perio ch 6 periodontitis

What is periodontitis?

A complex microbial infection that triggers a host-mediated inflammatory response within the periodontium, leading to progressive IRREVERSIBLE destruction of periodontal ligament and supporting alveolar bone.

what is a huge factor in periodontitis progression?

personal pt immune system

is biofilm-induced gingivitis reversible or irreversible? (the precursor of periodontitis)

reversible

once a pt is diagnosed with periodontitis...

remains periodontitis pt for life

periodontitis requires lifelong supportive care, what is the ideal interval for visits?

every 3 months

what are some disease characteristics of periodontitis?

JE apical migration

alveolar bone and PDL destruction

What is clinical attachment loss (CAL)?

A measurement of the amount of destruction affecting tooth-supporting structures around the tooth

what is clinical attachment loss characterized by?

characterized by apical migration of junctional epithelium and loss of alveolar bone support.

What are common signs and symptoms of periodontitis?

Accumulation of plaque biofilm, redness and swelling of gums, gingival bleeding, suppuration, periodontal pockets, clinical attachment loss, and tooth mobility.

What are the alterations in marginal gingiva associated with periodontitis?

Reddish or purplish tissue, rolled gingival margins, blunted or flattened papillae, and possible fibrotic appearance.

What initiates periodontitis?

Mature supra- and subgingival plaque biofilms and calculus deposits.

What is the significance of gingival bleeding in periodontitis?

Gingival bleeding, either spontaneous or upon probing, indicates inflammation and is a warning sign of periodontal disease.

What are the contributing factors to periodontitis?

Environmental factors (e.g., smoking), systemic factors (e.g., diabetes, HIV), genetic factors, and local intraoral factors (e.g., tooth crowding).

what percent of disease progression in the mouth is considered localized infection?

less than 30%

what percent of disease progression in the mouth is considered generalized infection?

30% or more

What is the difference between localized and generalized periodontitis?

Localized periodontitis affects less than 30% of teeth, while generalized periodontitis affects 30% or more of teeth.

is clinical appearance a reliable indicator of presence or severity of periodontitis?

NO, need radiographs

how do you watch disease progression?

compare to previous appt... how does the amount of attachment loss and bone destruction seen today compare with what was observed initially?

what is meant by "fibrotic appearance" in periodontitis?

chronic stippling that progresses with fibrotic tissue building under tissue; is not healthy

what are the accompanying features of "attachment loss" in periodontitis?

loss of alveolar bone support to teeth, periodontal pockets and/or apical migration of gingival margin, furcation involvement in multirooted teeth, pathologic tooth migration

list the warning signs of periodontitis...

red or swollen gingiva

bleeding during brushing

bad taste in mouth

persistent bad breath

sensitive teeth

loose teeth

pus around teeth and gingiva

check point: you visually look in your pt's mouth and notice their gingival tissues are pale pink, stippled, and do not notice any edema. is this a good indicator of health?

no, need to probe and get xrays, this is not enough information

What is the continuous disease hypothesis in periodontitis progression?

It suggests that untreated periodontitis progresses as a ongoing gradual process, with attachment loss of 0.05 mm to 0.3 mm per year.

What does the random burst model propose about periodontitis progression?

It proposes that untreated periodontitis progresses randomly, with episodic bursts of activity and some sites remaining dormant for long periods.

What is the asynchronous burst hypothesis?

It suggests that periodontitis progresses in short bursts followed by extended periods of remission.

What is the desired outcome of disease progression in periodontitis?

halt progression

What is the significance of lifelong supportive care for periodontitis patients?

Once diagnosed with periodontitis, patients require lifelong supportive care to manage the condition, even after successful therapy.

What are the clinical features of attachment loss in periodontitis?

Loss of alveolar bone support, periodontal pockets, apical migration of the gingival margin, and possible furcation involvement in multirooted teeth.

What are the common symptoms experienced by patients with periodontitis?

Patients often experience painless conditions, gingival bleeding while brushing, spaces between teeth, mobile teeth, and sensitivity to temperature.

What is the relationship between dental biofilm-induced gingivitis and periodontitis?

Dental biofilm-induced gingivitis always precedes the onset of periodontitis and may remain stable for many years.

What does the term 'recurrent' mean in the context of periodontitis?

Recurrent refers to the RETURN of periodontitis after treatment, indicating that the disease can reappear.

What does the term 'refractory' mean in relation to periodontitis?

Refractory refers to periodontitis that DOES NOT respond to treatment and continues to progress despite intervention.

What is the importance of radiographic features in diagnosing periodontitis?

Radiographic features help in assessing the extent of bone loss and the severity of periodontal disease.

What is the significance of probing measurements in periodontitis?

Probing measurements help determine the extent of periodontal disease and the inflammatory status of the periodontal tissues.

