Perio

Unit 1: Tissue of the Periodontium

1. Periodontium (Peri = around and odontos = tooth) …

- Functional system of tissues that surrounds the teeth and attaches them to the jawbone.

- Also called the “attachment apparatus”

2. The tissue of the Periodontium…

- Gingiva: tissue that covers the cervical 1/3 of the teeth and alveolar processes of the jaws.

- Periodontal Ligament (PDL): fibers that surround the root of the tooth. These fibers attach to the socket bone on one side and the root cementum on the other.

- Cementum: thin layer of mineralized tissue that covers the root of the tooth.

- Alveolar Bone: bone that surrounds the teeth's roots and forms the bony sockets that support the teeth's roots.

3. Tissue function of the Periodontium …

- Gingiva: covers alveolar process & holds tissue against the tooth during chewing.

- Periodontal Ligament (PDL): suspends & maintains the tooth in its socket.

- Cementum: protects the dentin of the root & anchors PDL fiber for tooth to be in socket.

- Alveolar Bone: surrounds & supports the roots of the tooth.

4. Each periodontium tissue is critical to maintaining the periodontium's health and function …

- Normal function of the periodontium | Disease prevention | Periodontal disease process

5. Gingival margin is located … coronal to the CEJ (1-2 mm is normal, healthy)

6. Gingival is divided into (4) anatomical areas …

- Free gingiva (cuff/collar) | Gingival sulus | Interdental gingiva | Attached gingiva

7. Free gingival groove is a shallow linear depression …

- That separates the free and attached gingiva.

8. The free gingiva is also known as the … unattached or marginal gingiva, scalloping.

9. The attached gingiva lies between the … free gingiva and alveolar mucosa.

10. Location of the attached gingiva … extends from free gingival groove to mucogingival junct.

11. Pigmented tissues (physiologic pigmentation) is due to …

- Increased production of melanin (pigment) from melanocytes (melanin-producing cells in

the epidermal layer.)

12. What is stippling?

- Acts to provide mechanical reinforcement to the gingiva.

- Seen on attached and interdental gingiva.

13. Attached gingiva …

- Allows gingiva to withstand mechanical forces in events of mastication, speech, brushing.

14. PDL (5) functions …

- Supportive: suspends and maintains the tooth in socket.

- Sensory: provides sensory feeling to the tooth, such as pressure and pain sensations.

- Nutritive: provides nutrients to the cementum and bone.

- Formative: build and maintains cementum and the alveolar bone of the tooth socket.

- Remodeling: can remodel the alveolar bone in response to pressure, ex. ortho treatment.

15. Cementum …

- Bone-like, mineralized connective tissue that is more resistant to resorption than bone,

which makes it possible for teeth to be moved during orthodontic treatment.

 -    (2) main types of cementum: cellular and acellular.  

 -    Receives nutrients from the PDL.  

 -    Function: give attachment to the collagen fibers of the PDL, without cementum the tooth

would fall out of its socket.

16. Alveolar process (bone) …

- Is the bone that surrounds and supports the roots of the teeth.

- Function: forms bony sockets that provide support and protection for the roots of the teeth

17. Layers of the Alveolar process consist of …

- Alveolar bone proper (cribriform plate): thin layer of bones that lines the socket that

surrounds the root of the tooth.)

- Cancellous bone (spongy bone): fills the interior portion of the alveolar process (between

cortical and alveolar bone proper.)

- Cortical bone (cortical plate): is a layer of compact bone that forms the hard, outer wall of

max & mand on the facial and lingual aspects. Surrounds the alveolar bone proper &

gives support to the socket.

Unit 21: Radiographic Analysis of the Periodontium

1. Radiolucent structures … easily penetrated by x-rays and appear dark gray to black.

- Ex… tooth pulp | PDL | bone loss due to a periapical abscess | bone marrow spaces |

bone loss and defects.

2. Radiopaque structures … resist penetration by x-rays, appear light gray to white.

- Ex… tooth enamel | dentin | restorations | pulp stones | compact or cortical bone.

