ORAL EXAM perio

5 Modes of action of fluoride

• replaces hydroxyapatite with flurapetite

• Critical pH 4.5

• Bacteriostatic - inhibits bacterial growth specifically strep. Mutants

• Lowers plaque acid production

• Systemically: flatter + wider cusps, flourosis

describe initial lesion

24-48 hrs after plaque accumulation

• vasodilation occurs which allows neutrophils to arrive at the side of infection via chemotaxis

• GCF increases to flush out bacteria starting to form

describe early lesion

1 week after plaque accumulation

• Increase in inflammatory infiltrate lymphocytes (esp T) + PMNs

• fibroblasts and collagen loss near the sulcus

• more inflammatory cells reqruited via chemotaxis - macrophages, Ig, complement

• GCF increases

describe established lesion

2-3 weeks of plaque accumulation / gingivitis

• junctional epithelium is leaky and ulcerated = BoP

• apical migration of plaque

• continued loss of collagen

• rete pegs start to form

• red complex bacteria begin to colonise

describe advanced lesion

this is periodontitis

• junctional epithelium migrates apically = pocket

• collagen loss up to 90% in the base of the pocket

• bone resorption due to cytokine release

• rete pegs infiltrate connective tissue - epithelial extensions which create more surface area and epithelial permeability for inflammatory cells to migrate to site of infection

orange and red complex

orange

• prevotella intermedia

• fusobacterium nucleatum

red

• tanerella forsythia

• treponema denticola

• porphynomas gingivalis

what does p. gingivalis produce

gingipains

(proteolytic enzymes) that help p.gingivalis colonise and dominate subgingival plaque by inhibiting neutrophils cell apoptosis facilitating inflammation, bone loss and destruction

whats the difference between gram +ve and -ve bacteria

+ve has single membrane layer and stains pink

-ve has double membrane layer (less permeable to host defences) and stains purple)

describe healing process after RSD

• from 24-48hours you get acute inflammation, 5 symptoms

  • redness (rubor),

  • swelling (tumor),

  • Heat (calor)

  • Loss of function (functino leasa)

  • Pain (Dolor)

• Neutrophils are the 1st responders that release cytokines + GCF increases

• LJE starts to form and basement membrane forms on the root surface

• These 2 things join together by hemidesmosomes to form NEW ATTACHMENT!!

  • No PDL fibres or sharpies fibres

  • Fibroblasts start laying down collagen: strengthening tissue attachment and tightens gingival cuff Resulting in SHRINKAGE Occurs because inflammation has subsided = reduced PPD, BOP

How does stress affect the periodontium

• reduced salivary flow → dry mouth → plaque buildup

• Increased cortisol → altered/weakened immunity making it difficult to fight off bacteria

• Disturbed routines → poor OH

• Potential bruxism

• Pre disposing factor for NG

How does diabetes affect periodontal disease?

• bidirectional relationship, each condition worsen the other

• only poor controlled diabetes has this effect

• altered immune cell function - less effective neutrophils

• poor fibroblast function which decreases collagen and tissue regeneration

• exaggerated inflammatory response leading to prolonged, intense inflammation that damages host tissues

How does bone resorb

• pathogens (p.gingivalis) releases toxins that trigger an immune response that release cytokines:

  • IL1: originate from epithelium: Pro inflammation and osteoclast activation.

  • TNF(a): originates from neutrophils: causes bone resorption + tissue damage

• these cytokines stimulate osteoclasts that breakdown alveolar bond by releasing acid and enzymes

What are the different types of periodontal disease

• inflammatory conditions

  • Gingivitis → no attachment loss

  • Periodontitis → attachment loss

• Clinical presentation

  • Acute eg necrotising gingivitis

  • Chronic most common form of

• By cause

  • Plaque induced vs non-plaque induced (rare, genetic, systemic)

how does smoking effect perio/mouth

Smoking is a major risk for periodontal disease as it affects immune response and tissue healing

• Vasoconstriction → Reduced blood flow, less BoP = delayed detection of disease. limits number of neutrophils that can reach the periodontium effectively

• Neutrophils → they are needed as they are the first line of defence in the inflammatory process = this weakens the immune response allowing bacteria to multiply and cause more severe disease.

• chemotaxis is impaired. this is the process by which cells like neutriphils move towards site of inflammation in response to chemical signals released by bacterial toxins

• Keratinisation → keratinisation of epithelial soft tissues causing them to become thick and hard

• Collagen → smoking inhibits fibroblasts and their ability to produce collagen, poor would healing after tx, weaker tissues = increased pocket formation

clinical presentation of smokers

• Deeper periodontal pockets

• More calculus and plaque

• Less bleeding on probing (masks disease)

• Vertical bony defects

• More keratinised tissue

• Tooth mobility

• Xerostomia (dry mouth)

• Increased risk of oral cancer and tooth loss

reasons for perio treatment failure

• incomplete RSD

• Poor OH

• Anatomical challenges (Narrow pockets, difficult access)

• Medical/social history (smoking, medication)

• Clinical skill level

• Inappropriate tx planning

• lack of motivation

• restoration deficiencies/overhangs

• local factors like crowding of teeth

• impaired would healing

• increased susceptibility

treatment options after failure of RSD

• Repeat another course of tx

• chemical adjuncts:

  • local:

    • Anticeptic: chlorhexidine: gel, mw + periochip (lasts 100 days)

    • Antibiotic: Tetracycline/metronidazole gel/fibres (eg actisite)

  • systemic: Antibiotics

    • metronidazole

    • tertracycline

    • doxacylin (subclinical dose): low dose for 3-12months

• surgical:

  • furcation:

    • furcationplasty - remove part of bone to make furcation bigger but not all the way through to make more accessible

    • Hemisection (root and a bit of crown removed)

    • tunnel prep (esp for grade 3 furcation = remove bone so can clean)

  • open flap surgery (flap raised to expose root, debridement of root and then flap sutured)

  • gingevectomy (removes excess gingival tissue)

  • root resection - remove a root to make to easier to clean

  • guided tissue regeneration: aids PDL and bone formation by excluding epithelium using a membrane.

