Perio II FInal

Good prognosis vs fair prognosis . (McGurie classification sysem)

*Good*= one or more of the following -Etiologic factors can be controlled -Adequate perio support -Tooth or teeth adequately maintained by professional and patient -Controlled systemic factors *Fair*= one or more of the following -Up to 25% CAL and radiographic loss -Grade 1 furcation -Tooth or teeth can be maintained with professional or patient and home care -LIMITED systemic factors

Poor vs questionable prognosis

*Poor*= one or more of the following -Up to 50% loss occurred -Grade II furcation with difficult access to depth and position of furcation -Greater than Miller class I mobility -Poorcrown to root raio -Lack of pt compliance -Systemic factors present *Questionable*= one or more of the following -Greater than 50% attachment loss -Grade II or III furcation which cannot be accessed for maintenance -Endo involved tooth that needs to be addressed before perio tx -Tooth or teeth are not easily maintained by professional and patient

Healing: Repair vs new attachment vs regeneration

*Repair*= arrests the bone resorption and heals by a SCAR. Does not include regaining of attachment level or new bone height. Restores the continuity of the marginal gingiva. Re-establishes a normal gingival sulcus at the base of the pre-existing pocket. *New attachment*= New perio ligamental fibers into new cementum and the attachment of the gingival epithelium to a tooth surface PREVIOUSLY DENUDED BY DISESE. *Regeneration*= New bone, new PDL or new cementum

Periodontium in leukemic patients

-ALWAYS experience spontaneous uncontrolled bleeding. -Also gingival enlargement 67% in monocytic 18.7% in myelocytic-monocytic 3.7% in myelocytic -CT components displaced by leukemic cells -Oral ulceration and infection usually in sites related to occlusion -Granulocytopenia= displacement of normal bone marrow with leukemic cells, host susceptibility is increased to opportunistic infections

Chronic periodontitis

-About half of american adults have it -Risk factors= male, older, non-white, smokers, low education and income -*Must classify by extent* Localized= <30% of teeth are affected Generalized= >30% of teeth are effected -Must classify by severity Slight/mild= 1-2mm of CAL moderate= 3-4mm of CAL severe= >5mm of CAL

Perio emergencies: Gingival abscess

-Acute infection localized to the gingiva, swelling of interdental papillae or marginal gingiva. May be painful with exudate TX: Drainage, careful removal of etiologic factor, Irrigate with *CHX 0.12%* Follow up after 1-2 weeks Gingival abscesses, unlike perio abscesses, have *NO CAL*

Oral irrigation devices

-Adjunctive plaque control method. -Helpful for removal of nonstructured debris from inaccessible areas around ortho and fixed prosthesis -Limited information to suggest that multiple in-office irrigation appts provide a substantial benefit beyond SRP -*Transient bacteremia have been reported after irrigation in patients with perio and pts in maintenance* thus, this may not be a choice for at home care in pt requiring PRE-MEDICATION

____ is linked to poor wound healing in DM patients. ___ is linked to CV events

-Altered collagen metabolism -AGEs (Accumulation glycation end products) Chronic hyperglycemia adversely effects the synthesis, maturation and maintenance of collagen and ECM. Collagen is less soluble and less likely to be repaired --> poor wound healing

Why are combo systemic antibx therapies good? disadvantages?

-Broadens the anti-microbial range in a single therapeutic dose -Prevents emergence of resistant bacteria by overlapping mechanisms of action -Lowers dose of individual antibiotics by exploiting synergistic effects of two EX: Amoxicillin + CA (Augmentin) + Metronidazole Ciprofloxacin + Metronidazole Disadvantages: May increase adverse reactions, potential for antagonist drug interactions with improper selection *Dont combine bacteriostatic and bactericidal agents*

Pathogenic bacteria as risk factor for perio

-Causal relationship btw bacterial plaque and gingival inflammation *Plaque leads to gingivitis* -Causal relationship btw plaque and perio more difficult to establish. Ex: Local aggressive perio Anatomic and restorative factors which harbor bacterial plaque predispose pt to periodontitis: -Cervical enamel projections, enamel pearls -Furcation and size of entrance -Root concavity of *max 1st premolar* -Close root proximity -Palatal or buccal radicular grooves -Overhang, poor margins, etc -Ill adapting class V restorations -Calculus

why is the occlusal examination an important part of the initial periodontal exam?