3. Cortical bone … outer surface of bone | thin on the maxilla | dense on the mandible (jaw)

4. Radiographic Features of the Periodontium …

- Alveolar bone | Cortical bone | Lamina dura | PDL | Cementum

5. Alveolar Crestal Bone in health …

- Interdental bone crests are smooth and covered with a thin white line of cortical bone.

- Thin and pointed in between incisor teeth | Flat or slightly rounded in posterior teeth.

6. Lamina Dura …

- An indicator of periodontal health that should be noted when reviewing radiograph. *

7. Periodontal Ligament Space …

- Appear as a thin black line around the tooth root, filled with PDL.

- An indicator of periodontal health that should be reviewed upon radiograph. * (widening

of PDL = tooth mobility)

8. What dental radiographs may reveal are bony changes associated with periodontitis?

- Tooth root morphology | Relationship of max. sinus to periodontal deformity | Widening

of PDL | Furcation bone loss | Alveolar bone loss | Open contacts and calculus

9. (2) early radiographic signs of periodontitis…

- Crestal irregularities: the appearance of breaks or fuzziness between the interdental crest.

- Triangulation (funneling) of the PDL: caused by resorption of bone on either mesial or

distal aspect on the interdental crestal bone.

10. What do you see on horizontal bitewings in differ from vertical bitewings? *

- Horizontal (caries) | Vertical (whole tooth and apex)

11. Radiographs Do Not Reveal …

- Presence or absence of periodontal pockets | Early stages of alveolar bone loss.

- Precise morphology of existing alveolar bone destruction.

- Tooth mobility | Early furcation | Level of epithelial attachment on tooth | Perio disease

12. Early Radiographic Signs of Disease …

- Fuzziness (in the crest of the interdental bone - foods get stuck there traumatizing the

PDL) | Widening (of PDL) | Radiolucent Lines (In the interseptal bone)

13. Interseptal Bone Changes … could be from ortho.

- Finger-like radiolucent: reduction of mineralized tissue adjacent to blood vessel channels

in the alveolar bone.

14. Assessment of Crown-to-Root Ratio … 1:2

- Determines the ability of a tooth to be maintained with becoming mobile and lost.

15. Recognizing other Local Risk Factors …

- Calculus deposits | Faulty restorations | Trauma from occlusion.

Unit 3: The Periodontium in Health and Disease

1. Disease Progression (pathogenesis):

- Sequence of events that occur during the development of a disease or abnormal condition.

2. (3) Basic states of the Periodontium: Health | Gingivitis | Periodontitis

3. In the absence of disease. The two basic categories of periodontal disease are ….

- Gingivitis and Periodontitis

4. 2 Types of Periodontal Disease …

- Gingivitis: a bacterial infection confined to the gingiva. Tissue damage is reversible.

- Periodontitis: bacterial infection to all parts of the periodontium including the Gingiva, PDL, Bone, and Cementum. Tissue damage is irreversible (permanent).

5. The onset of Gingivitis:

- Clinically observed 4- 14 days, after biofilm accumulates in the gingival sulcus.

6. Progression of Gingivitis: may persist for years without progressing into periodontitis (does not progress to bone loss)

7. Acute Gingivitis:

- Lasts for a short period of time. (punched out, cratered gingiva papilla) *

- Characterized by fluid in the gingival connective tissue that results in swollen gingiva.

- Tissue appears swollen (ex. menstrual cycle)

8. Chronic Gingivitis:

- Lasts for months or years. (bulbous) *

- Body may repair tissue damage by forming new collagen fibers in the gingival connective tissue. | (ex. pregnancy)

9. Tissue (Gingival) enlargement may be caused by …

- Swelling (acute gingivitis) or Fibrosis (chronic gingivitis)

10. Pesudopocket … produce false or gingival pocket due to tissue enlargement.

11. In Gingivitis …

- the gingival tissue is usually red or reddish-blue in color, from the congestion of vessels (slow-moving blood flow)

12. Periodontitis (periodontal disease) is characterized by …

- Apical migration of the JE

- Loss of connective tissue attachment

- Loss of alveolar bone (can get bone graft)

- Probing depths (4mm or >) | pus may be presented | pain when probing

13. The destruction of the periodontal ligament fiber bundles makes it easier for the junction epithelium to migrate apically along the root surface.

