DH129 Exam 2

Periodontal disease

any disease of the tissues surrounding the teeth, including gingival diseases and diseases of the supporting structures

periodontitis

When the bacterial assault and inflammatory response results in attachment loss/bone loss

What stimulates bone resorption?

prostaglandins

What inhibits prostaglandins (thus some bone loss)?

NSAIDs

What is the clinical appearance of periodontitis?

pocket formation, inflamed tissues and the loss of alveolar bone

What is the disease cycle of periodontitis?

Plaque biofilm--> destruction of the connective tissue --> apical migration of the epithelial cells and detachment of JE from root surface--> more engorged with inflammatory cells

What are the two reasons pocket depths increase?

1. coronal movement of the gingival through swelling (gingival enlargement) related to inflammation

2. systemic conditions not associated with bone loss

Periodontal pockets

progressive deepening of the sulcus through tissue destruction and associated with bone loss

Suprabony- pocket

above the crest and is horizontal

Infrabony-pocket

extends apically from crest and is vertical

What happens to the rete pegs with periodonitis?

epithelial lining loses its integrity and rete pegs spread from pocket lining to CT

Do rete pegs project into connective tissue in health?

NO

Biofilm leads to gingival inflammation which leads to pocket formation which leads to more biofilm formation

.

What does the pocket content include?

1. plaque biofilm

2. metabolic products from biofilm

3. virulent bacteria

4. calculus

5. suppuration (pus or exudate)

6. lipopolysaccharides (endotoxins) which interfere with epithelial adherence to the root surface

Episodic periodontal disease

characterized by bursts of activity followed by periods of remission

What are the two phases of episodic periodontal disease?

1. Active phase: loss of bone and periodontal tissues and pockets deepen associated with tissue bleeding

2. Remission-(quiescence): disease is static and pockets do not deepen

**Old AAP Classification of periodontal disease

1.chronic periodontitis and aggressive periodontitis were considered to be separate classifications

2. separated the mouth so a patient may have generalized chronic periodontitis and localized aggressive chronic periodontitis

**New (2017) AAP Classification of periodontal disease

Places both chronic perio and aggressive perio into one classification "periodontitis" and staging of the disease is based on a full mouth diagnosis

What does the new classification incorporate?

severity, tooth loss due to periodontitis, and complexity of management of the patient's periodontal and overall oral rehabilitation needs

Why were changes made to the classification?

to facilitate an international language for clinical communication to enable proper diagnosis and prognostication for patient communication and education, to ensure implementation of appropriate treatment, to facilitate international population surveys of disease prevalence and to enable research into the etiology, pathogenesis, natural history and treatment strategies

Stage I periodontitis (mild disease)

patients will have probing depths ≤4 mm, CAL ≤1-2 mm, horizontal bone loss, and will require non-surgical treatment.

Is post-treatment tooth loss expected?

No, indicating the case has a good prognosis going into maintenance.

Stage II periodontitis (moderate disease)

patients will have probing depths ≤5 mm, CAL ≤3-4 mm, horizontal bone loss, and will require non-surgical and surgical treatment.

Is post-treatment tooth loss expected?

No, indicating the

case has a good prognosis going into maintenance.

Stage III periodontitis (severe disease)

patients will have probing depths ≥6 mm, CAL ≥5 mm, and may have vertical bone loss and/or furcation involvement of Class II or III. This will require surgical and possibly regenerative

treatments.

Is post-treatment tooth loss expected?

There is the potential for tooth loss from 0 to 4 teeth. The complexity of implant and/or restorative treatment is increased. The patient may require multi-specialty treatment. The overall case has a fair prognosis going into maintenance.

Stage IV periodontitis (very severe disease)

patients will have probing depths ≥6 mm, CAL ≥5 mm, and may have vertical bone loss and/or furcation involvement of Class II or III.

Is post-treatment tooth loss expected?

Fewer than 20 teeth may be present and there is the potential for tooth loss of 5 or more teeth. The overall case has a

questionable prognosis going into maintenance.

What is the treatment for stage IV periodontitis?

Advanced surgical treatment and/or regenerative therapy may berequired, including augmentation treatment to facilitate implant therapy. Very complex implant and/or restorative

treatment may be needed. The patient will often require multi-specialty treatment.