Prognosis and maintenance of periodontitis

Once pt has periodontitis, they always have it

Once the disease is stabilised, they go on the supportive periodontal therapy (SPT) = maintenance phase post tx

• focuses on long term monitoring, OHI reinforcement and early intervention

types of ultrasonic

Magnetostrictive - magnetic stack creates vibrations, tip move back and forward

Piezoelectric - crystals deform under electric current causing vibrations, tip moves eliptically

modes of action of ultrasonic

• Acoustic streaming – movement of fluid around the tip which breaks up the biofilm

• Cavitation – produces bubbles that implode, releasing oxygen, which kills anaerobic bacteria (those that cant survive in oxygen)

• Mechanical Vibration – tip vibrates at a high frequency to mechanically disrupt plaque and calculus

Types of mouthwashes

• phenolic compounds + essential oils = listerine

• Antiseptic = chlorhexidine (stains), bisbiguanides

• Fluoride rinse = 225ppm

• Oxygenating (hydrogen peroxide) = NG, helps by releasing oxygen

what are the dental affects of hypertension

1. increased risk of bleeding - if uncontrolled

2. medication related side effects eg CCB Cause gingival overgrowth

3. xerostomia eg some meds cause xerostomua (diuretics, ACE Inhibitors) = higher risk for perio, caries and candida

4. delayed healing

smoking cessation

brief intervention 3-5 min chat

When patient isn’t motivated - 5Rs

• Relevance, Risks, Rewards, Roadblocks, Repetition

When patient is ready - 5As

• Ask, Advice, Assess, Assist, Arrange

Toothbrushing Techniques

• Bass Technique → 45 degrees towards sulcus, short, vibratory back and forth motion

• Stillman Technique → 45 degree angle, half on tooth and half on gum, gentle vibratory motion

• Modified bass → Same as bass but adds a sweeping motion at the end of the vibratory strokes

• modified stillman → 45 degrees but adds a sweeping or circular motion at the end of the stroke

• Roll Technique → Brush placed at gingivae and rolled downwards(away from gumline) Good for pts with abrasion and recession

• Mini scrub → Back and forth scrubbing, can cause abrasion and recession

Gingivitis case studies

Lose study

• dental students stopped brushing for 20 days to allow plaque accumulation = gingivitis

• When they started brushing = reversed

• Study shows that gingivitis is reversible

what are the acute perio conditions

• necrotising gingivitis

• acute herpetic gingivostomatitis

• periodontal abscess

• endodontic abscess

Necrotising gingivitis

• Treponema + f. nucleatum

  • necrotic ulcers, grey pseudomembranous sloth, halitosis, bleeding, metallic taste, pain

  • Side effects - necrosis and tissue destruction, necrotising fasciitis (a rapidly progressing "flesh-eating" condition), cancrum oris (a severe form of necrotising infection in the orofacial region, creating large tissue defects), Lymphadenopathy (swollen lymph nodes), cellulitis, Ludwig's angina

Acute herpetic gingivostomatitis

• herpes simplex 1

  • vesicles fill with fluid which burst and form ulcers: EO + IO

  • Systemic: fever, malaise, lymphadenopathy

  • Erythema + Odema on the gingiva

  • tx: analgesics (paracetamol), soft diet rest

  • Secondary: herpes labialis (cold sores)

Periodontal abscess

• acute infection in the perio pocket, due to blockage, incomplete RSD

• Pulp is vital but infection may enter via the accessory canals

• local swelling, pus, tender tooth

• tx - drainage, rsd, abx if systematic

endodontic abcess

• pulpal infection due to deep caries/trauma → necrosis → infection spreads to periapical tissues

• non - vital tooth, PA radiolucency, swelling at apex, TTP

• tx - RCT, XLA

nicotine replacement therapy

• provides low doses of nicotine without harmful tobacco chemicals

• Aims to reduce withdrawal symptoms and help pts quit

Examples

• patches

• Gum

• Lozenges

• Micro tabs (under the tongue)

• Inhalers

• Nasal spray

• Mouth spray

Non nicotine replacement therapy

Champix - works on acetylcholine receptors in the brain where nicotine binds. Reduces cravings and withdrawal symptoms and blocks nicotine to make smoking less enjoyable

Dummy cigs

Hypnotherapy

BPE

BPE (Basic Periodontal Examination)

• Screening tool; scores:
  

  • 0 = Healthy

  • 1 = Bleeding on probing only

  • 2 = plaque retentive factors (eg calculus/overhangs), black band fully visible

  • 3 = black band partially visible

  • 4 = black band not visible

• Children: only codes 0–2 up to 11 years.

• Children sites examined UR6, UR1, UL6, LL6, LL1, LR6