14. Why is there a band of intact transseptal fiber even in the presence of severe bone loss?

- They are regenerated continuously across the crest of bone. A band of intact transseptal fibers separates the site of inflammation from the remaining alveolar bone even in case of extensive bone loss.

15. Position of Junctional Epithelium in Health, Gingivitis, and Periodontitis.

- Health: JE coronal to CEJ, intact gingiva.

- Gingivitis: JE at CEJ

- Periodontitis: JE apical to CEJ

16. Bone Height in Health and Gingivitis:

- The crest of the alveolar bone is located 2-3 mm apical to (below) the CEJs of the teeth.

17. Bone Height in Periodontitis:

- Bone destruction may be severe, as periodontal disease progresses (worsen), tooth loss may occur from lack of alveolar bone support. More than 2 mm apical to the CEJ.

18. Level of Alveolar Crest a Disease Progresses:

- Progressive Alveolar bone loss in periodontitis. Bone destruction may lead to tooth mobility or loss due to insufficient bone support for the teeth.

19. 2 Types of Bone Loss… (take vertical bite wings)

- Horizontal: most common, results in an even reduction in the height of alveolar bone.

- Vertical: less common, also known as angular bone loss (progressive damage), results in an uneven reduction in the height of the alveolar bone. (leaves a trench-like area of missing bone alongside the root)

20. Pathway of inflammation that occurs in Horizontal Bone Loss… spread through in order

- Within the gingival connective tissue along the sheaths surround the blood vessels.

- Into the alveolar bone

- Lastly, into the PDL space.

21. Pathway of inflammation that occurs in Vertical Bone Loss … spread through in order

- Within the gingival connective tissue.

- Directly into the PDL space.

- Lastly, into the alveolar bone.

22. Activate Disease Site:

- Site that shows continued apical migration of the JE over time. (BOP and Inflammation)

23. Inactive Disease Site:

- Site that is stable, with the attachment level of the JE remaining the same over time; majority of adult patients with periodontitis are inactive disease sites.

24. Furcation Involvement:

- Occurs on a multirooted tooth when the periodontal infection invades the area between and around the roots. (results in loss of alveolar bone between roots of tooth)

25. Periodontal Pocket:

- An area of tissue destruction left by the disease process.

26. 2 Types of Periodontal Pockets …

- Suprabony: occurs when there is horizontal bone loss, the JE is coronal (above) the crest of the alveolar bone.

- Infrabony: occurs when there is vertical bone loss, the JE is apical (below) the crest of the alveolar bone.

27. Bone Defects in Periodontal Disease (periodontitis) …

- Results in different types of defects in the alveolar bone, these bony defects are called osseous defects.

28. Infrabony Defects:

- Results when bone resportion occurs in an uneven, oblique direction.

- Primarily affects one tooth; classified based on the number of osseous walls (may have 1 1 (worse prognosis) 2, or 3 (best prognosis) walls)

29. Osseous Craters:

- A bone defect in periodontal disease, a bowl-shaped defect in the interdental alveolar bone, with bone loss nearly equal on the roots of two adjacent teeth.

- The presence of this defect causes biofilm and makes it difficult to clean interproximal.

30. Inflammation: body`s reaction to injury or invasion by disease-producing organisms.

31. Attachment loss:

- Is the destruction of the fibers and bone that support the teeth.

- Spreads apical (vertical) direction but also in a lateral (side to side) direction.

32. Why are gingival pockets often called “false” pockets?

- Because there is no apical migration of the junctional epithelium.