-Check the pt bite, protrusive and excursive movements. Look for any interferences -If interferences, make sure to do an occlusal adjustment. WHY? -Perio tissue can change due to occlusal trauma. -Primary or secondary occlusal trauma CAN LEAD TO: Increased mobility, tooth migration, discomfort, pain upon biting, fremitus, *widened PDL and alveolar bone and root resorption* TX: occlusal adjustment, occlusal bite plane splint, ortho

Drug influenced gingival overgrowth

-Dont refer to it as gingival hyperplasia bc that is a pathologic condition 1) Anti-epileptics (phenytoin)= 50% 2) Immunosuppressants (Cyclosporins)= 30% adults, 70% children 3) Calcium channel blockers= between 5-20% 4) Oral contraceptives = reversible when discontinued or dosage modified. Plaque removal is crucial in these patients. May also ask dr to change their medication if possible. Surgical therapy may be indicated

Bisphosphonates and their importance in dentistry BRONJ

-Drugs that inhibit osteoclastic activity (inhibit bone resorption) used in osteoporosis pts -Can lead to BRONJ (bone related osteonecrosis of the jaw) when exposed to bisphosphonates *for more than 8 weeks w/o hx of radiation therapy* +BRONJ is clinically exposed alveolar bone which occurs spontaneously or after extractions +Radiologically appears as radiolucency, sclerosis or loss of lamina dura/widened PDL +Histologically= necrotic bone, lack of living osteocytes

First year, how often does pt need to come in for maintenance? After first year?

-During the first year, pt should come in every 3 months. UNLESS its an extensive case with complicated prosthesis, furcation involvement or questionable pt cooperation. AFTER the first year *Class A*= pt has excellent results, and well maintained for a year. Pt has minimal calculus, no occlusal problems and shallow pockets. Can move them to *6-12 month recalls* *Class B*= Generally good results but display inconsistent OH, heavy calculus, systemic diseases, occlusal problems, smokers, ortho etc. Maintain *3-4 month recalls* *Class C*= Generally poor results and several neg factors: perio surgery indicated but not performed, condition too advanced for surgery, recurrent decay etc. *recall every 1-3months*

Perio Emergencies: Periodontal abscess

-Etiology= untreated perio, moderate to deep pockets, incomplete calculus removal, tooth perforation or fracture, foreign body impaction, poorly controlled DM

Problem areas when brushing

-Facially displaced teeth -Tooth with minimum attached gingiva -Inclined teeth (L of mandibular molars) -Wide embrasures -Overlapped teeth -Wide embrasures -Surfaces of teeth next to edentulous areas -Exposed furcation areas. -Exposed cementum and dentin

When should you refer a patient to the periodontist?

-Furcation involvement, bc hard to keep furcation clean even when perio open a flap -Multiple teeth with attachment loss >5mm, PD>5mm or persistent inflammation -Perio destruction necessitating regeneration -Location of the periodontal deterioration. -Pt has systemic health problems -Pt with dental implants -Pt undergoing complex prosthetic rehabilitation

Why might topical antimicrobial agents be used for treating perio What are the ideal/functional requirements of local delivery

-If pt presents with recurrent pockets in the maintenance phase -Pathogens may be unreachable -Systemic antibiotics are not indicated= adverse reaxns or problems with pt compliance Antibx are locally delivered in an ointment or gel phase via irrigation and have prolonged release *IDEAL LOCAL DELIVERY DEVICE* -Should est a drug reservoir -Effective concentration -Be active for a prolonged period of time -No bacterial resistance -Easy application with favorable clinical outcome

Hopeless prognosis

-Inadequate attachment to support the tooth -Grade III or IV furcation -Miller class III mobility -Must be extracted What makes a tooth hopeless?? So mobile that function is prohibited, untreatable abscess, extensive severe bone loss, risk of aspiration, fracture

Diabetes as a risk factor for perio

-Inflammation is common in both diabetes and periodontal disease --> Hyper reactive inflammatory response to bacterial challenge is responsible for increased severity of periodontal destruction -Perio= 6th most common complication of diabetes -Elevated blood sugar levels suppress the host immune response resulting in poor wound healing, recurrent infections and altered neutrophil function -*Tx of periodontal disease and inflammation actually can reduce the level of glycosylated hemoglobin (tx diabetes as well)* -For DM pts, closely monitor blood glucose, effective perio therapy, strict recall appts and maintenance of OH.

