Professional Documents
Culture Documents
Perio 13-14
Perio 13-14
PERIODONTICS
f/g/s
Hemisection is most likely to be performed on:
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PERIODONTICS
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Autogenous free gingival grafts retain none of there own blood supply and are totally dependent on the bed of recipient blood vessels.
In some instances, it can be used to cover a root surface with a narrow denudation. The procedure yields a high degree of successful results when used for increasing the width of the attached gingiva. The free gingival graft may be
used therapeutically to widen the gingiva after recession has occurred. It may be used prophylactically to prevent
recession where the band of gingiva is narrow and of a thin, delicate consistency.
The free gingival graft is an autogenous graft of gingiva that is placed on a viable connective tissue bed where initially, buccal or labial mucosa was present. In most cases, the donor site from which the graft is taken is an edentulous region or the palatal area. The graft epithelium undergoes degeneration after it is placed. Then it sloughs, the
'epithelium "is reconstructed in about a week by the adjacent epithelium and proliferation of surviving donor basal
cells. In 2 weeks the tissue appears to have reformed, but maturation is not completed untinl 0 to 16 weeksjThe time
required is proportional to the thickness of the graft. Note: The free gingival graft receives its nutrients from the viable connective tissue bed.
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The procedure may or may not yield a successful result when used to obtain root coverage; the result is not highly
predictable in such cases. The graft may be used to correct localized narrow recessions or clefts but not deep, wide
recessions. In these instances, the-latecally. repositioned flap (a pedicle graft) or a subepithelial connective tissue
graft has a greater predictability. The free gingival graft is rarely used on the facial or lingual surfaces of mandibular third molars (especially facial).
Miller classification system for recession:
Class I: marginal tissue recession does not extend to the mucogingival junction. There is no loss of bone or soft
tissue in the interdental area. It can be narrow or wide.
Class II: marginal tissue recession extends to or beyond the mucogingival junction. There is no loss of bone or
soft tissue in the interdental areas. It can be wide or narrow.
Class III: marginal tissue recession extends to or beyond the mucogingival junction. There is bone and soft tissue loss interdentally or malpositioning of the tooth.
Class IV: marginal tissue recession extends to or beyond the mucogingival junction. There is severe bone and
soft tissue loss interdentally or severe tooth malposition.
In general, the prognosis for classes I and II is good to excellent; whereas for class III, only partial coverage can be
expected. Class IV has a very poor prognosis.
f/g/s
The main goal of osseous recontouring (surgery) is:
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All of the following statements regarding periodontal flaps are true EXCEPT
one. Which one is the EXCEPTION!
full-thickness periodontal flaps involve reflecting all of the soft tissue, including the
periosteum, to expose the underlying bone
the partial-thickness periodontal flap includes only the epithelium and a layer of the
underlying connective tissue
both full-thickness and partial-thickness periodontal flaps can be displaced
flaps from the palate are considered easier to be displaced than those from any
other region
flaps should be uniformly thin and pliable
PERIODONTICS
*** This is false; palatal flaps cannot be displaced (owing to the absence of unattached
gingiva).
A -periodontal flap is a segment of marginal periodontal tissue that has been surgically separated coronally from its underlying support and blood supply and attached apically by a
pedicle of supporting vascular connective tissue. Flap procedures are the most commonly used of all periodontal surgical techniques. The most commonly used flaps are
full-thickness mucoperiosteal flaps. These flaps.include the surface mucosa (defined as epithelium, basement membrane, and connective tissue lamina propria) and the contiguous
periosteum of the underlying alveolar bone. A partial-thickness flap includes only the epithelium and part of the connective tissue, which is separated from the periosteum by
sharp dissection. The periosteum remains in place on the bone. Alveolar bone is not
exposed. These flaps are used in thypreparatiqn of recipient sites for free gingival grafts
or *hen a dehiscence or fenestration is present on a prominent root.
The surgically created edge of the flap must be uniformly thin, usually about 2 mm
thick. One determinant of how the flap will be raised, that is either as full-thickness or as
a partial-thickness flap, is the thickness (amount) of the attached gingiva prior to surgery. Generally, a full thickness flap will be used where the attached gingiva is thin (2 mm
or less in width), and a partial-thickness flap may be used when the attached gingiva is
thick (2 mm or more).
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There are various distal flap approaches used for retromolar reduction. The
simplest is the:
gingivectomy
apically positioned flap
distal wedge
laterally positioned flap
PERIODONTICS
f/g/s
Contraindications to gingivectomy include all of the following EXCEPT one.
Which one is the EXCEPTION!
the need for bone surgery or examination of the bone shape and morphology
situations in which the bottom of the pocket is apical to the mucogingival junction
esthetic considerations, particularly in the anterior maxilla
elimination of gingival enlargements
PERIODONTICS
distal wedge
Distal wedge procedures (sometimes called proximal wedge procedures) are
frequently performed after wisdom teeth are extracted because the bone fill is usually
poor, leaving a periodontal defect. This region is occupied by glandular and adipose
tissue covered by unattached nonkeratinized mucosa. Only if sufficient space exists distal to the last molar, a band of attached gingiva may be present. In such a case, a distal
wedge operation can be performed.
These procedures are also performed in the following areas of the mouth:
The maxillary tuberosity region
The mandibular retromolar triangle area
Distal to the last tooth in an arch, or mesial to a tooth which approximates an edentulous area
Many designs have been presented for this flap procedure. However, the basic principle is one of making at least two incisions distal or mesial to the tooth and carrying these
incisions parallel to the outer gingival wall, thus forming a wedge; the base of which is
the periosteum overlying the bone and the apex of which is the coronal gingival surface.
Detachment of the wedge from the periosteal base and elimination of the tissues involved
in the distal pocket region also reduce tissue bulk and allow for access to the underlying bone.
The primary objective and advantage of surgical flap procedures in the treatment of periodontal disease is:
PERIODONTICS
f/g/s
The modified Widman flap:
PERIODONTICS
to provide access to root surfaces for debridementchoices are goals but not a primary objective
leo
The techniques vary with the goal that is sought. However, the common goal of all flap
procedures is to provide access for instrumentation. It gives the clinician the opportunity to visualize the roots so that calculus may be removed more completely.
Without direct visualization provided by a flap, it is rare that a clinician can effectively root plane
beyond 5 mm of probing depth or into furcations of lesser depth. It also makes removal of granulomatous tissue from the region of the periodontal defect difficult. It is important to remove this,
due to the fact it contains epithelium and the potential presence of bacterial infiltration.
Important: If a patient fails to demonstrate adequate oral hygiene during initial therapy (scaling
and root planing), surgery is contraindicated because, after surgery, the incidence of disease recurrence will be greater if oral hygiene remains poor. The best course of action is to continue to
stress oral hygiene and maintain areas with scaling and root planing.
The internal bevel incison' is basic to most periodontal flap procedures. It is the incision from
which a flap is reflected to expose the underlying bone and root. The internal bevel incision accomplishes three important objectives: < J ^ removes the pocket lining;\JJ25'it conserves the relatively uninvolved outer surface of the gingiva, which, if apically positioned, becomes attached
gingiva; and (3) reproduces a sharp, thin flap margin for adaptation to the bone-tooth junction.
A. Diagram of the internal bevel incision (first
incision) to reflect a full-thickness (mucoperiosteal) flap. Note that the incision ends on the
bone to allow for the reflection of the entire
flap. B. Diagram of the internal bevel incision
to reflect a partial-thickness flap. Note that the
incision ends on the root surface to preserve the
periosteum of the bone.
f/g/s
A soft tissue graft that is rotated or otherwise repositioned to correct an adjacent defect is called a:
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PERIODONTICS
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PERIODONTICS
pedicle graft
The pedicle graft was the first periodontal plastic surgery procedure to be used for root
coverage. It provides a superior result from an esthetic standpoint, but is less versatile
than the connective tissue graft. Important: The base of the graft remains attached to
the donor site to maintain the blood supply.
With pedicle grafts, there is less concern about nutrient flow from graft bed to graft. The
properly performed pedicle graft never loses its blood supply during the surgical procedure.
