during a dental exam?
Disclosure stain for plaque index
51
What are the 3 major components of a perio exam?
Diagnosis, treatment plan, prognosis
52
What code is used for OHI?
D1330
53
Chronic perio is most prevalent in what age group?
Adults
(can occur in children too tho)
54
Patients diagnosed with chronic perio under 25 years old must be evaluated for a differential diagnosis of what?
Molar/incisor pattern perio
55
What should you assess in a patient with chronic perio?
Localized bone loss of 1st molar and incisors
Assess OH
56
The amount of destruction present in chronic perio is consistent with the presence of what?
Local factors (ex: primary and secondary etiologic factors)
57
What is a frequent finding in chronic perio?
Subgingival calc
58
What is chronic perio associated with?
Variable microbial pattern
Predisposing factors
Systemic diseases (diabetes, HIV)
59
Describe the rate of progression of chronic perio
Slow/moderate
(but can have periods of rapid destruction)
60
How can chronic perio be further classified?
Extent and severity
61
What can chronic perio be modified by (other than systemic diseases)?
Cig smoking
Emotional stress
62
Localized vs generalized chronic perio is based on what?
% of sites affected
30% or greater = generalized
30% or less = localized
63
Describe severity CAL and Armitage system of diagnosis (outdated but seen in chart notes)
Slight chronic perio = 1-2mm CAL
Moderate chronic perio = 3-4mm CAL
Severe chronic perio = 5+mm CAL
64
What is "CAL"?
Clinical/calculated attachment loss
65
What should you do for a patient with > than 3mm pockets without loss in CAL?
Enter appropriate negative number OR leave blank
66
What must be entered into the appropriate charting for ID?
Pseudopockets
67
T/F: Pts with subgingival calculus on enamel w/o CAL are not appropriate for SRP codes
True
68
What is the code for scaling with inflammation?
D4346
69
What is the code for scaling/root planing?
D4341, D4342
70
Which types of patients are likely to have pseudo pockets?
Young pts with edema and subgingival calc
Pts with associated pharmacologic effects
71
Exposure of root surface by apical shift in position of gingiva
Recession
72
Apical migration of JE; apical shift of gingiva
Root exposure
73
CEJ to the attachment
Actual recession
74
Visible on clinical exam; gingiva margin to CEJ
Apparent recession
75
Level of attached perio tissue; not directly visible, but determined by probing
Actual position
76
Level of gingival margin or crest of free gingiva that is seen by direct vision
Apparent position
77
What are the 2 causes of recession?
Pt self-care
Anatomical
78
What are the reasons for recession due to pt self-care?
Incorrect brushing
Abrasive toothpaste
Hard brush
79
What are the reasons for recession due to anatomy?
Eruption pattern
Position of tooth in alveolus
80
What gingival phenotype?
Probe visible
Thin (<1mm)
81
What gingival phenotype?
Probe not visible
Thick (>1mm)
82
What recession type?
No loss of interproximal attachment. CEJ is clinically not detectable at both mesial and distal aspects of tooth
Recession Type 1
83
What recession type?
Associated with loss of interproximal
attachment. The amount of inter-proximal attachment loss is less than or equal to the buccal attachment loss
Recession Type 2
84
Measured from the interproximal CEJ to the depth of the interproximal sulcus/pocket
Interproximal attachment loss
85
Measured from the buccal CEJ to the apical end of the buccal sulcus/pocket
Buccal attachment loss
86
What recession type?
Associated with loss of interproximal attachment. The amount of inter-proximal attachment loss is higher than the buccal attachment loss
Recession Type 3
87
What class? (Miller)
Recession not to MGJ; no interproximal bone or papilla loss; 100% coverage
Class 1
88
What class? (Miller)
Recession past MGJ; no interproximal bone or papilla loss; 100% coverage; possibility of root coverage
Class 2
89
What class? (Miller)
Recession past MGJ; interproximal bone or papilla loss; malposition; partial coverage
Class 3
90
What class? (Miller)
Recession past MGJ; severe interproximal bone or papilla loss; malposition; no coverage
Class 4
91
What scenarios does the gingival margin go to the CEJ (loss of attachment)?
