Perio II Midterm COMBINED

What is Non-Plaque Induced Gingivitis

It is gingival inflammation with pseudo-pocket, meaning there is no associated bone loss

• may be mediated by systemic or local risk factors such as pregnancy or drug influenced

GENETIC

Hereditary Gingival Fibromatosis

• Clinical Signs

• Location

• Etiology

• Treatment

• Clinical Signs: Rare gingival benign enlargement in various degrees

• Location: Tuberosities, anterior free/attached gingiva, retromolar pad areas

• Etiology: Hereditary gene mutation; can occur in isolation or as part of a syndrome

• Treatment: Excisional (remove piece) biopsy (for diagnosis); recurrence expected

SPECIFIC INFECTIONS

Necrotizing Periodontal Disease

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs: Ulceration of papillae ("punched out"), painful bleeding gingiva, severe halitosis, systemic signs (fever, malaise, lymphadenopathy)

  • May be gingivitis (no bone loss) or periodontitis (bone loss)

  • May be Stomatitis: ulceration >1cm, from gingival margin including tissue beyond mucogingival junction

• Etiology: Bacterial (e.g., spirochetes, Prevotella intermedia); often seen in HIV patients

• Treatment: Gentle debridement, 0.12% CHX rinse,

  → If poor response: metronidazole ± amoxicillin/clindamycin, analgesics, antifungals if HIV-positive

SPECIFIC INFECTIONS

Gonorrhea (oral)

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs: Ulcer or fiery red mucosa halo with white pseudo-membrane inside ± symptoms, painful sore throat, lymphadenopathy

• Etiology: Neisseria gonorrhoeae *(bacteria)

• Treatment: Referral to physician

SPECIFIC INFECTIONS

Syphilis (oral)

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs: Fiery red edematous ulcerations, mucous patches, or atypical inflamed gingivitis

• Etiology: Treponema pallidum (bacteria)

• Treatment: Referral to physician

SPECIFIC INFECTIONS

Hand-Foot-Mouth Disease

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs: Small vesicles rupture to leave fibrinous ulcers; affects mucosa, gingiva, hands, feet; mainly in children

• Etiology: Coxsackie virus

• Treatment: Self-limiting (7–10 days); topical analgesics for pain

SPECIFIC INFECTIONS

Herpetic Gingivostomatitis

• Clinical Signs

• Location

• Etiology

• Treatment

• Clinical Signs: Vesicles that coalesce and leave ulcer coated by fibrin; affects keratinized gingiva/hard palate; contagious

• Etiology: Herpes Simplex Virus (Type 1 oral / Type 2 genital)

• Treatment: Self-limiting; antivirals may speed healing

SPECIFIC INFECTIONS

Varicella zoster: Chickenpox (top)/ Shingles (bottom)

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs:

  • Chickenpox (children): yellowish Vesicles rupture into ulcers

  • Shingles (adults): Unilateral ulcers with possible vision impairment

• Etiology: Varicella-zoster virus

• Treatment: Antiviral medication; refer to ophthalmologist if ocular involvement

SPECIFIC INFECTIONS

Squamous Cell Papilloma

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs: Asymptomatic exophytic papillomatosis

  • Verrucous or cauliflower-like lesion

• Etiology: Human Papillomavirus (HPV)

• Treatment: Biopsy

SPECIFIC INFECTIONS

Candidosis→ Pseudomembranous (top) and Erythromatous (bottom)

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs:

  • Pseudomembranous: White removable plaques

  • Erythematous: Seen with steroid use, dentures, or HIV

• Etiology: Candida albicans

• Treatment: Antifungals (e.g., fluconazole)

HYPERSENSITIVITY RXN

Plasma Cell Gingivitis(Top) / Contact Allergy (Bottom)

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs:

  • Contact allergy: Redness

  • Plasma cell gingivitis: Velvety erythematous gingiva, usually anterior maxilla

• Etiology: Allergic reaction to toothpaste, mouthwash, dental materials

• Treatment: Eliminate causative agent; biopsy to confirm

AUTOIMMUNE

Pemphigus Vulgaris (top is vesiculobullous and bottom is desquamative)

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs: Desquamative gingivitis (white patch shedding) or vesiculo-bullous lesions; intraepithelial bullae rupture to form erosions; positive Nikolsky sign, pain

• Etiology: Autoimmune disease; Autoantibodies against desmosomes in epithelial layer