The major advantages of pedicle grafting include:
Predictable correction of gingival recession is possible, because the graft has an uninterrupted blood supply
Postoperative discomfort is usually minor
Since the color of the graft matches the adjacent gingiva, the procedure provides good
esthetics
Indications include:
S^TO widen an inadequate zone of attached gingiva
VTo repair an isolated area of gingival recession
Contraindications include:
The prospective donor site lacks sufficient attached gingiva
The donor site has a fenestration or dehiscence of its supporting bone
Note: Pedicle grafts are not well suited for repairing generalized recession defects. They
were designed for repair of isolated recession. Many recession defects don't have a suitable adjacent donor site.
f/g/s
The primary reason for the failure of a free gingival autograft is:
infection
edema
disruption of the vascular supply before engraftment
the formation of scar tissue
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PERIODONTICS
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PERIODONTICS
1. Deep periodontal pockets are often treated by flap surgery. These cases
will often result in reduced pocket depth by formation of a long junctional
epithelium (soft tissue reattachment), even if there is no change in the position of the gingival margins.
2. The best indicator of success of a periodontal flap procedure is postoperative maintenance and plaque control by the patient.
3. One month after flap surgery, a fully epithelialized gingival crevice with a
well-defined epithelial attachment is present. Functional arrangement of supracrestal fibers is initiated.
f/g/s
All corners of a periodontal flap should be:
sharp
rounded
it doesn't matter whether the corners of a periodontal fla|o are sharp or rounded
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PERIODONTICS
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rounded
A periodontal flap is a section of gingiva and/or mucosa surgically separated from the underlying tissues to provide visibility of and access to the bone and root surface. The flap allows the gingiva to be
displaced to a different location in patients with mucogingival involvement.
Periodontal flaps can be classified based on the following:
Bone exposure after flap reflection:
- full-thickness (mucoperiosteal) flaps: all soft tissues, including the periosteum, are reflected to
expose the underlying alveolar bone.
- partial-thickness (mucosal) flaps: only the epithelium and a layer of the underlying connective
tissue are reflected. Also called split-thickness flap.
Based on flap placement after surgery:
- nondisplaced flaps: when the flap is retained and sutured to its original position.
- displaced flaps: which are placed apically, coronally, or laterally to their original position.
Based on management of the papilla:
- conventional flap: the interdental papilla is split beneath the contact point of the two approximating teeth to allow reflection of buccal and lingual flaps.
- papilla preservation flap: incorporates the entire papilla in one of the flaps.
The Four Basic Rules For Flap Design:
1. The base of the flap should be wider than the free margin in order to afford sufficient blood circulation to the free margin of the flap.
2. The lines of the incision must not be placed over any defect in the bone to prevent delayed healing.
3. Incisions that traverse a bony eminence (canine) should be avoided. The mucosa covering bony
eminences is thin and healing is slow and may result in an ugly scar formation.
4. All corners of the flap should be rounded. Sharp points will delay healing.
Important:
Healing should take place without complication if basic surgical principles are followed.
Incisions made in tissues that harbor uncontrolled infection may cause rapid spread of the infection. Do not do this. Most periodontal surgical procedures are performed only after anti-infective
therapy has been completed.
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PERIODONTICS
f/g/s
A free mucosal autograft (subepithelial connective tissae graft) differs from a
free gingival graft in that the transplant in a free mucosal graft is:
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PERIODONTICS
f/g/s
Which of the following terms refer storeshapi ng the bone without removing
tooth-supporting bone?
ostectomy
osteoplasty
positive architecture
negative architecture
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PERIODONTICS
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PERIODONTICS
osteoplasty
Procedures used to correct osseous defects have been classified in two groups:
Osteoplasty: refers to reshaping the bone without removing tooth-supporting bone
Ostectomy (or osteoectomy): includes the removal of tooth-supporting bone
*** One or both of these procedures may be necessary to produce the desired results.
Morphologically descriptive terms (these terms all relate to a preconceived standard of ideal osseous
form):
Positive and negative architecture refer to the relative position of interdental bone to radicular bone.
The architecture is said to be "positive" if the radicular bone is apical to the interdental bone. The bone
is said to have "negative" architecture if the interdental bone is more apical than the radicular bone.
Flat architecture is the reduction of the interdental bone to the same height as the radicular bone.
Note: Osseous form is considered to be "ideal" when the bone is consistently more coronal on the interproximal surfaces than on the facial and lingual surfaces. The ideal form of the marginal bone has
similar interdental height, with gradual, curved slopes between interdental peaks.
Following ostectomy, peaks of bone typically remain at the facial and lingual/palatal line angles of the
teeth (widow s peaks). If these are not removed, periodontal pockets can recur. Ostectomy to a positive
architecture requires the removal of the line-angle inconsistencies (widow s peaks), as well as some of
the facial, lingual, and palatal and interproximal bone. The result is a loss of some attachment on the facial and lingual root surfaces but a topography that more closely resembles "ideal" bone.
Terms that relate to the thoroughness of the osseous reshaping techniques include:
Definitive osseous reshaping: implies that further osseous reshaping would not improve the overall
result.
Compromise osseous reshaping: indicates a bone pattern that cannot be improved without significant osseous removal that would be detrimental to the overall result.
Note: The relationship between the depth and configuration of the bony lesionfi) to root morphology and
the adjacent teeth determines the extent that bone and attachment is removed during resection. The technique of ostectomy is best applied to patients with early to moderate bone loss (2-3 mm) with moderatelength root trunks that have bony defects with one or two walls. These shallow-to-moderate bony defects
can be effectively managed by osteoplasty and ostectomy. In some surgical procedures, it is necessary
to leave interradicular bone exposed. This usually results in bone loss of no clinical consequence.
ging/pdl dis
Smoking has been identified as a significant variable to predict the response
to periodontal treatment.
Smoking has a negative effect on periodontal therapy.
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PERIODONTICS
ging/pdl dis
Prevotella intermedia was formerly known as:
bacteroides melaninogenicus
wolinella intermedius
bacteroides gingivalis
bacteroides intermedius
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both statements
Most investigations that evaluated the effect of smoking on nonsurgical therapy have demonstrated less
reduction in probing depth and smaller gains in attachment levels in smokers compared with nonsmokers.
Depending on which clinical parameters are used to assess periodontal disease, smokers are 2.6 to 6
times more likely to develop periodontal disease than nonsmokers.
Important point: Smoking is one of the most significant risk factors currently available to predict the
development and progression of periodontitis.
Smokers:
Demonstrate more orange and red microbial complexes
Flave an increase in Tannerella forsythia levels
Have a depressed immune system; smoking exerts a significant negative effect on the protective
elements of the immune system. Studies show that smoking not only dampens the response of host
defense cells, such as neutrophils, but also leads to increased release of tissue-destructive enzymes.
1. Most systemic diseases and conditions that may affect periodontal diseases generally alter
Notes host barrier and host defense mechanisms. Although many conditions cause gingival inflammation and ulcers, not all people develop periodontal disease. Certain factors put individuals at higher risk than others.
2. Osteoporosis (loss of bone density) has been associated with periodontal disease in postmenopausal women. There is some evidence that some treatments for osteoporosis, such as
bisphosphonates, may reduce bone loss, including the bony structures that support the teeth.
3. Autoimmune conditions (e.g., Crohn disease, rheumatoid arthritis, lupus erythematosus,
CREST syndrome) have been associated with a higher incidence of periodontal disease.
4. Smokless tobacco use has been associated with oral leukoplakia and carcinoma. However,
no generalized effects on periodontal disease progression seem to occur, other than localized
attachment loss and recession at the site of tobacco product placement.
5. Patients receiving radiation therapy show periodontal attachment loss and tooth loss to
be greater on the radiated side compared with the nonradiated side. Periodontal health should
be established prior to beginning radiation therapy.
bacteroides intermedius
The purpose of this card is to hopefully clear up any confusion on the recent reclassifications of a number of peridontal pathogens. The bacteria have stayed the same, but the
names have changed.