Previous perio therapy
Recession
Attrition w/ age
Malposition teeth
92
What is the easiest way to identify gingival margin at the CEJ (loss of attachment)?
Embrasure space btwn 2 teeth is NOT filled with gingival tissue/papilla
93
What probe do you use to find furcations?
Nabers
94
Which furcation class?
Depression that does not catch probe
Class I
95
Which furcation class?
Furcation deep enough to catch probe, but not continuous w/ other furcations on same tooth
Class II
96
Which furcation class?
Bone loss through and through, but covered with gingival tissue
Class III
97
Which furcation class?
Bone loss through and through, directly exposed to oral environment, gingival margin is apical to entrance of furcation
Class IV
98
Marker of disease activity
Bleeding on probing
99
Should BOP be noted in chart?
YES - it is a marker of disease activity
100
Measures actual positives correctly identified (% of population that has a condition)
Sensitivity
101
Measures the actual negatives correctly identified (% of population that does NOT have a condition)
Specificity
102
BOP specificity/sensitivty
High specificity
Low sensitivity
103
Degree of looseness of a tooth when we move it
Mobility
104
What is mobility caused by?
Inflammation, bone loss, trauma
105
Which degree of mobility?
Within physiologic limits
0
106
Which degree of mobility?
< than 1mm BL/MD direction
1
107
Which degree of mobility?
1mm+ in BL/MD direction
2
108
Which degree of mobility?
Exceeding 1mm and depressible occluso-apical direction
3
109
Movement of teeth during function or parafunction
Functional mobility
110
Often detected earlier than bidigital tooth mobility and has been associated in the presence of inflammation, with increased bone
and attachment loss; pocket formation
Fremitus
111
How is fremitus seen/felt?
Place index finger on labial surface and pt grinds in lateral and protrusive movements
112
How do you measure the amount of attached gingiva?
Measure probing depth (ex: 2mm)
Measure height of keratinized gingiva (ex: 7mm)
Attached gingiva = keratinized gingiva - PD
Attached gingiva = 7-2 = 5mm
113
What do you enter in the GM in chart if there is recession?
+ number
114
What do you enter in the GM in chart if there is a PD of 3mm or less?
Reciprocal of PD or blank
115
What do you enter in the GM in chart if there is a pseudopocket?
Reciprocal of PD
116
What do you enter in the GM in chart if there is a PD of 3mm or greater and the pt has perio?
-2
117
What do you enter in the GM in chart if the free gingival margin is at the CEJ?
0
118
If you have a PD of 4mm or greater, what should you be thinking based on X-Rays and clinical impression?
"Where am I headed"
119
What should you do if you can't probe?
Tell faculty
Triage X-Rays for exts
Plan SRP
Obtain baseline measurements quad by quad, appt by appt, AFTER removal of debris
Complete chart on last SRP if appropriate
Never do a full mouth debridement!!
120
What are the 5 disadvantages of the Armitage severity guidelines?
Time consuming
Inaccuracies from probing angles
Root length disregarded
Difficult to determine CEJ
Systemic diseases/local infections disregarded
121
What is the new classification based on?
Oncology
122
What are the 2 main factors of the new classification?
Stage
Grade
123
Severity and extent of disease at most affected area (CAL, RBL), tooth loss that has occurred bc of perio, complexity assessment of tx required
Stage
124
Stage is based on the most ________ ______ of perio
severe area
125
Estimate of future risks, rate of progression, response to therapy, systemic implications
Grade
126
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 (CAL)
127
The new disease classification system uses clinical attachment loss primarily at
___________ sites but may also include buccal/lingual sites
interdental
128
What factors define perio?