• Treatment: Systemic steroids, immunosuppressants; refer to dermatologist

AUTOIMMUNE

Pemphigoid

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs: VERY RED Desquamative gingiva, bullae from rubbing (NEGATIVE OR positive Nikolsky sign); painful; scarring can cause blindness if ocular lesions present

• Etiology: Autoimmune disease; Autoantibodies against basement membrane desmosomes

• Treatment: Systemic steroids, immunosuppressants; refer to ophthalmologist

AUTOIMMUNE

Lichen Planus

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs:

  • Reticular: White lace-like striae (not painful)

  • Atrophic: Erythematous, painful, desquamative gingivitis

• Etiology: Inflammatory reaction to unidentified antigen in basement layer of the epithelium → HAS PREMALIGNANT POTENTIAL!

• Treatment: Steroids, topical analgesics

AUTOIMMUNE

Lupus Erythematosus

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs: Butterfly rash on face (nose/cheeks), photosensitivity

• Etiology: Autoimmune inflammatory reaction to unidentified antigen in basement membrane

• Treatment: Avoid sun, NSAIDs, immunosuppressants, steroids

GRANULOMATOUS (but technically also autoimmune)

Crohn’s Disease

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs: Cobblestone oral mucosa, GI symptoms like abdominal pain, fever, altered bowel habits

• Etiology: Autoimmune; a form of IBD

• Treatment: Nutritional support, corticosteroids, anti-inflammatory meds

REACTIVE PROCESSES: EPULIDES

Pyogenic Granuloma

• Clinical Signs

• Location

• Etiology

• Treatment

• Clinical Signs: Red/pink, painless, fast-growing, compressible, painless gingival mass; common during pregnancy

• Etiology: Hormonal changes or irritation/minor injury

• Treatment: Biopsy; high chance it may recur

REACTIVE PROCESSES: EPULIDES

Peripheral (soft tissue) or Central (osseous) Giant Cell Granuloma

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs: Purple/blue-brownish soft mass; resembles pyogenic granuloma, mainly in gingiva but can be in mucosa

• Etiology: Reaction to irritation

• Treatment: Biopsy

PRE-MALIGNANT NEOPLASMS

Leukoplakia

• Clinical Signs

• Location

• Etiology

• Treatment

• Clinical Signs: Fully White lesion (smooth, corrugated, or verrucous); not removable; premalignant

• Location: Tongue, floor of mouth, buccal mucosa

• Etiology: Often linked to tobacco/alcohol

• Treatment: Biopsy

PRE-MALIGNANT NEOPLASMS

Erythroplakia

• Clinical Signs

• Location

• Etiology

• Treatment

• Clinical Signs: Red, velvety, sharply demarcated lesion; higher premalignant potential than leukoplakia

• Location: Floor of mouth, soft palate

• Etiology: Often linked to tobacco/alcohol

• Treatment: Biopsy

PRE-MALIGNANT NEOPLASMS

Squamous Cell Carcinoma

• Clinical Signs

• Location

• Etiology

• Treatment

• Clinical Signs: Painless masses, red/white patches, non-healing ulcers; may spread to lymph nodes; higher malignant potential

• Location: Gingiva, floor of mouth, tongue

• Etiology: Often linked to tobacco/alcohol

• Treatment: Biopsy and urgent referral

NUTRITIONAL

Vitamin C Deficiency (Scurvy)

• Clinical Signs

• Location

• Etiology

• Treatment

• Clinical Signs: Gingival bleeding, ulceration, swelling

• Etiology: Lack of ascorbic acid (affects connective tissue)

• Treatment: Vitamin C supplementation and balanced nutrition

TRAUMATIC

Frictional Keratosis

• Clinical Signs

• Location

• Etiology

• Treatment

• Clinical Signs: White, sharply demarcated lesion; painless; non-removable

• Location: Facial attached gingiva; buccal mucosa (linea alba)

• Etiology: Local trauma

• Treatment: Remove irritant

Chemical Insult or Thermal

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs: Sloughing or ulceration of gingival surface

• Etiology: Overuse of CHX, aspirin, hydrogen peroxide, whitening agents, etc.