Perio emergencies Pericoronitis

-Inflammation of the soft tissue typically associated with partially erupter/impacted 3rd molars. -Skin flaps retain plaque, food and can cause occlusal trauma -May produce a pus exudate, lead to pain and limited opening of the mouth. Radiating pain to the ear, throat and floor of the mouth. -Systemic involvement= fever, malaise and lymphadenopathy TX: remove debris and exudate, swab with antiseptic under the flap, evaluate occlusion, *antibx if SYSTEMIC involvement*, after sx subside, evaluate tooth prognosis *Extraction indicated* 1)Bone loss on the DISTAL surface of the second molar 2) Increase risk of bone loss or caries distal of 2nd molar due to partially or completely impacted 3rd molar

How many times does a pt with NUG need to return to you

-Initial treatment and supragingival scaling -24-48 hours after first visit to scale the areas previously subgingival before the gingiva shrank -5 days after second visit to consult over OHI, smoking, additional SRP (*continue CHX 0.12% for 3 weeks) -4-6 weeks follow up after final SRP

Occlusal trauma

-Injury resulting in tissue changes within the attachment apparatus as a result of occlusal forces. *primary*= injury resulting in tissue changes from excessive occlusal forces applied to a tooth or teeth with normal support *secondary*= injury resulting in tissue changes from normal or excessive forces applied to a tooth or teeth with reduced support Signs= mobility, fremitus, widened PDL, funnel shaped vertical defects

CTX (C terminal telopeptide) Results of test

-Measures the amount of bone turnover for the ENTIRE body -During bone resorption, the dominant type 1 collagen is degraded and the telopeptide CTX is released -CTX > 150pg/ml *No action needed* -CTX<150pg/ml *Drug holiday for 3-6 months* -CTX<100pg/ml *high risk for BRONJ* If after drug holiday numbers are back around 150, can continue using

When do you use ANTIBX in the following cases? -Medical conditions -Gingivitis -NUG, NUP -Perio -Periodontal surgical therapy -Implant dentistry

-Medical conditions= prophylaxis AHA guidelines, total joint prophy, diabetes -Gingivitis= When associated with bacteremia, septicemia or systemic disease -NUG/NUP= when systemic signs and symptoms are present -Perio= Aggressive cases or refractory cases -Periodontal surgery= Regenerative surgeries, extensive cases or post-surgical infection -Implant dentistry= Before and after surgical placement

Chronic complications of diabetes

-Microvascular diseases (cerebro and CV) -Microvascular (neutropathy, retinopathy and neuropathy) -Infections -Poor wound healing ORAL: Mucosal drying and cracking, burning mouth and tongue, diminished salivary flow, candida, dental caries and abscess formation *PMNs, monocytes and macrophages are impaired in DM, leads to deficient chemotaxis, phagocytosis and adherence*

Aggressive periodontitis (localized vs generalized)

-Much less common than chronic perio. Pts are typically healthy except for presence of perio. -Characterized by rapid attachment and bone loss. FAMILIAL AGGREFGATION -Microbial deposits are inconsistent with severity of perio tissue destruction -*elevated aggregatibacter actinomycetemocomitans and P gingvalis* -Predominantly occurs in african americans *Localized*= pubertal onset, localized to permanent 1st molars and incisors with *no more than 2 other teeth involved*. robust serum antibody response to infecting agents *Generalized*= usually infecting people under 30. Affects 1st molars and incisors with *more than 3 other teeth*. Poor serum antibody response to infecting agents. Amount of local factors like plaque and calculus can be significant.

Dental plaque induced gingivitis on a reduced periodontium

-Plaque present in gingival margin, but confined there -Increased BOP, temperature, exudate -Absence of progressing CAL or bone loss -*Reversible if etiology removed*

Perio emergencies: NUG

-Pt will present with pain, odor, metallic taste, craterlike papillae, spontaneous bleeding and pseudomembrane formation -CAUSES: Stress, depression, smoking, poor oral hygiene, HIV, dietary background -BEFORE TX: take a complete medical history, extraoral examination to check for systemic involvement (fever and lymphadenopathy), Check for intraoral signs. Evaluate the OH and other contributing factors. TX: -Remove the pseudomembrane and supragingival calculus using an ultrasonic scaler. *No subgingival scaling at this point* -Postpone extractions until pt sx free for *4 weeks* -If systemic factors, rx Metronidazole 500mg bid for 7 days Instructions for pt: -Avoid tobacco, alcohol . and condiments -Rinse with CHX 0.12% -Ultrasoft toothbrush to remove surface debris -NSAIDs recommended. *Warn pt that tx is not complete when pain ceases, will return if underlying chronic disease persists.*

Necrotizing Ulcerative Gingivitis (NUG)/ NUP

-Rarely occur -Clinical manifestations= punched out/necrotic papilla, fetid odor, pseudomembrane, spontaneous bleeding, pain -Systemic fever, malaise and lymphadenopathy -Associated with immunosuppression from malnutrition, AIDS, stress or smoking -*Fusiform bacteria and spriochetes* -Can involve only the gingiva or gingiva and periodontium.

What happens at the re-evaluation appointment and when should this appt take place

-Re-evaluation is the first appointment after the hygienic phase (SRP, plaque removal). Should occur *4-6 weeks after*. This allows adequate time for tissue healing and to see if the SRP was successful in reducing BOP, CAL, plaque levels. -At the re-evaluation need to re-do the entire perio charting so that you can compare. -If everything is good , can place the patient on *Perio maintenance phase*

How do you choose a good systemic antibx for perio tx?