New Classification
Bacteroides gingivalis
Porphyromonas gingivalis
Bacteroides endodontalis
Porphyromonas endodontalis
Bacteroides intermedius
Prevotella intermedia
Bacteroides melaninogenicus
Prevotella melaninogenica
Bacteroides denticola
Prevotella denticola
Bacteroides loescheii
Prevotella loescheii
Bacteroides forsythus
Tannerella forsythia
Wolinella recta
Campylobacter rectus
Wolinella curva
Campylobacter curvus
ging/pdl dis
Mediators produced as a part of the host response that contribute to tissue
destruction include all of the following EXCEPT one Which one is the EXCEPTION!
free radicals
proteinases
prostaglandins
cytokines
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ging/pdl dis
Which of the following is the LEAST mportant diagnostic aid in recognizing
the early stage of gingivitis?
bleeding on probing
gingival color
pocket depths
stippling of the gingival tissue
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PERIODONTICS
free radicals
ging/pdl dis
In a clinically healthy periodontium, the microbial flora is largely composed
of:
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ging/pdl dis
Endotoxins are the lipopolysaccharide component of the cell wall of:
gram-positive bacteria
gram-negative bacteria
both gram-positive and gram-negative bacteria
neither gram-positive and gram-negative bacteria
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Fusobacterium nuclealum
Actinobacillus actinomycetemcomitans
Peptostreptococcus micros
. Treponema denticola
mportant: Decreases in the prevalence and numbers ofP.,.gingiyalis, '^forsythia, and J^foifco/a are
associated with successful clinical treatment of disease.
Nonspecific Plaque Hypothesis: maintains that periodontal disease results from the "elaboration of
noxious products by the entire plaque flora." Inherent in this hypothesis is the concept that control of periodontal disease depends on control of the amount of plaque accumulation. This hypothesis is contradicted by the finding that some patients with little plaque have severe periodontitis.
.Specific Plaque Hypothesis:states that only certain plaque is pathogenic, and its pathogenicity depends
on the presence of or increase in specific microorganisms. This concept predicts that plaque harboring
specific bacterial pathogens results in a periodontal disease because these organisms produce substances
that mediate the destruction of host tissues. Note: Acceptance of this hypothesis was spurred by the
recognition of A. actinomycetemcomitans as a pathogen in localized aggressive periodontitis.
gram-negative bacteria
The cell wall of gram-negative bacteria consists of a lipopolysaccharide (LPS) base, also
known as endotoxin, that has significant pathogenic potential. Typically, LPS-containing
gram-negative cell wall extracts are capable of promoting bone resorption, inhibiting osteogenesis, chemotaxis of neutrophils, and other events associated with active periodontitis.
Important facts:
Free endotoxin is present in dental plaque and inflamed gingiva
Plaque accumulation has a direct effect on the severity of gingivitis
Plaque bacteria produce enzymes (hyaluronidase, collagenase, chondroitin sulfatase, elastase and proteases) that may initiate periodontal disease.
1. Collagenase (which is produced by BjudQidgs species) catalyzes the degradation (hydrolysis) of collagen.
2. Hyaluronidase (which is produced by Streptococcus mitans and salivarius) and
chondroitin sulfatase (which is produced by Diphtheroids) may lead to the destruction of the amorphous ground substance.
Antibodies or immunoglobulins are produced by plasma cells in response to oral
bacteria or their by-products. The most numerous are IgG, which act to neutralize
bacterial toxins by enhancing phagocytosis.
The most likely source of bacteria found in diseased periodontal tissue is subgingival plaque.
The likelihood that bacterial endotoxins play a major role in gingival inflammation is evidenced by the following:
1. A reduction in inflammation by the removal of plaque.
2. A reduction of the inflammatory state with antibiotic treatment.
Important^Tbe predominant periodontal disease is gingivitis.
ging/pdl dis
Which of the following clinical signs and symptoms is characteristic of
necrotizing ulcerative gingivitis (NUG)!
minimal bleeding
"punched-out" papillae
painless
periodontal pocket formation
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PERIODONTICS
ging/pdl dis
In a healthy sulcus, which of the bacteria below are most abundant?
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"punched-out" papillae
Two forms of necrotizing ulcerative periodontal diseases are necrotizing ulcerative gingivitis (NUG)
and necrotizing ulcerative periodontitis (NUP). These conditions represent acute forms of periodontal destruction typically associated with some form of host compromise.
The essential components of NUG are:
Interdental gingival necrosis: often described as "punched-out" papillae
Pain
Bleeding
*** Variable features include a fetid oris (offensive odor), lymphadenopathy, fever, and malaise.
Predominant organisms associated with NUG include PJntermedia Fusobacterium species, and
spirochetal microorganisms. Note: EM studies of NUG reveal a zone of tissue infiltration of spirochetal microorganisms in advance of the region of tissue necrosis. NUG is usually associated with predisposing host factors, including stress, srnoking, invmunosuppression (as seen with HIV infection),
andmalnutrition.
NUP is distinguished from NUG by the loss of clinical attachment and bone in affected sites, but
the clinical presentation and etiologic factors are similar to that of NUG in the absence of systemic
disease. In the presence of systemic immunosuppression, exemplified by HIV infection, NUP may
result in rapid and extensive necrosis to the tissues and underlying alveolar bone.
The treatment of NUG or NUP includes debridement, hydrogen peroxide (or chlorhexidine) rinses,
and antibiotic therapy (Pen^V) if there is systemic involvement (manifested by fever, malaise, and lymphadenopathy). Important: Patients with HIV-associated NUG require gentle debridement and antimicrobial rinses.
Note: For patients with acute herpetic gingivostomatitis:
If diagnosed within 3 days of onset, acyclovir suspension should be prescribed, 15 mg/kg five
times daily for 7 days
All patients, including those presenting more than 3 days after disease onset, may receive palliative care, including plaque removal, systemic NSAIDs, and topical anesthetics
Patients should be informed that herpetic gingivostomatitis is contagious at certain stages, such
as when vesicles are present
Gram-negative:
Veillonella
Campylobacter
Fusobacterium
Eikenella
Corynebacterium
ging/pdl dis
Early microbiologic studies of localized aggressive periodontitis (LAP) provided clear evidence of a strong association between disease and a unique
bacterial microbiota dominated by:
tannerella forsythia
prevotella intermedia
porphyromonas gingivalis
actinobacillus actinomycetemcomitans (aa)
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ging/pdl dis
Diseases that clinically present as desquamative gingivitis include the
following?
Select all that apply.
lichen planus
pemphigoid
pemphigus vulgaris
leukemia
chronic ulcerative stomatitis
lupus erythematosus
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PERIODONTICS
lichen planus
pemphigoid
pemphigus vulgaris
chronic ulcerative stomatitis
lupus erythematosus
The following diseases also present as desquamative gingivitis; linear IgA disease, dermatitis herpetiform, and
erythema multiforme.
Desquamative gingivitis (DG) is only a clinical term that describes a peculiar clinical picture. This term is not
a diagnosis, and once it is rendered, a series of laboratory procedures should be used to arrive at a final diagnosis. It is important to be aware of this rare clinical entity so as to distinguish desquamative gingivitis from
plaque induced gingivitis, which is an extremely common condition, easily recognized, and treated daily by
the dental practitioner.
DG is characterized by fiery red, glazed, atrophic or eroded-looking gingiva. There is loss of stippling and the
gingiva may desquamate easily with minimal trauma. As opposed to plaque-induced gingivitis, DG is more
common in middle-aged to elderly females, is painful, predominantly affects the buccal/labial gingiva, frequently spares the marginal gingiva but can involve the whole thickness of the attached gingiva, and its clinical appearance is not significantly altered by traditional oral hygiene measures or conventional periodontal
therapy alone. Note: The role of plaque is vague in desquamative gingivitis.
Important point: The multiplicity of causes of DG lesions with a focus on dematologic disease makes it imperative that clinicians develop diagnostic skills and good communication with physicians such as internists
and dermatologists. Because microscopic evaluation is the foundation for diagnosis of DG lesions, clinicians
must take the responsibility to biopsy all desquamative lesions.