Interdental CAL at 2 or more non-adjacent teeth
OR
Buccal or lingual CAL is 3mm or greater with pockets greater than 3mm at 2 or more teeth
129
3 main factors to establish severity in staging
1. Interdental CAL
2. Radiographic bone loss (RBL)
3. Tooth loss due to perio
130
Severity Stage I
Interdental CAL = 1-2mm
RBL = Coronal 1/3 (<15%)
Tooth loss = None
131
Severity Stage II
Interdental CAL = 3-4mm
RBL = Coronal third (15-33%)
Tooth loss = None
132
Severity Stage III
Interdental CAL = 5mm+
RBL = Middle 1/3 of root+
Tooth loss = 4 teeth or less
133
Severity Stage IV
Interdental CAL = 5mm+
RBL = Middle 1/3 of root+
Tooth loss = 5 teeth+
134
7 main factors to establish complexity in staging
1. PD
2. Type of bone loss
3. Furcation
4. Ridge defect
5. Masticatory dysfunction
6. Occlusal trauma
7. Bite collapse, drifting, flaring
135
Complexity Stage I
PD = 4mm or less
Bone loss = horizontal
136
Complexity Stage II
PD = 5mm or less
Bone loss = horizontal
137
Complexity Stage III
PD = 6mm+
Bone loss = vertical, 3mm+
Furcation = class II or III
Ridge defect = moderate
138
Complexity Stage IV
PD = 6mm+
Bone loss = vertical, 3mm+
Furcation = class II or III
Ridge defect = severe
Masticatory dysfunction
Secondary occlusal trauma (mobility degree 2+)
Bite collapse, drifting, flaring
Remaining teeth = <20
139
For each stage, how do you describe extent as?
Localized (<30% teeth involved)
Generalized (>30% teeth involved)
Molar/incisor pattern
140
Which stage?
Pt shows perio of mild to moderate severity
Stage I and II
141
Which stage?
Pt has not lost any teeth due to disease
Stage I and II
142
Which stage?
More complex; require more advanced perio tx
Stage III and IV
143
Which stage?
Extent of tooth loss requires extensive rehab
Stage IV
144
Allows the clinician to incorporate individual patient factors into the diagnosis, which are crucial to comprehensive case management
Grade
145
Observed/inferred progression rate; risk for further deterioration due to environmental exposures (e.g., smoking) and co-morbidities (e.g., diabetes); risk that disease or treatment may adversely affect general healthy
Grade
146
What are the 3 fundamental principles that grading is based on?
1. Not everyone is equally susceptible to perio
2. Perio progression/severity is due to many influences on a response to microbial challenge
3. Some cases require more intensive control of biofilm/inflammation than achieved during current principles of care
147
Grade A progression
Slow
148
Grade B progression
Moderate
149
Grade C progression
Rapid
150
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
151
3 main factors to establish primary criteria in grading
1. CAL or RBL
2. % bone loss/age
3. Case phenotype
152
Primary Criteria Grade A slow rate
CAL or RBL = No loss over 5 yrs
% bone loss/age = <0.25
Case phenotype = heavy biofilm; low destruction
153
Primary Criteria Grade B moderate rate
CAL or RBL = <2mm over 5 yrs
% bone loss/age = 0.25-1.0
Case phenotype = destruction commensurates w/ biofilm
154
Primary Criteria Grade C rapid rate
CAL or RBL = 2mm+ over 5 yrs
% bone loss/age = 1.0+
Case phenotype = destruction exceeds expectations given biofilm
155
2 main factors to establish grade modifiers in grading
1. Smoking
2. Diabetes
156
Grade Modifiers Grade A slow rate
Smoking = non-smoker
Diabetes = non-diabetic
157
Grade Modifiers Grade B moderate rate
Smoking = <10 cigs/day
Diabetes = HbA1c < 7%
158
Grade Modifiers Grade C rapid rate
Smoking = 10+ cigs/day
Diabetes = HbA1c is 7%+
159
Revision of Grade upwards is possible if the % bone loss / age ratio _________ substantially or the risk profile of the patient __________
increases; decreases
160
What are the 3 steps to staging and grading a patient?