-Readily concentrates at infection site -Large concentrations in GCF, gingiva and bone -Minimal side effects -Research showing its efficacy -Microbiological culture and sensitivity test

Why is plaque control important

-Retards calculus formation -Prevents gingivitis (and treats gingivitis) -Critical in prevention of perio (primary etiology)

Clinical signs of chronic perio

-Supra and subgingival plaque and calculus, gingival swelling, redness and loss of gingival stippling -Perio pocket formation -BOP -CAL -bone loss -Furcation involvement -Increased tooth mobility -Change in tooth position -Tooth loss

When and why should SYSTEMIC antibiotics be used in periodontal therapy

-Using antibx is the exception not the rule. -If prescribed, should be used a adjunct to mechanical therapy during the *NON SURGICAL PHASE OF TREATMENT* -Only used in Refractory, Aggressive or severe periodontal cases, not just bc of poor plaque control. -*Offer little adjunctive effect on smokers!*

Tobacco smoking as a risk factor for perio

-direct relationship exists btw smoking and prevalence of perio independent of other factors. -4x as likely to have perio. Former smokers 1.68x as likely. -Smoking has a negative response to therapy. -Smoking cessation has therapeutic impact on response to perio therapy -5 step program recommended: Ask, advise, assess, assist, arrange -Nicotine replacement therapy or buproprion *Impact of smoking on:* 1) Gingivitis= Smoking causes vasoconstriction. Pt appears to have less gingival inflammation and there will be no BOP 2) Perio= increase prevalence, severity and rate of destruction. Increased PD and CAL, Increased tooth loss. Increased prevalence with increased # cigarettes smoked/day (Dose response) 3) Microbiology= Increased levels of periodontal pathogens found in pockets 4) Immunology= Altered neutrophil function (chemotaxis and phagocytosis). Increased neutrophil *collagenase and elastase* (destructive enzymes), Increased release of pro-inflammatory cytokines such as *PGE2 and TNF-A* 5) Physiology= vasoconstriction and decreased gingival blood vessels 6) Non surgical therapy= Decreased clinical response to SRP, less PD reduction and attachment gain 7) Surgical therapy= Less PD reduction and CAL gain. Less bone fill 8) Perio maintenance= Increased PD

MOA of bisphosphonates

1) Attachment to HA binding sites on bony surfaces undergoing resorption 2) Impair the ability of osteoclasts to form the ruffled border- cant produce protons necessary for resorption 3) Decrease osteoclast activity by dec osteoclast progenitor dev --> leads to apoptosis 4) Inhibition of bone metabolism via anti-angiogenic activity

Examples of local antimicrobials used in perio tx

1) Chlorhexidine gluconate gel chip 2) Doxycycline (ATRIDOX)= Uses a blunt cannula to dispense into the pocket May lead to CAL gain 3) Minocycline microspheres (ARESTIN) Lead to greater reduction in PD! IN SMOKERS= Greater reduction in PD as well *After being tx with ARESTiN, pt should avoid chewy, crunchy or sticky foods and no interproximal cleaning devices for 10 days* OVERALL, meta-analysis say there is greater PD reduction and CAL gain by using combo SRP and local antimicrobials. But the effects are limited (0.5mm)

Phases in the treatment plan

1) Emergency phase 2) Non-surgical phase (phase 1) 3) Re-evaluation/maintenance phase 4) After perio is under control, can move on to *surgical phase* if needed or if not, to the *restorative phase* 5) After surgery, restorative phase 6) Then the patient moves back into the re-evaluation/maintenance phase

Chemical components of dentrifices that are actually approved by FDA for plaque control

1) Fluoride for caries reduction 2) Pyrophosphate for supragingival calculus 3) Triclosan= broad spectrum antibacterial agent, ADA seal for protection against plaque, caries and gingivitis

Non-plaque induced gingival lesions

1) Herpes virus= usually self-limiting. Tx is palliative 2)Fungal origin= candida, histoplasmosis, linear gingival erythema. Tx=antifungals 3)Hereditary gingival fibromatosis= usually requires repeated gingivectomies 4)Manifestations of systemic conditions -Lichen planus, pemphigoid, pemphigus, lupus erythematosus , allergic reactions (toothpastes, mouth rinses, chewing gum, etc) 5) Traumatic lesions= thermal or chemical burns, physical trauma 6) Foreign body reactions= dental prophy paste left in sulcus, rubber dam, etc. Tx- subgingival scaling or gingival flap surgery.