• Treatment: Resolves once irritant is removed

Gingival Pigmentation (Melanoplakia)

• Clinical Signs

• Location

• Etiology

• Treatment

• Clinical Signs: Brown-black diffuse pigment; symmetrical

• Location: Gingiva, buccal mucosa, lips, tongue

• Etiology: Physiologic (common in darker skin); can occur in systemic diseases such as Addison’s disease (Hypocortisolism)

• Treatment: Laser/scalpel depigmentation (optional)

Amalgam Tattoo

• Clinical Signs

• Etiology

• Treatment

• Clinical Signs: Small bluish/grey/black localized pigmentation; flat

• Etiology: Amalgam particles embedded during restorations

• Treatment: Biopsy if diagnosis is uncertain

What are the 3 factors causing plaque induced gingivitis?

• Plaque biofilm

• Systemic Factors : smoking, diabetes hyperglycemia, nutrition, Sex steroid hormones (puber, pregn, menst, contracept) Hematological conditions

• Drug-influenced: Phenytoin, Cyclosporine, CCB

Predesposing vs Modifying Factors

• Predisposing factors: agents or conditions that contributes to the accumulation of plaque; anatomy, position, restorations

• Modifying factors: agents or conditions that alters the way in which and individual RESPONDS to subgingival plaque accumulation; smoking, systemic cond, medications

Categories of Periodontal Health

• Pristine Gingival health: TOTAL absence of clinical inflammation and physiological immune surveillance on periodontium. Not likely observed clinically

• Clinical periodontal health with intact/reduced periodontium: absence or minimal levels of clinical inflammation in a periodontium with normal support

  • <10% BOP sites with probing depths <_3mm

  • Reduced periodontium non periodontitis patient like crown lengthening, recession, elderly OR successfully treated periodontitis pt that is stable

Categories of Gingivitis

>_10% BOP sites with probing depths <_3mm, swelling, loss of knife edged gingival margin, blunting of papillae, redness, discomfort on gentle probing, halitosis

• Gingivitis on intact periodontium

• Gingivitis on reduced periodontium

What are the 3 forms of periodontitis

• Necrotizing Periodontitis Diseases

• Periodontitis as manifestation of systemic disease

• Periodontitis

How do you determine the normal alveolar crest level?

0.4 to 1.9mm from CEJ to alveolar bone crest in bitewing

Clinical features of Necrotizing Periodontal Disease

• Papilla necrosis (punched out)

• Bleeding

• Extremely foul smelling breath

• Host immune impairment

• Severe malnourishment, severe viral infection, severe living cond, stress, tobacco and alcohol

Periodontitis as a manifestation of Systemic Disease can be due to what conditions

• Disorders causing bone loss

• Genetic disorders

• Down syndrome

• Papillon-Lefevre Syndrome

• SLE

• Acquired immunodeficiency

• HIV

• Inflammatory diseases

• Inflammatory Bowel Disease

• Diabetes mellitus

• Obesity

• Osteoporosis

• Stress and depression

• Smoking

• Oral squamous cell carcinoma

• Giant cell granulomas

• Hyperparathyroidism

Define the Periodontitis Diagnosis

Chronic (calculus frequent finding) or aggressive (pt younger than 25 with bone loss associated with first molars and incisor teeth

3 Components to form periodontitis diagnosis

1. Identify pt as a periodontitis case by finding:

   • Interdental CAL detectable at 2mm or >2 non adjacent teeth OR buccal/Lingual CAL 3 or >3mm and 3 or + mm PD in 2 or > teeth

     • CAL cannot be due to non-perio causes such as recession due to trauma, caries extending to cervical area, CAL on distal of 2nd molar, malpositioning or extraction of 3rd molar, endodontic lesion draining, occurrence of vertical root fracture

2. Identification of the specific form of periodontitis

   • Periodontitis, Periodontitis due to systemic disease and necrotizing periodontitis

3. Description of the presentation and aggressiveness of the disease by stage and grade

How deep should the probe penetrate into JE

0.5mm, stopping 0.4 coronal to termination of JE

What is CAL

CAL is the distance between CEJ and base of the sulcus, calculated as:

• PD (GM to base of pocket) + Recession (CEJ to GM)

• In health = 0

Explain What staging and grading means

Staging = Severity of disease at presentation + Complexity of disease management

Grading = Information on biological features of disease + Rate of progression + Risk assessment

Staging

Grading

Molar incisor pattern Periodontitis

• Genetic

• Due to P. gingivalis and A.A bacteria

• 3:1 female to male ratio

• 30 years or younger patient

• Usually stage 3 grade C, rapid sudden disease and gross deposits of calculus are uncommon

• Mirror images of RBL

• Refer to PG Perio for amoxicillin + metronidazole adjunct treatment to SRP

Can a patient have periodontitis even if there is no discernible bone loss?