The majority of cases of DG are now known to be due to mucocutaneous conditions, in particular lichen planus,
pemphigoid, and pemphigus. DG can be mistaken for plaque-induced gingivitis, and this can lead to delayed
diagnosis and inappropriate treatment of serious dermatological diseases such as pemphigoid or pemphigus.
Remember: Histologically, where nonulcerated areas are found, the stratified squamous epithelium is significantly atrophic. Rete pegs are short or absent. Inflammatory cells, mainly plasma cells, may be found on the
basal layer.
WMlW"'****''*"*'^
ging/pdl dis
A cuplike resorptive area at the crest of the alveolar bone is a radiographic
finding of:
gingivitis
occlusal trauma
early periodontitis
acute necrotizing ulcerative gingivitis
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ging/pdl dis
Which of the following statements regarding periodontitis is incorrect?
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early periodontitis
Radiographic Changes in Periodontal Disease:
Early periodontitis: areas of localized erosion of the alveolar bone crest (blunting of the crest in
anterior regions and a rounding of the junction between the crest and lamina dura in the posterior
Tegionsf"
Moderate periodontitis: the destruction of alveolar bone extends beyond early changes in the
alveolar crest and may include buccal or lingual plate resorption, generalized horizontal erosion or
localized vertical defects, and possible clinical evidence of tooth mobility.
Advanced periodontitis: the bone loss is so extensive that the remaining teeth show excessive mobility and drifting and are in jeopardy of being lost. There is usually extensive horizontal bone loss
or extensive bony defects.
1. In gingivitis, the radiographic appearance of the bone will be normal.
Notes 2- The crest of the alveolar bone is affected in periodontal disease. In health, it lies 1-2 mm
below the level of the CEJs of adjacent teeth.
3. A reduction of only 0.5 or 1.0 mm in the thickness of the cortical plate is sufficient to permit radiographic visualization of destruction of the inner cancellous trabeculae.
Important: Diabetes mellitus is an extremely important disease from a peridodontal standpoint. It is a
complex metabolic disease characterized by chronic hyperglycemia. Individuals with diabetes have a
higher prevalence and severity of peridontal diseae than do those without diabetes. Diabetes does not
cause periodontal disease, but studies show that it alters the response of the periodontal tissues to bacterial plaque. Poorly controlled diabetics often have:
Enlarged gingiva, sessile or pedunculated gingival polyps, polypoid gingival proliferations, abscess
formation, and loosened teeth
Polymorphonuclear leukocyte deficencies resulting in impaired chemotaxis, defective phagocytosis, or impaired adherence
The chronic hyperglycemia adversely affects the synthesis, maturation, and maintenance of collagen and extracellular matrix. Numerous proteins and matrix molecules undergo a nonenzymatic glycosylation, resulting in accumulated glycation end products (AGEs).This increase in AGEs affects
how collagen is normally repaired or replaced and may play a role in the progression of peridontal dis-
ging/pdl dis
Which of the following is most significant in regard to the prognosis of a
periodontally involved tooth?
pocket depth
attachment loss
anatomical crown length
bleeding on probing
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ging/pdl dis
Gingivitis is most often caused by:
a hormonal imbalance
inadequate oral hygiene
occlusal trauma
a vitamin deficiency
aging
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attachment loss
Attachment loss is much more significant than periodontal pocketing (actually it is the most significant factor) because with attachment loss, supportive structures are being destroyed.
Pocket depth is the distance between the base of the pocket and the gingival margin. The level of attachment
on the other hand, is the distance between the base of the pocket and a fixed point on the crown, such as the
CEJ. Changes in the level of attachment can be caused only by gain or loss of attachment and, thus, provide a
better indication of the degree of periodontal destmction.
Important: The two most critical parameters for the prognosis of a periodontally involved tooth are attachment loss (most critical) anfTjHtSfiility.
"^
In periodontics, factors often considered in the generation of a prognosis include, but are not limited to, tooth
type, furcation involvement, bone loss, pocket depth, tooth mobility, occlusal force, patient's home care, presence of systemic disease, and cigarette smoking.
The prognosis is usually classified as excellent (no bone loss, gingival health, good patient cooperation, no
secondary systemic or environmental factors), good (adequate bone support, good patient cooperation, no
environmental facctors, and well-controlled systemic factors), fair (less than adequate bone support, mobility, grade I furcation involvement, good patient cooperation, and limited environmental and/or systemic factors), poor (moderate to advanced bone loss, mobility, grade I and II furacation involvement, questionable
patient cooperation, and presence of environmental and/or systemic factors), questionable (advanced bone
loss, grade IandIIfuraction involvements, mobility, and presence of enyironmenta7"ah"a7orsystemic factors),
and hopeless (advanced bone loss, inability to establish maintainable situation, and the presence of uncontrolled environmental and/or systemic factors extraction(s) is/are indicated).
Notes
1. Pocketing can increase or decrease, depending on the amount of inflammation without attachment loss. On the other hand, extensive attachment loss and gingival recession may be accompaI nied by shallow pockets (poor prognosis of tooth).
2. When the gingival margin is located on the anatomic crown, the level of attachment is determined by subtracting from the depth of the pocket the distance from the gingival margin to the
CEJ. If both are the same, the loss of attachment is zero.
3.When the gingival margin coincides with the CEJ, the loss of attachment equals the pocket
depth.
4. When the gingival margin is located apical to the CEJ, the loss of attachment is greater than the
pocket depth, and therefore, the distance between the CEJ and the gingival margin should be added
to the pocket depth.
All surfaces of the oral cavity (both hard and soft tissues) are coated with a pellicle (initial phase of
plaque development). Within nanoseconds after vigorously polishing the teeth, a thin, saliva-derived
layer, called the acquired pellicle, covers the tooth surface. This pellicle consists of numerous components, including glycoproteins (mucins), proline-richproteins, phpsphoproteins (e.g., statherin), histidinerich proteins, enzymes (e.g., alpha-qmylase), and other molecules that can function as adhesion sites for
bacteria (receptors).
Halitosis (bad breath/oral malodor): At least 85% of breath malodors have an oral source. Gingivitis,
periodontitis, and tongue coating are the predominant causes of bad breath. The gram-negative anaerobic bacteria associated with gingivitis and periodontitis cause bad breath by their proteolysis, which produces foul-smelling volatile sulfide compounds (VSCs).
Notes
1. The overall pattern observed in dental plaque development is a very characteristic shift
from the early predominance of gram-positive facultative microorganisms to the later
predominance of gram-negative anaerobic microorganisms.
2. The major factor in determining the different bacteria is oxygen. The redox potential of
the gingival sulcus greatly influences the bacterial composition.
ging/pdl dis
Which of the following needs to be evident in to make a diagnosis of periodontitis?
> bleeding
pocket depths of 5 mm or more
radiographic evidence of bone loss
a change in tissue color and tone
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ging/pdl dis
The degree of gingival enlargement can be scored as follows: Grade 0, Grade
1, Grade II, and Grade III. Enlargement confined to the interdental papilla
would be scored as:
grade 0
grade 1
grade II
grade III
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Note: Bitewing x-rays tend to be most accurate in assessing alveolar bone resorption. If extensive bone
loss has occurred, vertical bitewings should be taken. They will reveal more of the periodontium. Bone
loss may be horizontal or vertical. Also remember that more than 30% of the bone mass at the alveolar crest
must be lost for a change in bone height to be recognized on radiographs. Remember: The clinical feature
IHa^ferftfptslferp^Hc^rjffi
the presence of clinically detectable attachment loss.
Other clinical criteria that should be evaluated during a periodontal exam (besides color, tone, contour,
and size of gingiva):
Level of the free gingival margin in relation to the CEJ: the normal level of epithelial attachment
should be on enamel or at.the CEJ. This would place the free gingival margin 2 to 3 mm coronal to this
sulcular base, on enamel..
Periodontal pocket depth: all measurements in excess of 3 mm are recorded for sulcular depth, as
well as any reading that locates the free gingival crest 2 mm or more apical to the CEJ. *** The loss
of attachment is determined by measuring the disttance between the CEJ and the base of the attachment.