What might be considered a periodontal emergency that presents to your office?

1) Necrotizing Ulcerative Gingivitis 2) Pericoronitis 3) Acute herpetic gingivostomatitis 4)Gingival abscess 5) Periodontal abscess

Distance between walking strokes

1-2mm

At what angle should the stone be placed to the instrument for sharpening?`

110 degrees

Piezo tips 1 1S H3

1= blue, supra gingival ONLY. Use ay 70-75% power 1S= suprea and sub. Also blue and 70-75% power H3= sub-gingival scaling PD greater than 4mm. GREEN. 10-20% power

How much more likely are diabetic pts to have perio

2.8-3.4X more likely.

Periodontal disease is associated with a ______X increase in non-hemorrhagic strokes

4.3X increase Mechanism is through the narrowing of the vessel lumen and increase CRP!

Universal curette

4R/4L Columbia curettes

Why do you need lubricant for sharpening stone? Which lub for natural vs artificial stones

Lub reduces frictional heat and prevents metal shavings from embedding in stone NATURAL= OIL -India and Arkansas ARTIFICIAL = WATER -Ceramic, carborundum and ruby

RX for NUG with systemic factors

500mg Metronidazole bid for 7 days

Sickle scaler functions at ___ degrees to the tooth surface Face is ____ degrees to terminal shank THESE ARE THE SAME MEASUREMENTS FOR UNIVERSAL CURETTE AS WELL!

70 90

Gracey curettes, unlike sickle scalers and universals, have an angle of ____ degrees between the face and terminal shank

70!!!!!!

What should the plaque score be

<25%

The curettes used for PD greater than 6mm with an additional 3mm added to the terminal shank are called?

AFTER FIVE Mini Fives have working ends that are 1/2 the lenght

Acute vs Chronic perio abscess

Acute= pain, localized swelling, perio pocket, mobility, tooth elevation in the socket, tenderness in percussion, exudation, fever, lymphadenopathy Chronic= No pain or dull pain, localized inflammatory lesion, slight tooth elevation, intermittent exudation, fistulous tract often assoc w/deep pocket, NO SYSTEMIC involvement

Periodontal host modulation

Agents used to modify host factors contributing to perio disease, instead of bacterial load 1) Periostat, subantimicrobial dose *Doxycycline (20mg bid)*= an anti-collagenase (enzyme that breaks down collagen). Typically taken long term, 3-12+ months *After 18 months, no reduction in bacteria or bacterial resistance bc its the submicrobial dose!* -Other things to consider: patient compliance long term, cost, limited effects (PD/CAL about 0.5mm) Periostat works to limit the #s of destructive enzymes and pro-inflammatory factors. Tips the balance back towards periodontal health

Carborundum is a ____ textured stone

COARSE Only use to reshape instruments

Which bacterial spp are associated with diabetic patients due to increased glucose in the gingival fluid

Capnocytophaga Actinomyces spp Anaerobic vibrios VAC VAC VAC

Flowchart for furcation defects

Check for 1) Occlusion 2) tooth vitality 3) Accessory canal 4) Cervical enamel projections (cause 99% of the time when isolated furcation involvement 5)Root fracture

Miller's mobility classification

Class I: First sign of movement <1mm Class II: 1mm of movement Class III: More than 1mm plus depressable.

Tarnow and Fletcher Vertical furcation involvement

DIFF BC MEASURES VERTICAL INVOLVEMENT A: 0-3mm B: 4-6mm C: >7mm

Avoid wire edge instruments by finishing with a ____ stroke

DOWN

SRP

Debridement, instrumentation for removal ad disruption of microbiota biofilms, scaling= instrumentation for removal of CALCULUS root planing= instrumentation for flattening the root surface Hand instruments vs ultrasonics? -Hand= better tactile sensation but need to be sharpened more often and can hurt your hand -Ultrasonic= less time consuming, less tactile sensation

Hamp furcation classification

Degree 1= less than 3mm of furcation involvement Degree 2= more than 3mm Degree 3= probe passes through and through.

Desquamative gingivitis

Descriptive term, NOT diagnosis -Indicated presence of *erythema, desquamation, erosion, blistering of the attached and marginal gingiva* -Can be seen in any age past puberty, often seen in females over 30. Diseases that cause DG: *Lichen planus, pemphigoid, pemphigus, psoriasis*

Risk DETERMINANTS for periodontal disease

Determinants are risk factors that CANNOT be MODIFIED! Genetic factors may explain why some develop perio and others do not 1) Familial aggregation in aggressive perio 2) Alterations is genes encoding for *IL-1* cytokines associated with chronic periodontitis in non-smoking subjects. -Be aware of these factors, may want to extend periodontal evaluation to family members of infected individuals 3) Age? prevalence and severity increase with age. Not an inevitable consequence of aging process- age alone does not increase disease susceptibility 4) Gender? Men have more CAL than women, but they also have poorer oral hygiene than women 5) Socioeconomic status? 6) Stress? Stress interferes with normal immune function which can affect periodontium