1. Initial case overview
2. Stage
3. Grade
161
Which step to staging/grading a patient?
Screen:
Full mouth PD
FMX
Missing teeth
Step 1 - initial case overview
162
Which step to staging/grading a patient?
Mild/moderate perio:
Confirm CAL; rule out non-perio causes
Determine max CAL or RBL
Confirm RBL patterns
Step 2 - staging
163
Which step to staging/grading a patient?
Moderate/severe perio:
Determine max CAL or RBL
Confirm RBL patterns
Assess tooth loss due to perio
Evaluate for complexity
Step 2 - staging
164
Which step to staging/grading a patient?
Calculate RBL/age
Assess risk factors (smoking, diabetes)
Measure response to SRP/plaque control
Assess expected rate of bone loss
Detailed risk assessment
Medical and systemic inflammatory considerations
Step 3 - grading
165
What are the 3 diagnostic aids for implant health?
Visual inspection
Probing
X-rays at 1 yr and after abutment connection
166
Absence of erythema, bleeding on probing, swelling, and suppuration.
Peri-implant health
167
The main characteristic is BOP on gentle probing; erythema, swelling, and/or suppuration may also be present
Peri-implant mucositis
168
Increased PD; absence of additional bone loss beyond initial bone remodeling
Peri-implant mucositis
169
What is the cause of peri-implant mucositis?
Plaque
170
Plaque-associated pathological condition,
characterized by inflammation in the peri-implant mucosa and subsequent progressive bone loss
Peri-implantitis
171
Clinical signs of inflammation, increased probing depths, and/or mucosal recession in addition to loss of supportive bone
Peri-implantitis
172
Absence of erythema (inflammation), BOP, swelling, and suppuration with no bone loss < 2.0 mm
Peri-implant health
173
Inflammation, presence of BOP, swelling, no BL < 2.0 mm, and strong evidence that plaque (biofilm) is the etiologic factor
Peri-implant mucositis
174
Inflammation, plaque-associated pathological condition in tissue, PD ≥ 4–8 mm, and subsequent progressive BL
Peri-implantitis
175
Records should include previous radiographs, PD at one-year postload.
In the absence of a previous exam, refer to the guidelines for peri-implantitis, PD ≥ 6 mm, BOP, and BL ≥ 3 mm with concurrent peri-implantitis diagnosis
Peri-implantitis in absence of previous exam
176
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/hard tissue deficiencies
177
All competencies must have an approved _____ entered in axium
plaque index
178
T/F: DO NOT polish calc
True
179
What is the code for dental prophylaxis?
D1110
180
What must be present in order to do SRP (D4341/D4342)?
Attachment loss
PDs 4mm+
181
When should you polish?
Only at re-eval appt
182
What is the code for perio re-eval?
D0171P
183
At the re-eval, PDs greater than what require referral to grad perio?
6mm
184
At the re-eval, what Stages/Grades require referral to grad perio?
Stage III/IV and/or Grade C
185
At the re-eval, how many sites with PDs of 5mm with BOP require referral to grad perio?
3+ sites
186
What is the code for perio maintenance?
D4910
187
What do you remove in a perio maintenance (D4910) appt?
Plaque, calc, stain
188
What is part of the perio maintenance code explanation (D4910)?
Limited SRP w/ anesthesia
189
Do NOT confused which 2 codes/appts?
Perio maintenance (D4910) and Prophy (D1110)
Insurance fraud!
190
What is the order of the tx plan?
Begin with OHI
Choose btwn prophy, SRP, scaling w/ inflammation
Re-eval 4-6 weeks after SRP
Recall or maintenance
191
What 2 clinical observations are an automatic Stage III?
Vertical bone loss 3mm+
Furcation involvement of Class II/III
192
What clinical observation is an automatic Stage IV?
<20 remaining teeth
193
Why should you not cross the midline during SRP?
Don't want tongue to be completely numb
Want to give pt. one "good"/not sore side to chew on after tx
194
At the re-eval, what should you never tx plan for?
Another round of SRP and re-eval