Bleeding: physiologically, bleeding from the gingival sulcus should not be caused by gentle provocation. Bleeding in the absence of local irritants may indicate a systemic disease.
Exudate: the presence of exudate, specifically suppuration (which is due to the presence of large numbers of neutrophils in the pocket), is evaluated by digital pressure on the buccal and lingual of each tooth.
Mucogingival complications: this term indicates the involvement of not only the gingival component
in the disease state, but also the presence of imminent involvement of the alveolar mucosa.
The following should also be noted:
Erosion: usually found on the cervical area of the facial surface of a tooth.
Abrasion: loss of tooth structure by mechanical wear horizontal toothbrushing with a hard toothbrush and abrasive dentifrice is the most common cause.
Attrition: occlusal wear due to functional contacts with opposing teeth. Results in wear facets on the
occlusal surfaces of teeth.
Abfraction: occlusal loading resulting in tooth flexure, mechanical microfractures, and tooth structure
loss in the cervical area.
Hypersensitivity of roots: due to exposure of dentinal tubules to thermal changes following recession
and removal of cementum by toothbrushing, root decay, or scaling and root planing.
grade I
The degree of gingival enlargement can be scored as follows:
Grade 0: no signs of gingival enlargement
Grade I: enlargement confined to interdental papillae
G r a d e I I : enlargement involves papilla and marginal gingiva
Grade EH: enlargement covers three-quarters or more of the crown
Using the criteria of location and distribution, gingival enlargement is designated as follows:
Localized: limited to the gingiva adjacent to a single tooth or group of teeth
Generalized: involving the gingiva throughout the mouth
Marginal: confined to the marginal gingiva
Papillary: confined to the interdental papilla
Diffuse: involving the marginal and attached gingivae and papillae
Discrete: an isolated sessile or pedunculated, tumorlike enlargement
Gingival enlargement may result from chronic or acute inflammatory changes; clrfflffle^lvanges
are much more common. Chronic inflammatory gingival enlargement originates as a slight
ballooning of the interdental papilla and marginal gingiva. In the early stages, it produces a life
preserver-shaped bulge around the involved teeth. This bulge can increase in size until it covers part of the crowns. The enlargement may be localized or generalized and progresses slowly
and painlessly.
Note: Chronic inflammatory gingival enlargement is caused by prolonged exposure to dental plaque. Factors that favor plaque accumulation and retention include poor oral hygiene,
as well as irritation by anatomic abnormalities and improper restorative and orthodontic appliances.
Important: A pseudopocket is a pocket formed by gingival enlargement_withont apical migration of the junctional epithelium. It does not involve the loss of bone. Pseudopockets are
also referred to as gingival, false, or relative pockets. All pseudopockets are suprabony (the
base of the pocket is coronal to the crest of the alveolar bone).
D
ii
1 . 1
'
ging/pdl dis
The most important plaque retentive factor is:
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ging/pdl dis
During pregnancy there is an increase in levels of both progesterone and
estrogen.
The so-called pregnancy tumor is not a neoplasm.
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calculus
Distinguishing between the effects of calculus and plaque on the gingiva is difficult because calculus is always
covered with a nonmineralized layer of plaque. The nonmineralized plaque on the calculus surface is the principal irritant, but the underlying calcified portion may be a significant contributing factor. It does not irritate
the gingiva directly but provides a fixed nidus for the continued accumulation of plaque and retains it close to
the gingiva.
Plaque initiates gingival inflammation, which starts pocket formation, and the pocket, in turn, provides a sheltered area for plaque and bacterial accumulation. The increased flow of gingival fluid associated with gingival inflammation provides the minerals that convert the continually accumulating plaque into subgingival
calculus.
Calculus (which is mineralized bactrialplaque) plays an important role in maintaining and accentuating periodontal disease by keeping plaque in close contact with the gingival tissue and creating areas where plaque
removal is impossible.
Other contributing or complicating factors in periodontal disease include:
Food impaction or retention: overlapping, malposed, tilted, or drifted teeth are frequently associated
with food impaction or retention. If not removed, this will lead to inflammatory periodontal disease.
Open and loose contacts: leads to food impaction and possible retention.
Overhanging margins of restorations and improperly designed prostheses: can contribute to the initiation of periodontal disease. There is a direct correlation between surface roughness or mariginal irregularities of a restoration and the retention of plaque.
Soft or sticky consistency of diet: food debris tends to collect between the teeth and along the gingiva
and can be a prominent cause of inflammation.
Violation of the "biologic width": if margins of a restoration infringe on the biologic width (junctional epithelium and connective tissue attachement), gingival inflammation, pocket formation, and alveolar bone loss may occur.. Note: The average biologic width is approximately 2 mm (approximately 0.97 mm
for the junctional epithelium and 1.07 mm for the connective tissue attachment).
Occlusal trauma
Orthodontic therapy: has been shown to increase plaque retention and to result in increases in the numbers of P. melaninogenica, P. intermedia, and A. odontolyticus.
ging/pdl dis
Conditions in which the influences of periodontal infection are documented
include the following.
Select all that apply.
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ging/pdl dis
PMNs are the predominant immune cells in which stage of gingivitis?
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Notes
1. The relationship between diabetes mellitus and periodontal disease has been extensively examd . It is clear that diabetes increases the risk for and severity of periodontal diseases. The increased prevalence and severity of periodontitis typically seen in patients with diabetes, especially
those with poor metabolic control, led to the designation of periodontal disease as the "sixth complication of diabetes." The others are retinopathy, nephropathy, meuropathy, magtovascular disease, and altered wound healing.
2. When considering factors that increase an individual's risk for developing periodontitis, it has
been recognized that genetic, environmental (e.g., tobacco use), and acquired risks factors (e.g.,
systemic disease) can increase a patient's susceptibility to developing this disease. Risk factors
can affect onset, rate of progression, and severity of periodontal disease, as well as response to therapy.
me
Neutrophils, or polymorphonuclear leukocytes (PMNs), predominate in the early stages of gingival inflammation, and these cells phagocytose and kill plaque bacteria. Bacterial killing by PMNs involves both intracellular mechanisms (after phagocytosis of bacteria within membrane-bound structures inside the cell) and
extracellular mechanisms (by release ofPMN enzymes and oxygen radicals outside the cell). These enzymes
include the MMPs (matrix metalloproteinases), such as collagenases (MMPS and MMP-1), which break down
collagen fibers in the gingival and peridontal tissues. Note: Oxygen radicals (superoxide and hydrogen peroxide) produced by PMNs and macrophages are toxic as well to cells of the periodontium having a direct effect on cell functions and DNA.
Stages of Gingivitis
Stage
Junctional and
Sulcular Epithelia
Predominant Collagen
Immune Cells
I. Initial
lesion
2-4
II. Early
lesion
4-7
Vascular
Proliferation
III. Established
lesion
14-21
Same as stage I
Rete pegs
Atrophic areas
Clinical
Findings
Perivascular Gingival
loss
fluid flow
Lymphocytes
Increased
loss around
infiltrate
Erythema
Bleeding on
probing
Plasma cells
Continued
loss
Changes in
color, size,
texture, etc.
Stage IV Gingivitis The advanced lesion: extension of the lesion into alveolar bone characterizes a fourth
stage known as the advanced lesion or phase of periodontal breakdown. Microscopically, there is fibrosis of
the gingiva and widespread manifestations of inflammatory and immunopathologic tissue damage. In general
at this advanced stage, plasma cells continue to dominate the connective tissues, and neutrophils continue to
dominate the junctional epithelium and gingival crevice.
Note: Abnormalities in neutrophil function found in patients with neutropenia, agranulocytosis, Chediak-Higashi syndrome, Papillon-Lefevre syndrome, leukocyte adhesion deficiency type 1 (LAD-1), and leukocyte
adhesion deficiency type 2 (LAD-2) make the patient more susceptible to aggressive periodontitis.