Risk PREDICTORS of perio disease

Do not cause the disease but are associated with increased risk for the disease 1) Previous hx of periodontal disease= good predictor of risk for future disease. Pts with most severe existing attachment loss are at the greatest risk for future attachment loss. 2) BOP= best clinical indicator for gingival inflammation. Although this indicator alone does not serve as a predictor for CAL, BOP coupled with increase PD may serve as an excellent predictor for future attachment loss. Lack of BOP is an excellent indicator for periodontal health

Risk FACTORS for perio

Environmental, behavioral or biologic factors that, when present, increase the likelihood that an individual will develop the disease. When absent, directly results in a decreased likelihood. 1) Tobacco smoking 2) Diabetes 3) Pathogenic bacteria

If a patient comes in for re-evaluation and the BOP, calculus and plaque levels have decreased and PD have decreased as well but still > 5mm, what should you do?

Even though you have gotten a good response, if the patient cannot clean the pockets, they need to be referred to Grad Perio in order to have perio surgery to correct the pockets

T/F stress decreases ACTH and leads to immunosuppression

FALSE Stress INCREASES corticosteroid release. Causes immunosuppression that can lead to potential destruction from periodontal pathogens

A person can have both gingivitis and periodontitis

FALSE , only assign one diagnosis. If the patient has perio then who cares about the areas that dont have bone loss yet. Treat whole mouth as a perio case.

It is ok to write 0 for the FGM-CEJ value

FALSE!!!!!! The free gingival margin and CEJ are never at the same height unless you have a crown or implant that was designed that way. FGM is usually 0.6mm above CEJ (recorded as 1!) EX: in a posterior tooth, FGM may be +3mm above the CEJ. If you put this value as 0, and then record a pocket depth of 5mm, it looks like there is CAL. However if you marked it correctly as +3mm, than you really only have a pocket of 2mm and there is not attachment loss.

Sharp instruments reflect light

FALSE, dull instruments reflect light

Ceramic is a ______ coarse stone

FINE routine use on instruments

Arkansas is a _____ coarse stone

FINE routine use on instruments

T/F you should sharpen ultrasonic tips

False After 2mm of wear they should be discarded and replaced

T/F you can diagnose furcation classification based on xray

False. Radiograph is a suggestion only. must measure with a nabers probe

Functional vs terminal shank

Functional= extends from working end to the shank ben closest to the handle Terminal= extends between the working end and FIRST bend

Which tissue enzymes/inflammatory cytokines are considered destructive and lead to more inflammation associated with perio

IL-1, IL-6, TNFa, PGE, MMP Poor oral hygiene, and systemic factors such as smoking, genetics and diabetes leads to the overproduction of these factors

Prevalence of BRONJ from oral vs IV bisphosphonates

IV= 2.5-5.4% of patients will experience Oral= 0.007-0.04% Occurs in areas of dense bone and thin overlying mucosa. Mandible/Maxilla = 2:1 ratio

TX for ACUTE periodontal abscess

Indications for antibiotic therapy= cellulitis, deep and inaccessible pockets, fever, lymphadenopathy or immunocompromised patient RX: 1) Amoxicillin 1g loading dose, then 500mg tid for 3 days If allergic to amoxicillin 2) Clindamycin 600mg loading, then 500mg qd for 3 days 3) Azithromycin 1g loading dose, then 500mg qd for 3 days (Z pak doubled)

Dental plaque induced gingivitis

Inflammation of the gingiva in the ABSENCE of CAL (no bone loss) -Redness and edema of gingiva -Presence of plaque/calculus -BOP -PD mostly *1-3mm* -CAL mostly 0 or on reduced periodontium -No radiographic crestal bone loss Do not need to specify the extent (generalized/localized) or severity of disease

Define periodontitis

Inflammation of the supporting tissues of the teeth. Usually a progressively destructive change leading to loss of bone and PDL. An extension of inflammation from gingiva into adjacent bone and ligament *Has CAL and bone loss unlike gingivitis*

Hemoglobin A1C should be

Less than 8.5 Has to have been taken within last 2-3 months. Pt must eat breakfast and take medication/insulin before tx provided

Manual vs power instruments

Less time may be required with power instruments. Special ultrasonic tips may be more efficacious in class II and III furcation involvement bc they are designed smaller. HOWEVER, electric produce aerosol. Reduce risk by pre-op rinse, high speed evac and PPE.