33. Periodontal pocket is determined by …

- The relationship of the JE to the crest of the alveolar bone.

34. Epidemiology …

- Study of health and disease within the total population, behavioral, environmental, and genetic risk factors that influence health and disease.

35. Epidemiological research 3 objectives:

- To determine the amount & distribution of a disease in the total population in subgroups.

- To investigate the causes of disease.

- Apply this knowledge to the control and prevention of disease.

36. Disease Prevalence:

- Number of both old and new cases of a disease, that is identified in a specific population at a given point in time.

37. Disease Incidence:

- Number of new disease cases in a population that occurs over a period.

38. Periodontal disease is one of the most widespread diseases in adults …

- 47% of American adults (have mild-severe disease)

- > 65 prevalence increases to 70%

39. Periodontal disease is the leading cause of tooth loss in adults … > 45 years

Unit 6: Periodontal Health, Gingival Disease, and Conditions

1. Periodontal health …

- A state free from inflammatory periodontal disease that allows an individual to function normally and avoid consequences (mental or physical) due to current or past disease.

2. Periodontal health is characterized by …

- The absence of BOP | Erythema | Edema | Patient symptoms | Attachment & Bone loss

** Erythema (redness) – can be caused by localized trauma, infection, allergy, etc.

** Edema (swelling) - IGF sent to areas with biofilm/plaque to fight bacteria or infection.

3. Periodontal health can occur in …

- Intact Periodontium or Reduced Periodontium

4. Intact Periodontium: healthy

- With no loss of periodontal tissue (no loss of connective tissues or alveolar bone)

5. Reduced Periodontium: healthy

- With the pre-existing loss of periodontal tissue, but not currently undergoing loss of connective tissue/alveolar bone.

6. Perio. Health on an Intact Periodontium:

- Patient exhibits no clinical signs of gingival inflammation and no previous loss of periodontal tissue.

- X-ray. doesn`t reveal any changes in bone height or the morphology in alveolar bone.

7. Perio. Health on a Reduced Periodontium in a non-periodontitis patient:

- Clinical signs of periodontal health on a periodontium with pre-existing connective tissue and/or alveolar bone loss due to non-periodontitis causes.

8. Perio. Health on a Reduced Periodontium in successfully treated stable periodontitis patient:

- Clinical signs of periodontal health on a periodontium with pre-existing loss of connective tissues, alveolar bone attributed to periodontitis but successfully treated and

now stable.

- A dental radiograph reveals loss of alveolar bone height.

9. Gingival Disease and Conditions classification:

- Gingivitis: dental biofilm-induced

- Gingival Disease: non-dental biofilm-induced

10. Plaque-induced gingivitis … is an inflammatory response of gingival tissues.

11. Classification of Plaque-Induced Gingivitis and Modifying Factors:

- Systemic conditions:

o Sex & Steroids Hormones: Puberty | Menstrual Cycle | Pregnancy | Oral condition

o Hyperglycemia: poorly controlled diabetes

o Leukemia: plaque biofilm not a prerequisite

o Smoking: gingival fibrosis is evident

o Malnutrition: lack of vitamin C

- Oral factors enhancing plaque biofilm accumulation.

o Subgingival restoration margins.

o Hyposalivation (reduced saliva production) xerostomia

- Drug-influenced gingival enlargements: medication side effects.

12. The most common form of periodontal disease is … Plaque-induced gingivitis.

13. Plaque-induced gingivitis causes … Systematic factors | Medications | Malnutrition.

15. Local factors that act as sites for biofilm retention that may contribute progression of disease:

- Dental restoration | appliances | root fractures | tooth anatomy

16. Common clinical signs of plaque-induced gingivitis …

17. Papillary gingivitis …

- Earliest signs of gingivitis, gingival inflammation involving interdental papilla.

18. Marginal gingivitis …

- Inflammation involve the gingival marginal and portion of attached gingiva.