Grade A (slow progression)

No BL or CAL over 5 years, no smoking, no diabetes, heavy biofilm but no destruction

Grade B (moderate progression)

Less than 2mm of bone loss or BL or CAL over 5 years, half pack or less per day smoking, HBA1C < 7%, biofilm commensurate with destruction

Grade C (rapid progression)

Greater than 2mm BL or CAL for 5 years, half pack or more per day smoking, HBA1C > 7%, destruction exceeds amount of biofilm

Characteristics of Periodontitis

1. May have preclinical onset in adolescence, if not halted, progresses for life becomes clinically significant about age 35.

2. Bone resorption progresses slowly and horizontally

3. Severity directly related to plaque biofilm and calculus on surfaces of the teeth

4. May be either localized or generalized

5. Progresses until teeth are lost by extraction/exfoliation

6. Halts when host resistance controls disease process with therapy/or natural defenses

What does the rate of periodontal destruction depend on?

Bacterial assault and host response

What is the defining element for classifying periodontal disease?

Clinical attachment loss (CAL

Recession

the measurement from the CEJ to the gingival margin

Pocket depth

the measurement from the gingival margin to the bottom of the sulcus/pocket

How is CAL determined?

Pocket depth + gingival recession

What is the most reliable method of determining disease activity?

document the loss of periodontal attachment by measuring clinical attachment loss (CAL) over time.

What does subgingival plaque biofilm consist of?

high levels of gram negative anaerobic and motile organisms (primary pathogen is P. gingivalis)

What are the treatments for stage 1-3 of periodontitis?

OHI- plaque control and patient education

SRP- plaque and calculus removal

When should you refer to a specialist?

Consider in moderate to very severe stages (II-IV)

When are locally delivered antibiotics (LDAs) indicated?

stages II - IV

Periodontitis and Cardiovasclar disease (CVD)

Related to chronic infection

Precedes many heart attacks, and specific perio pathogens are associated with coronary heart disease

Adverse health effects are related to chronic infections, mediated by inflammatory agents that trigger the development of atherosclerosis

Periodontitis and Preterm Birth

Evidence suggests that active perio disease may account for preterm birth and low birth weight

Periodontal care and personal oral hygiene during pregnancy are extremely important

Periodontitis and Bacterial Pneumonia

Many virulent species associated with pneumonia reside in perio plaque biofilm, improving OH may decrease the pneumonia

Periodontitis and Diabetes

Patient is susceptible to many infections

Type I diabetes and periodontitis

patients are usually younger with more aggressive disease

PMN's have altered characteristics= adherence, chemotactic capacity and phagocytosis potential are diminished.

Type II diabetes and periodontitis

Usually older than 50 rarely younger than 40 yrs old.

Poor glycemic control may be related to perio disease and increased clinical attachment loss.

Cytokines interfere with the action of insulin.

Necrotizing ulcerative periodontitits (NUP)

Severe progressive destruction of gingiva and alveolar mucosa spreads rapidly to deeper tissues, gingiva is red with necrosis of soft tissue-forming a pseudomembranous surface

Severe loss of CT but perio pockets usually not present because gingiva erodes away

Intense pain, fetid mouth odor, "punched out" tips of papilla and spontaneous bleeding

What is NUP associated with?

HIV and other immunocompromised patients

How do systemic factors worsen the symptoms of periodontitis?

reducing patient's resistance to disease

Abscesses

acute localized purulent infections of the periodontium, rapid bone loss may occur

How do you treat a chronic periodontal abscess?

Pocket debridement

Surgical removal of the pocket lining

Antibiotics

Pericoronitis

occurs on partially erupted teeth, usually mandibular 3rd molars, painful and may spread to submandibular tissues.

How do you treat pericoronitis?

removal of the operculum or extraction

Pregnancy tumor (also known as pyogenic granuloma)

Related to poor plaque biofilm control during pregnancy

Tissues highly inflamed, bleed easily and may cause teeth to be mobile (resolve after birth)

Periodontitis/Endodontic Lesions

Usually single isolated deep pocket or present in furcation, frequently sensitive to percussion

How do you treat a combination of periodontitis and endodontic lesions?

root canal treatment

If a combined endo/perio lesion: endodontic first then scaling is performed

Calculus by itself does not cause periodontal disease but the presence of calculus on a root indicates there is always biofilm present.

.