How many mm from the CEJ are the furcations on MAX molars

M= 3mm B= 4mm D= 5mm the M and D are very hard to detect, Need to see a horizontal bone loss of 5-6mm on the xray before trying to measure. Measured from the *PALATAL* aspect only

Normal appearance of marginal gingiva and papilla

MG= knife edge and flat following the curve of the tooth Papilla= Pointed, pyramidal and fills the interproximal area.

Mechanical vs chemical removal of plaque

Mechanical- daily removal of plaque with toothbrush, floss -use soft bristles, replace every 3 months -time more important than force! -Modified bass technique Chemical= fluoride, chlorhexidine, essential oils, alcohol, triclosan in mouthrinses, dentrifices or gels that are antimicrobic.

India stone is a ____ coarse stone

Medium used on dull instruments only

Dysbiosis

Microbial imbalance on or inside the body- Perio is a well characterized human disease associated with dysbiosis Health= Proportional host response with ACUTE resolution of inflammation and low biomass. No Dysbiosis. Gingivitis= INCIPIENT dysbiosis (quorum sensing bacteria) with a PROPORTIONAL host response. Chronic resolution of inflammation Periodontitis= FRANK dysbiosis (pathogenic biofilm) with a DISPROPORTIONATE host response. Failed resolution of inflammation

How many cells/microliter in the following neutropenias Mild Moderate Severe

Mild= 1000-1500 Moderate= 500-1000 Severe= less than 500 Generalized aggressive perio common with cyclic neutropenia Infections may be life threatening

Is it ok to say "Generalized severe with localized slight chronic periodontitis?"

NO Can only differentiate between localized and generalized if the localized diagnosis is MORE SEVERE Otherwise, it doesnt matter and they should just be treated for the generalized condition

Does recession= perio?

NO! Recession just means CAL. But that doesnt necessarily mean there is perio disease Can be caused by: Aggressive brushing, ortho tx, mal-alignments, tongue piercing, or perio Thus CAL caused by recession can be a misleading reason for a perio diagnosis. Must consider all the other factors (BOP, radiographic findings, plaque level etc). Instead should be diagnosed *Reduced periodontium*

Explorer in our kit

ODU 11/12

Maintenance phase

Occurs after the hygienic phase has been completed, the patient has come back for re-evaluation and is cleared for maintenance phase! -Used to assess the maintenance of their oral health since perio cannot be "cured" -Used in pts who are not candidates for surgery (health, financial reasons or non-compliant) -With maintenance you can catch recurrence quicker and prevent advancement -during the appointment *perio charting, cleaning and select SRP at sites > 5mm, schedule the next appointment, OHI* -ALL SHOULD BE COMPARED TO PREVIOUS: Xrays, perio charting, clinical presentation, bone height, PA changes etc

Some evidence suggesting that perio pathogens could modulate initiation and perpetuation of atherosclerosis. Which pathogen most likely

P gingivalis S. Sanguinins Enters via flossing/brushing as bacteremia. Can cause focal thickening of arterial intima --> Atherosclerosis

Severe chronic perio

PD are greater than 7mm BOP More than 30% radiographic bone loss CAL= >5mm

Slight chronic perio

PD greater than 3 mm but less than 5mm BOP More than 15% radiographic bone loss CAL= 1-2mm

Moderate chronic perio

PD more than 5mm but less than 7mm BOP Between 15-30% radiographic bone loss CAL= 3-4mm

Periodontal vs pulpal abscess

PERIO: associated with an existing perio pocket, radiographs show horizontal bone loss and furcation radiolucency, *tests show vital pulp*, swelling of gingival tissue, dull and localized pain PULPAL: large restoration of offending tooth, if pocket present NARROW defect, *NON-VITAL* tooth, swelling is localized at APEX with fistulous tract, severe pain difficult to localize, sensitivity on percussion

When is PerioStat indicated for your patient?

PerioStat+ SRP indicated if: 1) At initial therapy pt has risk factors such as smoking 2) Patient with RECURRENT perio disease 3) At maintenance recall, or recall from surgery, pt has 5-6mm recurrent pockets.