19. Diffuse gingivitis …

- Gingival inflammation affecting (3) parts of the gingiva: interdental papilla | marginal gingiva | contiguous attached gingiva

20. Acute gingivitis … Necrotizing gingivitis (fire red, painful, strong odor)

- Short duration, followed by professional care and patient self-care to restore gingiva to healthy state.

21. Chronic gingivitis…

- Long-lasting; may exist for years without ever progressing to periodontitis. Is usually painless and more common than acute gingivitis.

22. (3) Categories of Plaque-Induced Gingivitis …

- Gingivitis on an intact periodontium

- Gingivitis on a reduced periodontium in a non-periodontitis patient (Ortho patient)

- Gingivitis on a reduced periodontium in a successfully treated stable periodontitis patient

23. Mushroom-like tissue mass occurrences in pregnancy…

- Is called Pyogenic Granuloma (pregnancy tumor) commonly occurs between 8 and 9.

24. Pregnancy-associated pyogenic granuloma …

- Is painless and noncancerous, and usually resolves after childbirth.

25. Leukemia …

- Is cancer of the body`s blood-forming tissues, includes bone marrow / lymphatic system.

- The first clinical sign would be oral lesions. *

26. Leukemia associated with Gingivitis …

- Is an exaggerated inflammatory response, resulting in increased bleeding and tissue enlargement (swelling).

27. Epidemiologic studies show that one major lifestyle risk factor for periodontal disease is…

- Smoking

28. Lack of Vitamin C will lead to …

- Scurvy (swollen bleeding gum and opening to previous wounds), or delayed healing.

29. Scurvy is also known as … Ascorbic Acid-Deficiency Gingivitis.

30. Hyposalivation (decreased flow of saliva) may be caused by …

- Sjogren syndrome | Anxiety | Poorly controlled diabetes | Side effect of medications.

31. Medications that are associated with gingival enlargement …

- Anticonvulsants (seizure meds) – phenytoin induced

- Calcium channel blockers (hypertension meds)

- Immunosuppressants (HIV/AIDS) – cyclosporine-induced

32. Non-plaque-induced gingival diseases… are painful

- Hereditary Gingival Fibromatosis: rare, benign, with gingival overgrowth

33. In patients with specific underlying risk factors, severe inflammatory periodontal diseases caused by bacterial infection (poor oral self-care, smoking, stress, poor nutrition, compromised immune status) are known as … Necrotizing Periodontal Disease.

- Necrotizing gingivitis: involves only gingival tissue, with no loss of perio. attachment.

(Sudden onset pain, necrosis of interdental papillae (cratered, punched out papillae))

- Necrotizing periodontitis:

- Necrotizing stomatitis:

34. Primary Herpetic Gingivostomatitis… painful (do not treat)

- Initial oral infection with the Herpes simplex type-1 virus (HSV-1)

- Clinical signs: Fiery red GM | Swollen papillae that bleed easily | Yellowish ulcers with red halo | Swollen lymph nodes | Dehydration.

35. Mycoses (histoplasmosis, aspergillosis) infection caused by a fungus that invades tissues…

- Common in asthma patients with inhaler (must educate patient to clean inhaler after use)

36. Hypersensitivity Reactions - Intraoral Allergic Reactions …

- Can be caused by ingredients in toothpaste, mouth rinse, and gum (flavor/preservative)

- Flavors that can cause gingival reactions are cinnamon and carvone.

- Clinical Signs: marginal redness, diffused fiery red.

37. Erythema multiforme … uncommon acute immune-inflammatory disorder of skin/ mucosa

- Clinical signs: large, symmetrical red blotches, resembling a target, circular pattern.

- Begins as blisters then into ulcers.

38. Oral Lichen Planus of Buccal Mucosa … inflammatory condition

- White lines arrange like a web (BM)

- Erythematous, ulcerated, and painful (GM)

- Is a chronic condition that can lead to oral cancer.

- Good patient self-care can relieve painful symptoms.

39. Six Types of Clinical Manifestations of Oral Lichen Planus …