What is the clinical appearance of healthy gingiva compared to gingiva affected by periodontitis?

Healthy gingiva appears pale pink and stippled, while gingiva affected by periodontitis may be red, swollen, and exhibit changes in contour.

What are some common misconceptions about the appearance of gingiva in periodontitis?

The clinical appearance of gingiva is not a reliable indicator of the presence or severity of periodontitis; deep pockets may be present even with seemingly healthy tissue.

list the contributing factors of periodontitis...

environmental factors such as smoking

systemic factors such as diabetes or HIV

genetic factors

local intraoral factors such as tooth crowding or overhanging restorative margin (home for plaque to accumulate)

true or false? periodontitis only happens to adults.

false! onset at any age, but most commonly affects adults

What are the therapeutic endpoints of periodontal therapy?

Eliminate microbial etiology and contributing factors, preserve the current state of teeth and periodontium, prevent disease progression and reoccurrence, and reinforce behavioral modifications.

What is the primary goal of periodontal treatment?

To reinforce daily self-care and perform effective periodontal instrumentation to remove microbial etiology.

What defines a compromised periodontal maintenance?

Treatment not intended to attain optimal results, but designed to slow down the progression of periodontitis in patients who do not respond favorably to active therapy.

What is recurrent periodontitis?

The return of destructive periodontitis that had been previously arrested by conventional therapy, common in anyone with a history of periodontitis.

what must be done for recurrent periodontitis in terms of the pt?

must refocus attention in arresting disease and re-establishing pt adherence to treatment, self care, and frequent professional maintanence

What characterizes refractory form of periodontitis?

Continued attachment loss despite appropriate professional therapy, satisfactory self-care, and adherence to maintenance visits

if a pt is doing proper self-care, why would continued attachment loss be present in the refractory form of peridontitis?

etiology is unknown

What are the treatment options for refractory periodontitis?

pt education, behavior modification, periodontal instrumentation, antibiotics, removal of hopeless teeth, correction of restorations, and surgical therapy.

check point: recurrent periodontal disease vs refractory periodontal disease?

recurrent = comes back after it was taken care of

refractory = everything was done right but disease progression is continuous

What is the case definition for periodontitis?

Interdental clinical attachment loss detectable at TWO or more nonadjacent teeth or facial/lingual attachment loss of 3 mm or more with pocketing over 3 mm at TWO or more teeth.

What are the STAGES of periodontitis? (1-4)

Stages I, II, III, and IV, defined by disease severity and complexity of management.

what is INTERDENTAL clinical attachment loss?

attachment loss between teeth (mesial and distal)

What defines Stage I periodontitis?

Interdental CAL of 1-2 mm, radiographic bone loss in the coronal third, and maximum probing depths of 4 mm or less.

What defines Stage II periodontitis?

Interdental CAL of 3-4 mm, radiographic bone loss in the coronal third, and maximum probing depths of 5 mm or less.

What defines Stage III periodontitis?

Interdental CAL ≥5 mm, radiographic bone loss extending to mid-third of root, and tooth loss of 4 or fewer teeth.

What defines Stage IV periodontitis?

Interdental CAL ≥5 mm, radiographic bone loss extending to mid-third of root or beyond, and tooth loss of 5 or more teeth.

if stage I and stage II periodontitis both have radiographic bone loss extending to coronal third of root, horizontal bone loss, and no tooth loss... what makes them different?

Stage I: 1-2 mm interdental CAL at site of greatest loss, 4 mm or less max probing depths

Stage II: 3-4 mm interdental CAL at site of greatest loss, 5 mm or less probing depths

defining way to differentiate stage III and stage IV...?

stage III shows 4 or fewer teeth lost, stage IV shows 5 or more teeth lost

what are healthy bone levels?

1-2 mm from CEJ to crest of bone

how is bone loss determined on a radiograph?

by root length: at deepest bone loss: CEJ to apex (in mm) divided by 3

when determining the stage of periodontitis, the clinician should keep in mind that there may be individual complexity factors or severity factors that may shift the stage to a higher level... give an example.

could have all factors from stage I, but 6 mm probing depth indicates it is stage III

What is the significance of probing depths in periodontitis staging?

Probing depths help determine the complexity of management and can shift the stage to a higher level.

What is the purpose of the periodontitis GRADING system? (A, B, C)

To estimate the FUTURE rate of progression of periodontitis based on direct and indirect evidence.

what does the periodontitis grading system determine?

future rate of progression of peridontitis

direct evidence =

longitudinal evaluation; compares rate of attachment loss and/or bone loss over 5 years or more

indirect evidence =

percent of bone loss at worst affected tooth

case phenotype - level of destruction is in line with the level of plaque biofilm

how does a clinician evaluate indirect evidence?