Remember: The four stages of the periodontal lesion are: initial, early, established, and advanced.
ging/pdl dis
The frequency of maintenance visits for a patient who has had previous
periodontal treatment should depend on which two factors?
on whether or not the patient feels that frequent visits will help maintain his/her
periodontium
on the appearance and clinical condition of the gingival tissues
on the amount of attachment loss prior to the periodontal treatment
on the patient's ability to perform in-home-care
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open-tray impression
closed-tray impression
either of the above
neither of the above
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on the appearance and clinical condition of the gingival tissues this will determine
if the patient is maintaining adequate plaque control
on the patient's ability to perform in-home-care this will determine the effectiveness of the patient's oral hygiene
The main goal of the dentist, dental hygienist, and patient is the maintenance of good oral health. This
will prevent the recurrence of disease, which is the main objective of the maintenance phase of periodontal therapy. The primary cause of recurrence of disease is the dental team's failure to motivate the
patient to practice effective plaque control.
The first year after treatment is a critical period, since the patient has already demonstrated susceptibility to periodontal disease, the cause of which tends to be persistent and recurrent. The appearance and
condition of the gingival tissues will determine if the patient is maintaining adequate plaque control.
_ 1. Bleeding during circumferential probing indicates that the crevicular epithelium is ulcerNotes a t e d due to active periodontal disease.
2. After periodontal treatment, the first recall visit should be scheduled at Joapnths. With excellent plaque control and maintenance of periodontal health, the interval may be lengthened
to 4 to 6 months.
IMHLII 1111 " I ' l W i . J U I J I n . l . i i i l l M . nt
Remember:
1. Puberty is often accompanied by an exaggerated response of the gingiva to plaque. Gonadotropic
hormones during puberty may lead to increased levels of P. intermedia and. Capnocytophaga species
in the dental plaque.
2. As a general rule, the menstrual cycle is not accompanied by notable gingival changes, however,
increased gingival bleeding is often seen during this time.
3. Hormonal contraceptives aggravate the gingival response to local factors similar to that seen in
pregnancy.
4. Oral disturbances are not a common feature of menopause. Some females may develop gingivostomatitis.
5. Patients with blood dyscrasias (i.e., leukemia, anemia, neutropenia, agranulocytosis, thrombocytopenia purpura, etc.) often demonstrate disturbances to the gingiva and periodontium.
closed-tray impression
A closed tray impression refers to the impression being made in a tray with no access hole
cut over the implant, and with an impression coping in place in the mouth attached directly
to the implant or abutment. When the impression tray and impression material are removed from the mouth after setting, the impression coping remains in the mouth, still attached to the implant or abutment. The coping (also called the impression post) is
removed from the mouth, joined to an implant analogue (also called an implant replica),
and the analogue and impression coping are inserted back into the set impression material before the cast is poured. This is also called an indirect transfer impression technique.
When making a pick-up impression, the impression coping is already attached to the abutment by a retaining screw when the impression tray and impression material are placed
into the mouth. After the impression material has set, the retaining screw is released (unscrewed) through a hole in the tray, and the impression coping is freed from the implant.
When the tray is removed from the mouth, the impression coping remains in the impression material. This technique is also called an open top tray pick-up impression.
A pick-up impression may be used with divergent implants.
The master impression should accurately relate the implants and/or abutments to each
other, the opposing occlusion, and adjacent teeth. For the impression to be accurate, all of
the components must be properly seated at the time of the impression. Verification of the
proper seating ("down ") of the abutments is difficult if the junction or the impression
coping-to-implant interface is subgingival. Radiographic verification of seating is required
before the impression is made.
implants
An "implant level impression" means that:
* the impression coping (or impression post) was attached to the implant
the impression coping was attached to the abutment
the impression captured or recorded the actual abutment attached to the implant
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implants
Which of the following is NOT an advantage of retaining an implant-supported crown to an abutment with a screw (rather than with cement)!
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the impression coping (or impression post) was attached to the implant
The impression coping (or impression post) was attached to the implant at the time of the
impression, thus recording the implant position at the "implant level." If the impression
coping was instead attached to the abutment (which was attached to the implant), the impression is termed an "abutment level impression."
If the impression is made of the already seated abutment without the use of an impression
coping, just as a standard crown and bridge impression of a prepared abutment, it is a direct impression of the abutment.
implants
In implantology, "countersinking" refers to the process of:
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implants
The purpose of the second-stage surgery in the creation of an implant restoration is to:
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implants
The"macro design"of implants describes:
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implants
The soft tissue interface between the oral tissue and titanium can be?
Select all that apply.
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N>
When considering probing depths around implants and the associated attachment level, what landmark is used to determine the"clinical"attachment
level?
CEJ
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implants
The advantage of using a screw- -shaped irr iplant instead of a straight cylinder
implant without threads is:
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implants
Which of the following occlusal conditions would exert the lowest amount of
biting force under normal conditions?
PERIODONTICS
implants
If the implant-to-abutment interface consists of a permanent extension on
the top of an implant and a receptacle inside the abutment, the implant connection is categorized as:
an internal connection
an external connection
a cone in a socket connection
a nonengaging connection
a rotational element
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an external connection
The junction of the abutment and the implant is important from an engineering standpoint
and a biological standpoint. The restorative platform of the implant forms an interface, or
a joint with the abutment. Ttysaxea is also referred to as the microgap. The precision of
the fit between these components influences how much movement will occur between
these parts ajnd how well the associated screws will remain tightened over time. Precision fit,N,fnternaI or external connection, andlntirotational elements are part of this
junction and all require close manufacturing tolerances.
The closeness of the fit of the components plays a significant role in how much bacterial contamination occurs at the interface. The term "microgap" emphasizes the space between the components and the space available for bacterial growth and the resultant
inflammation at the location. Achieving a precise fit of these parts is unlikely if the abutment is cast in the laboratory rather than milled by the manufacturer. Minimizing bacterial contamination at this site influences how stable the bone will remain over time.
J h e healing reaction of thejbone surrounding the mierogap is determined by the
Tnacrostructure of the implant~me precision of the fit, ancnhe location of the microgap.
Bone remodels and adapts to different configurations and locations of the interface during the first year after placement of a restoration, and a characteristic bony shape is established by that time. Following that time of initial bone remodeling, a very small
amount of bone loss should then be noticeable over time, approximately 0.02 mm per
year.
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implants
Osseointegration can fail due to:
occlusal overload
bacterial plaque
micromotion during healing
excessive cantilevering of the prosthesis
all of the above
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\
-.-.
*4
**i
*%
'%
implants
"Antirotational" element is added to an implant to:
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implants
"Site development" for implants includes the following techniques.
Select all that apply.
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%L\.
^V^
ie regenere
guided tissue
regeneration
socket grafting
bone grafting with cow bone
orthodontic tooth movement
Bisphosphonates (e.g., alendronate) are used to treat osteoporosis and cancer. Bisphosphonate therapy, especially a history of IV bisphosphonate therapy, is one of the few absolute contraindications for implant placement. BONJ, or bone osteonecrosis of the jaw,
is a serious complication and is difficult to manage successfully. It can occur following
dental surgery such as extractions and dental implant placement.
Guided tissue regeneration techniques have been adapted for bone augmentation in edentulous areas, and the technique has become guided bone regeneration. Several bone
graft materials and combinations of these materials are used in this procedure and are
often covered with a protective "membrane." Bovine (cow) bone processed as a particulate graft material is commonly used for oral bone grafting applications, including ridge
augmentation and maxillary sinus augmentation or sinus "lifts." The bovine bone is classified as a xenograft, or bone that is transplanted to the recipient from a member of another species. It can be combined with an autograft (or autogenous bone) from the
recipient patient, or combined with bone from another human being (an allograft), or
combined with a fabricated bone graft substitute material such as tricalcium phosphate or
hydroxyapatite, which are forms of alloplasts.