Yes, if there is enough CAL; Clinical bone loss appears before RBL

Signs and Symptoms of Periodontal abscesses

Signs: suppuration, gingival ovoid elevation, increased PD, tooth mobility/elevation, regional lymphadenopathy

Symptoms: pain, tenderness to palpation, lateral percussion, fever and malaise

Tx: antibiotics if systemic involvement (fever/malaise, lymphadenopathy)

Classifications of Periodontal abscess in perio pt vs non-perio pt

Perio: can be acute exacerbation or after treatment

N-Perio: due to harmful habits, ortho, impaction, alteration of root surface, perforation, enamel pearl, fissure/fracture

How to identify Perio-Endo Abscess??

There is a periodontal pocket reaching the apex of the root AND there is absence of pulp vitality, sensitive to percussion and palpation

• Could also be bone resorption at apex, spontaneous pain, purulent exudate, mobility, sinus tract

• an be primarily endo, perio or combined

• root damage has poor prognosis

• Always do endo first

Indicators of Traumatic Occlusal forces: treat and improve pdl or reduce by 0.1 per year

• fremitus

• Mobility

• occlusal discrepancies

• Wear facets

• Tooth migration

• Fracture

• Thermal sensitivity

• Discomfort when chewing

• Widened PDL space

• Root resorption

• Cemental tear

Types of Traumatic occlusal forces

Primary: trauma applied to a tooth with normal periodontal support

Secondary: trauma applied to tooth with reduced periodontal support

Orthodontic forces: sometimes can adversely affect periodontium and result in root resorption, pulpal disorders, recession and alveolar bone loss

Crown margins/restorations may be placed up to ___mm inside the gingival sulcus, if not CAL can appear as well as bone loss and recession within ____ weeks

T/F There is evidence to suggest that tooth supported/retained restorations and their design, fabrication, delivery, and materials can be associated with plaque retention and loss of clinical attachment

Crown margins may be placed up to 0.5mm inside the gingival sulcus, if not CAL can appear as well as bone loss and recession within 0-8 weeks

T/F There is evidence to suggest that tooth supported/retained restorations and their design, fabrication, delivery, and materials can be associated with plaque retention and loss of clinical attachment

What are some tooth related factors that can cause periodontitis

Cervical enamel projections, developmental grooves

• Position, root proximity, root resorption, root fracture

What is the name of the Prognosis System and what is the purpose of it

KWOK and CATON 2007 PROGNOSIS is based on the prediction of future stability of the periodontal supporting tissues

Local Factors

Objective findings in the mouth contributing to periodontal disease

• Pocket depths >5mm

• Plaque retentive factors such as furcation involvement, enamel pearls, palatal groove, root proximity, open contacts, overhang restorations

• Trauma from occlusion causing progressive mobility

General Factors

Factors that contribute to progression of the disease

• Pt compliance

• Smoking

• Uncontrolled diabetes

• History of periodontal disease

• Systemic disease

Explain each prognosis category in KWOK and CATON system

Favorable: Tooth will be stabilized with comprehensive perio tx and PMT, loss of periodontal supporting tissues is unlikely

Questionable: Local/systemic factors may or may not be able to be controlled. periodontium can be stabilized with comprehensive perio treatment and maintained only is these factors are controlled, otherwise breakdown may occur

Unfavorable: Local and systemic factors cannot be controlled> Perio breakdown is likely even with comprehensive periodontal tx and maintenance

Hopeless: Tooth must be extracted

7 factors Miller McEntire Periodontal Prognosticator Index for Molar Teeth (MMPPI)

• Include goal scores

• Pocket Depth

• Mobility

• Furcation involvement

• HbA1C levels

• Molar type

• Smoking

• Age

Scores: 1-4 = Excellent, 5-8 = Good, 9-11=Guarded

• <5 is the target

Gingivitis : Prophylaxis

D1110

Scaling for Gingivitis

D4346

Scaling for Gingivitis with re-eval

D0171P

SRP: 3 or less teeth involved in the quadrant

D4342

SRP: 4 or more teeth involved in the quadrant

D4341

SP with prophy

N1110

Periodontal Re-evaluation after SRP

D0171P but can also just do prophy

PMT

D4910