How does nicotine inhibit healing?

vasoconstrictor= less bleeding and also causes a diminished neutrophil function and impaired fibroblast function

Stages III-IV (possibly stage II based on clinical judgment) of periodontal disease may benefit from which antibiotics?

1. Tetracycline

2. Metronidazole

3. Combo of penicillin and clindamycin

Locally delivered antibiotics (LDA's)

Antibiotic directly at the infection site which reduces risk of allergic reactions

Dose is lower than for systemic antibiotics (usually 1mg)

Active agent is present in high concentration at site of infection

What does a significant portion of tissue destruction in periodontal disease result from?

enzymes released by the inflammatory response to bacterial plaque

What is the first step in clinical assessment?

complete medical history and dental history

What does the medical history help the clinician do?

evaluate oral manifestations of systemic conditions, detect systemic conditions that effect the periodontal tissue response, and detect systemic and infectious conditions that require special precautions.

Things to investigate about your patient's dental history include:

Previous dental experiences

Current oral hygiene practices

Attitudes toward dentistry

Information about the patient's habits:

tobacco use

alcohol use

possible recreational drug use

When should vital signs be taken?

At EACH appointment

If a patient reports dental problems, further questioning should include:

Specific location

Stimulus that elicits pain

Duration of stimulation

Frequency of occurrence

Date of the initial problem

Changes in the problem since the initial identification

Clinical Examination

Extra oral and Intraoral assessment

Oral Hygiene assessment

Periodontal assessment

Implant assessment

Dentition assessment

What can systemic problems cause?

Increase the susceptibility to infection

Interfere with wound healing

Require modification of standard approaches to treatment

Complicate patient cooperation

Diseases that may affect periodontal disease

Cardiovascular Disease

Anticoagulants

Arthritis

Progressive Systemic Sclerosis

Artificial Joints

Diabetes Mellitus

Pregnancy

Infectious Diseases

Dermatological Diseases

Oral Cancer

Blood dyscrasias

What are major risk factors for hypertension?

cardiovascular disease, stroke, kidney failure

What is contraindicated for hypertension?

Use of epinephrine

Atherosclerosis

cholesterol in the arteries leading to narrowing which results in occlusion of the vessel

What are clinical manifestations of coronary artery disease?

Angina pectoris and myocardial infarction

What is a side effect of nifedipine and other calcium channel blockers?

Gingival enlargement

Is local anesthesia okay to use for angina pectoris?

Yes

What does a patient with angina typically have with them?

Nitroglycerin

Following a heart attack, elective dental appointments should wait...

6 months to treat patient

Stenosis

narrowing of the valve (failure of valve to open)

Valvar insufficiency

failure of valve to close

Do innocent or functional murmurs require premed?

No, but organic murmurs might

Is pre-med indicated for mitral valve prolapse?

no

Is pre-med indicated for rheumatic fever?

No

What are damaged heart valves at risk for?

Infective endocardidits

Is heart valve disease acquired or congenital?

both

Cardiac Arrhythmias

Irregular heartbeat-may be associated with a variety of systemic conditions

What medications cause gingival enlargement?

Dilantin (Cardizem), verapamil (Calan), diltiazem

Neutropenia

decreased neutrophils which increases susceptibility to perio disease and other infections

Does a pacemaker require pre-med?

AHA does not recommend premed, however cardiologist or physician might

Is a pre-med required for Defibrillators (AICD)?

No

Can dental procedures be safely performed on patients with cardiac arythmias?

yes

Dental considerations for congestive heart failure

Patients with congestive heart failure are ok to be treated in the dental office if the patient is stable. If laying down is difficult for the patient, the dental chair should be placed in an erect or partially reclined position.

warfarin (Coumadin)

may result in more gingival bleeding, however it is controllable

recent INR should be presented prior to treatment

aspirin therapy (80-325mg/day)

does not significantly alter bleeding time

What are dental considerations for arthritis?

can cause issues with dexterity. The patient may have difficulty with OH

What are considerations for joint replacement?

Infection can cause of a failure of the prosthesis

PSS- progressive systemic sclerosis

Chronic connective tissue disease with abnormal amounts of collagen deposits

Dexterity is a problem

What are clinical features of progressive systemic sclerosis?

Skin is inflexible, increased caries and periodontitis gingival recession

Widening of PDL space on xrays