% of bone loss / pt's age

what are individual risk factors?

may shift the grade to a higher level

ex: pt who smokes less than 10 cigarettes/day but exhibits no evidence of CAL (loss) over the last 5 yrs would be classified as Grade B

What should a periodontal diagnosis include?

Confirmation of periodontitis case

identification of the form of periodontitis

description of presentation and aggressiveness by stage and grade.

What is the role of patient education in managing REFRACTORY periodontitis?

To encourage behavior modification and adherence to maintenance regimens.

What factors can shift the stage of periodontitis to a higher level?

Individual complexity factors or severity factors, such as Class II furcation involvement.

What is the significance of attachment loss in periodontitis?

It is a key indicator for diagnosing and staging the severity of periodontitis.

What is the importance of maintenance regimens in periodontal therapy?

To prevent disease RECURRENCE and ensure long-term oral health.

What might indicate a patient is at risk for recurrent periodontitis?

A history of periodontitis and failure to adhere to treatment and maintenance recommendations.

How can periodontal disease terminology evolve?

Terminology like chronic periodontitis may relate to current classifications but may not be officially recognized in newer systems.

What is the relationship between smoking and periodontitis grading?

Smoking can influence grading, with lower smoking rates potentially leading to a lower grade if attachment loss is absent.

What is the clinical significance of gingival assessment?

To identify the state of the periodontium and guide treatment decisions.

What should be done if a patient shows signs of reoccurring periodontitis?

Reassess their self-care practices and reinforce the importance of maintenance appointments.

what grade?

direct evidence: no additional bone or attachment loss over past 5 years

indirect evidence: percent of bone loss/pt age < 0.25

low levels of tissue destruction not commensurate with the heavy biofilm deposits

grade modifiers: nonsmoker, no history of diabetes

grade A

what grade?

direct evidence: less than 2 mm additional bone or attachment loss over a 5 year prd

indirect evidence: percent of bone loss to pt age is 0.25 - 1.0

tissue destruction in line with the biofilm deposits

grade modifiers: smoking less than 10 cigarettes a day and/or an HbA1c of less than 7% in pts with diabetes

grade B

what grade?

direct evidence: 2 mm or more of bone or attachment loss over a 5 year period

indirect evidence: > 1.0

tissue destruction exceeds given biofilm deposits

grade modifiers: smoking 10 or more cigarretes a day and/or HbA1c 7% or greater in pts with diabetes

grade C

practice:

45 years of age

interdental CAL of 1 to 2 mm

no tooth loss due to peridontitis

no probing depths over 4 mm

horizontal bone loss

no additional bone loss over last 5 years

nonsmoker no history of diabetes

stage I, grade A

practice:

5 years of age

interdental CAL of 3 to 4 mm

no tooth loss due to periodontitis

probing depths of 4 mm or less

tissue destruction exceeds expectations based on amount of biofilm present

rapid progression

stage 2, grade C (based on indirect evidence)

practice:

44 years of age

interdental CAL 5 mm or more

4 teeth lost due to periodontitis

probing depths 6 mm or more

radiographic bone loss extends to the mid-third of root

evidence of 2 mm or more additional attachment loss over a 5 year period

bite collapse with drifting teeth and multiple teeth with degree 2 mobility

stage 4, grade C

practice:

50 years of age

interdental CAL of 3 to 4 mm

no tooth loss due to peridontitis

probing depths 5 mm or less

radiographic bone loss extends to coronal third of root

mostly horizontal bone loss

evidence of less than 2 mm additional loss over a 5 year period

nonsmoker

no history of diabetes

stage 2, grade B

practice:

53 years of age

interdental CAL 5 mm or more

more than 5 teeth lost due to periodontitis

probing depths 6 mm or more

radiographic bone loss extends to the mid-third of the rooth

vertical bone loss

evidence of less than 2 mm additional attachment loss over a 5 year period

nondiabetic

smokes half a pack of cigarettes a day

stage IV, grade B

practice:

47 years of age

interdental CAL 5 mm or more

4 teeth lost due to periodontitis

probing depths of 6 mm or more

radiographic bone loss extends to mid third of root

some vertical bone loss

evidence of less than 2 mm of attachment loss over a 5 years period

nonsmoker

diabetes HbA1c levels less than 7%

stage III, grade B

practice:

43 years of age

interdental CAL of 4 to 12 mm

no tooth loss due to periodontitis

probing depths of 4 to 10 mm

mostly horizontal bone loss, extending to apical thirds of most teeth

evidence of 2 mm or more attachment loss over a 5 year period

percent of bone loss/pt age > 1.0

nonsmoker, nondiabetic

masticatory dysfuntion, flaring, drifting, tooth mobility

stage IV, grade C