Contraindications for PerioStat

Periostat is doxycycline, a tetracycline -Do not rx if pt is pregnant -Pt under 8 years old (staining) -Allergy to tetracyclines -Other possible drug interactions

Drugs that cause gingival overgrowth

Phenytoin (Dilantin)= 50-62% cyclosporine= 30% Ca channel blockers= 6-20% Tacrolimus (immunosuppressive) = 5%

What is a reduced but stable periodontium

Previously diseased periodontium that has been treated and is now stable and NOT PROGRESSING -Same characteristics as healthy periodontium but will have attachment loss or bone loss -This person is at an increased risk for recurrence of periodontitis

Risk indicators for periodontal disease

Probable or putative risk factors that have been identified in cross-sectional studies but not confirmed through longitudinal studies 1) HIV/AIDS= immune dysfunction associated with HIV and AIDS increases hosts susceptibility to perio disease. Often had NUG. Seems reasonable but not conclusive. 2) Osteoporosis= Reduced bone mass and deterioration. Proposed contributing factor to periodontitis- may place the attachment apparatus around the tooth at greater risk from bacterial insult. However causal link between skeletal and oral bone mineral density is scarce. 3) Infrequent dental visits= some studies show increased risk for perio in patients who had not visited the dentist in more than 3 years. Not proven.

Risk assessment

Process of predicting an individuals probability of developing disease clinicians perform risk assessment to 1) Predict which pts are at risk for disease 2) Help in dx the disease 3) prevent disease by modifying the risk factors

What must you do if pt has pemphigoid

Refer to ophthalmologist for synplefaron. Could lead to blindness

Maintenance for implant patients

Requires special instruments that will not scratch the implant surface. Scratches can lead to even more plaque retention. -Non-abrasive prophy pastes -Periodic removal of the prosthesis should be done in the office responsible for placing the prosthesis Use titanium or graphite curettes

TX for chronic perio abscess

SRP Periodontal surgery: -Vertical defects -Bifurcation or trifurcation involvement Consider antibx therapy when indicated. OHI reinforcement

Perio emergencies: Acute herpetic gingivostomatitis

Signs and symptoms: -Prodromal phase = slight fever and malaise -Pain to touch, acidic foods and thermal changes -Cervical adenitis, fever, malaise and dehydration due to pain -Diffuse red and shiny lesions throughout gingiva, lips, cheeks and palate *Runs its course in 7-10 days, but very contagious* TX: -if caught before vesicular rupture *Acyclovir* antiviral 15mg/kg 5 times a day for 7 days -If vesicles already erupting, analgesics and removal of food and debris. May give topical anesthetics before eating to aid in proper nutrition.

Overall conclusions regarding use of Periostat (host modulation)

Statistically significant (0.5mm) improvement in PD reduction and CAL gain when compared to SRP alone. Use is safe and may be indicated as adjunctive aid in CHRONIC periodontitis

Supra vs subgingival irrigation

Supra= will not reach the deeper parts of the pocket where the anaerobic bacteria reside Sub= Washed out rapidly by the GCF. Half life of a non-binding drug is 1 minute. Levels *do not reach MIC*

Never remove metal from the face of the instrument

T

Sharpening horse is easier to use and preserves the instrument longer than handheld stone

TRUE Increased safety, instrument longevity, maintains instrument design, and is a stabilized fulcrum -Use a modified pen grasp, ring finger as fulcrum with *instrument face parallel to the beam*

T/F For common forms of gingivitis and periodontitis, SRP should always be done BEFORE rx antibiotics

TRUE Bc want to try and tx by mechanical removal first (no substitute for mechanical perio tx) as development of resistant bacterial strains is a major concern in medicine

T/F GN spp associated with periodontal infections INCREASES insulin resistance in DM pts

TRUE It leads to worsened glycemic control. *Tx with scRP improves insulin sensitivity and brings down A1C by 0.4%* equal to 1 pill!

T/F If a tooth is hopeless and slated for extraction you still have to treat it

TRUE Untreated retained hopeless teeth can affect the periodontal condition of adjacent teeth

Local contributing factors to plaque induced gingivitis

Tooth crowding Ortho or prosthodontics appliances Overhanging restorations By themselves, these factors do not cause gingivitis but they may contribute to the retention of the plaque and therefore increase chances to develop gingivitis

Chemical plaque control ADA accepted mouth rinses

Used as an ADJUNCT to mechanical techniques. -Usually in forms of rinses, pastes or gels -Agents should not be absorbed through the membrane of the GI tract. *ADA accepted mouth rinses* -Chlorhexidine, by prescription. Rinsing twice a day inhibits plaque and gingivitis. causes reversible staining of teeth. 12% alcohol may be of concern to allergic and religious -Listerine, non prescription. Contains essential oils. Contains 26% alcohol

In magnetistrictive ultrasonics ___ part of the tip is active. For piezos ____ part of the tip is active

WHOLE TIP SIDES OF TIP

Powered toothbrushes are measured by

amplitude= sweep or distance covered by bristles during cycle movement frequency= number of cycles the bristles move within a uit of time, usually measured in brush strokes per minute powered vs regular= both are effective, cost of powered may be a concern to some patients. -Only specifically recommended for handicapped or hospitalized patients. People lacking motor skills

What disease may present like NUG and should be considered in your differential?

desquamative gingivitis