Other site development techniques include orthodontic tooth movement to create space for
implants. The tooth movement could include orthodontic extrusion of teeth to bring bone
volume occlusally with the tooth, and thus increase bone volume at the site of the planned
implant placement.
implants
The hole that is surgically created in the bone to receive the implant body is
called the:
osteotomy
bone channel
smokestack
callus core
chimney
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implants
should be exposed and interpreted at which of the following
A radiograph
radio
points during implant placement and restoration:
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osteotomy
The osteotomy is prepared with precision to make it the prescribed size that is appropriate for the implant being used. If the osteotomy is too small, either in width or length, the
implant may not go to depth or seat completely to the desired level in the bone. The overall implant shape (macrostructure) and the bone "quality" at any site dictate how the osteotomy must be prepared. If the bone is very dense and a screw-shaped implant is being
used, the osteotomy may be "tapped" meaning that screw threads are created on the walls
of the osteotomy to receive the screw threads on the implant. AJrill designed as a "thread
tap" is used for this purpose. Many implants are designed to be "self-tapping," meaning
that tapping of the bone as a separate step is not necessary because the threads of the implant are designed to engage the bone and guide the implant forward.
If the osteotomy is too large for the implant diameter, or if the osteotomy is overprepared
or poorly prepared, the implant will lack primary stability, an unacceptable result that
will cause osseointegration to fail.
implants
The most common source of patient dissatisfaction with implants is:
pain
appearance
mobility
loss of osseointegration
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implants
Which of the following was/were included in the 1986 Albrektsson et al criteria for functional implant success?
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appearance
Implants have become very predictable and successful from a functional standpoint, and
failure of implants due to loss of osseointegration is not common. Satisfying patient expectations of esthetic outcomes is a most difficult aspect of implant treatment since
restoration of bone, gingival contours, and papillae is sometimes not possible. Absence of
a papilla between adjacent implants is a common problem, and for this reason, it may be
advantageous to avoid placing adjacent implants, if possible.
Note: "Black triangle disease" refers to an absence of one or more papillae, which creates an esthetic concern.
CXo
"'
implants
"Direct structural and functional <:onnecti<>n between ordered, living bone
and the surface of a load-carrying implant" is the definition of:
a cold weld
ankylosis
osseointegration
metal callous formation
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true
false
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osseointegration
Osseointegration means direct bone-to-implant contact with no intervening periodontal
ligament or any other tissue. There is no insertion of connective tissue fibers into tita-'
nium, meaning there cannot be a functional periodontal ligament. Connective tissue presence around an implant means failure of osseointegration and implant failure. Epithelium
does attach to titanium via a "junctional epithelium" structure comprised of hemidesmosomes and a basal lamina. Titanium is usually covered by an oxide (Ti02) that is biologically inert and prevents host tissue access directly to titanium itself and allows
osseointegration.
At the light microscopy level, there is an intimate association of bone to the titanium.
Within a few weeks of placement of the implant, woven bone is laid down at the boneimplant interface. Wav.rxJbone is characterized by a very random orientation of its collagen fibrils, and it is the first bone to be established on the implant. Within a few more
weeks, the woven bone becomes lamellar bone. The conversion to lamellar bone is thought
to be encouraged by the presence of functional forces placed on the implant to stimulate
the bone. Roughened implant surfaces, such as those created by sandblasting and acid
etching, etc., encourage and accelerate the bone formation at the titanium surface.
true
Implants are essentially ankylosed structures and do not erupt or move physiologically
within bone. If the growth of the individual has not been completed, the original positioning of the implant in the jaws may become increasingly unfavorable due to changed
shape or size of the surrounding tissues. Early successful esthetic outcomes can be lost.
The implant may also prevent normal development of the jaws.
implants
The highest rate of implant failure occurs in:
type 1 bone
type 2 bone
type 3 bone
type 4 bone
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implants
In patients with normal bone and normal healing capabilities, one should anticipate dental implant success rates of:
35%
50% to 60%
74%
90% to 95%
100%
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type 4 bone
?one quality is categorized according to its cortical plate thickness and cancellous/trabecular density. The thicker the cortical plate and the higher the cancellou!lIensnEy7me
hig^eTffie"quaTity of the bone in terms of implant stability and support. Type 1 bone is the
best quality and most suitable for retention of implants.
Type I bone occurs in the anterior mandible, for example, where the bone is mostly cortical bone. Type 2 bone is a thick layer of cortical bone and the cancellous bone core is
most dense. Type 3 bone is composed of a thin layer of cortical bone surrounding a dense
core of cancellous bone. Type 4 bone is characteristic of the posterior maxilla and has a
typically thin cortical plate and low density cancellous bone core, and thus is the least
well suited to promoting osseointegration and supporting occlusal loads.
The risk of implant failure is higher than normal in:
N^Cigarette smokers
VPoorer "quality" bone
s*The maxilla than in the mandible
^^Individuals with uncontrolled diabetes
Risk factors for implant failure or complications include metabolic diseases that can influence systemic healing.sJJticontrolled diabetes is one of these conditions as are bone
metabolic diseases.^hjstory of head and neck radiation therapy, and^paunosuppressive
medications. Implant failures are recognized to be more frequent in smokers. Failure rates
are highest where the bone is of the poorest quality, such as D4 bone quality bone in the
posterior maxilla.
90% to 9 5 %
In patients with normal healing capabilities, especially good bone healing capabilities, and
sufficient bone of good quality, implant success rates are often quoted in the range of 90% to
95%.
Diminished healing capacity would possibly be encountered in patients with uncontrolled or
poorly controlled diabetes mellitus, immunocompromised states, radiation treatments, and
chemotherapy. Patients with well-controlled diabetes do not have compromised implant outcomes. Patients with a diminished capacity for fighting infection could be expected to experience problems with oral surgical procedures, including implants.
Smoking is not a contraindication for the placement of dental implants, however, failure
rates are higher in smokers. The failure rate is related to the amount of smoking on a daily
basis and the pack/years history for the patient.
Remember: Implants should not be considered for children who are still experiencing growth.
Note: Implant failures are generally considered to be "early," meaning soon after surgical
placement and before prosthetic loading, or "late," meaning after an extended period of time
following placement of the prosthetic restoration on the implant. Early failures are related to
sujgical, trauma and/or ipaplant instability at the time of placement. Late failures are most often
related to microbial plaque accumulation equivalent to periodontal disease and/or to excessive
occlusal forces.
"Periimplant mucositis" denotes inflammation of the soft tissues surrounding the implant but
wWE"f5crlWrW,bMle"''e^eriimpIantitisj' refers to this inflammation but with accompanying
loss of implant-supporting bone. Both conditions require treatment.
implants
Implants are useful for orthodontic anchorage because implants:
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implants
The greatest esthetic challenge for the restorative dentist occurs in the
patient having a:
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implants
The "anterior loop" is descriptive of the:
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implants
Assessment of the potential implant patient should include:
PERIODONTICS
' course of the inferior alveolar nerve anterior to the mental foramen
When treatment planning mandibular implant locations, the possibility that the inferior
alveolar nerve courses anterior to the mental foramen by as much as 4 mm before looping back distally to exit through the mental foramen must be considered. If imaging data
does not clearly identify the canal of the inferior alveolar nerve as it approaches the mental foramen, the implant location should be planned to be at least 5 mm or more anterior
to the foramen.
The inferior alveolar nerve also courses from lingual to buccal as it moves anteriorly.
When planning implant position, the osteotomy preparation should be planned to end a
minimum of 2 mm vertically away from the mandibular canal, and 2mm away from any
other vital structure.
implants
The "anterior loop" is descriptive of the:
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implants
Assessment of the potential implant patient should include:
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implants
Where should the healing abutment be placed at the stage II (uncovering) sur
gery for a two-piece implant system?
Select all that apply.
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implants
At the conclusion of surgical placement of a titanium implant, complete soft
tissue coverage of the implant is required for successful osseointegration to
occur.
true
false
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This concept was adhered to in the early techniques for surgical placement of two-piece
(or two-stage, or "submerged") implant systems. Two-piece systems typically involve
initial osseous placement of the implant and coverage with primary closure of the gingival flaps.
Current surgical placement techniques for two-piece systems also include leaving the attached abutment exposed to the oral cavity at the time of implant placement. One-piece
systems (also called one-stage or nonsubmerged systems) are typically placed with the implant exposed to the oral cavity, also called "transgingival" placement.
IIIIIIIIIII m i ..ijij.uiiwuj.il n ""' inww nm i J U M J J I I J I J J
implants
The clinical examination of osseointegrated dental implants should include:
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implants
Cross-sectional imaging is produced by all of the following EXCEPT one.
Which one is the EXCEPTION!
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Tissue observation around implants is based on many of the same parameters that are
used when assessing natural teeth. Bleeding on probing or absence of bleeding on probing are useful indicators of inflammation. Purulence, edema, erythema, and loss of attachment can be used to assess soft tissue health. Probing depths are generally deeper
than around teeth and can be difficult, to interpret due to surgical variability. Deeper probing depths tend to harbor a more pathogenic flora. Probing depths can be difficult to measure due to the size and access limitations of implant restorations. Changes in attachment
level around an implant are useful in recognizing progression of periimplantitis.
Remember: The term "relative attachment level' is used when the attachment is calculated from a landmark beside the CEJ.
Important: The use of plastic probes has been widely recommended to avoid scratching of titanium components.
panoramic radiography
Cone beam computed tomography (CBCT) is a 3-dimensional imaging modality that produces digital
data that can be reformatted to produce multiple cross-sectional slices and other views of the jaws. CBCT
exposes the patient to a relatively low dose of radiation when compared to medical-grade CT. "Cat Scan"
refers to CT. Conventional linear tomography utilizes a radiation source and an x-ray film which rotate
in tandem around a single point to produce a cross-sectional view left over after everything else is blurred
out in the image. Image quality of linear tomography is of significantly lower quality than CBCT.
Advantages
High resolution and detail, easy
acquisition, low exposure,
inexpensive
Disadvantages
Unpredictable magnification, small imaged area, 2D
representation of anatomy
Lateral cephalometric
radiography
..Conventional
3D representation, predictable
magnification, sufficient detail,
low exposure, images area of interest only
VComputed tomography
(CT)
3D representation, predictable
magnification, sufficient detail,
digital format, images whole arch
3D representation, predictable
Requires special equipment, expensive, images whole
magnification, sufficient detail,
arch
digital format, images whole arch,
low dose
tomography
tomography (CBCT)
implants
Of the following factors, which determine(s) the abutment that the restorative
dentist should select?
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implants
Which of the following dimensions is not part of routinely recommended
space requirements for root form implants?
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implants
A "polished collar," or the smooth polished exterior surface of the implant
closest to or in the oral cavity, is designed to:
":: :
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implants
A "Morse taper" is one of many designs for:
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implants
Which of the following is NOT acceptable for cleaning of titanium surfaces,
either by the patient or the dental clinician?
powered toothbrushes
end-tufted brushes
plastic curettes
conventional ultrasonic tips
floss, especially multifilament varieties
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implants
If the space available for the abutment and the crown is limited vertically, i.e.,
a small interarch space, which of the following abutment combinations would
be least advantageous:
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^<m
This combination would take up the greatest amount of space vertically due to the requirements for adequate abutment length needed to provide retention for the cemented surfaces Screw-retained combinations can be shorter and take up less space, the same being
true for restorations designed to fit directly to the implant with no intervening abutment.
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implants
Which of the following conditions is not a contraindication to dental implant
placement?
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infl
Which cells control all three stages of inflammation?
plasma cells
red blood cells
leukocytes
Sertoli cells
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implants
If two adjacent implants are surgically placed too close together:
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Inflammation is an observable alteration in tissues associated with changes in vascular permeability and dilation, often with the infiltration of leukocytes into affected tissues. These
changes result in erythema, edema, heat, pain, and loss of function that are the "cardinal
signs" of inflammation.
Typical inflammation can progress through three stages:
Immediate
Acute
*** Leukocytes, the white blood cells, control all three stages
Chronic
Leukocytes originate in the bone marrow and exit from the blood by transendothelial migration under normal conditions, accounting for the resident leukocytes found in tissues. Among
the most important resident leukocytes are mast cells, peripheral dendritic cells, and monocyte
derivatives such as dermal dendrocytes (histiocytes). These resident leukocytes transmit information that initiates the process of immediate inflammation.
Immediate inflammation is followed within minutes by a short-lived period (up to several
hours) of acute inflammation that is characterized by an influx of neutrophils to the area after
they exit the blood. If the problem is not resolved, acute inflammation gives way to a potentially unending period of chronic inflammation dominated by the migration of lymphocytes
and macrophages to the local tissues.
Note: Cells of the immune system that are important in inflammation and host defenses include
mast cells, dermal dendrocytes (histiocytes), peripheral dendritic cells, neutrophils, monocytes/macrophages, T cells, B cells, plasma cells, and natural killer (NK) cells.
Remember: Mast cells, dendritic cells, neutrophils, and monocytes/macrophages are considered to be cells of the innate immune response (from birth). Lymphocytes (T cells, B cells, and
plasma cells) are considered to be part of the specific immune response and develop antigenspecific responses throughout life.
infl
Which cells of the immune system possess receptors for the complement
component C3a, by which they participate in immediate inflammation?
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infl
Initially, the first group of cells to arrive at the site of injury are neutrophils.
Later,
become more numerous. In certain parasitic infections,
rather than neutrophils
predominate. In viral infection,
usually predominate.
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infl
. has emerged as a unique immune cell that could be activated
The
by many nonimmune processes, including acute stress, and could participate
in a variety of inflammatory diseases in the nervous system, skin, joints, as
well as cardiopulmonary, intestinal, and urinary systems.
neutrophil
epithelioid cell
mast cell
eosinophil
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infl
The main cells involved in chronic infection are lymphocytes and:
plasma cells
mast cells
neutrophils
macrophages
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mast cell
Mast cells originate from pluripotent cells. The mast cells enter the bloodstream, migrate
throughout the body, and mature. They frequently locate at perivascular sites in tissues,
such as the lungs, where they interact with the external environment.
Mast cells become activated when surface receptor-bound antigen-specific immunoglobulin E (IgE) encounters an antigen that the IgE recognizes. This triggers mast cell degranulation, leading to the rapid release of inflammatory mediators, such as^JjUtamine,
jjpeteoglycans, andcjrtokines. Mast cell activation also stimulates the arrival of other inflammatory cells a critical step in local inflammation.
Mast cells are not only necessary for allergic reactions, but recent findings indicate that
they are also involved in a variety of neuroinflammatory diseases, especially those worsened by stress. In these cases, mast cells appear to be activated through their Fc receptors
by immunoglobulins other than IgE, as well as by anaphylatoxins, neuropeptides, and cytokines to secrete mediators selectively without overt degranulation.
Notcs
1. The mast cell content in human gingiva is high. The mast cell content of inflamed gingiva increases as the severity of inflammation increases.
2. Remember:The anaphylactic response is characterized by the degranulation
of mast cells as a result of antigen-antibody complexes affixed to cell surfaces.
macrophages
Inflammation that has a slow onset and persists for weeks or more is classified as being chronic. The
symptoms are not as severe as with acute inflammation, but the condition is insidious and persistent. The
main cells involved in chronic infection are macrophages and lymphocytes. With the aid of chemical
mediators, such as lymphokines, macrophages do an excellent job of engulfing and neutralizing or killing
foreign antigens. Lymphocytes are the predominant cell in chronic inflammation. Note: Macrophages
and lymphocytes are interdependent in that the activation of one stimulates the actions of the other.
Chronic inflammation:
Lymphocyte, macrophage, and plasma cell infiltration
Tissue destruction by inflammatory cells
Attempts at repair with fibrosis and angiogenesis (new vessel formation)
When acute phase cannot be resolved
- Persistent injury or infection (ulcer, TB)
- Prolonged toxic agent exposure (silica)
- Autoimmune disease states (RA, SLE)
Macrophages
Scattered all over (microglia, Kupffer cells, sinus histiocytes, alveolar macrophages, etc.)
Circulate as monocytes and reach site of injury within 24 to 48 hrs and transform
Become activated by T cell-derived cytokines, endotoxins, and other products of inflammation
T and B lymphocytes
Antigen-activated (via macrophages and dendritic cells)
Release macrophage-activating cytokines (in turn, macrophages release lymphocyte-activating
cytokines until inflammatory stimulus is removed)
Plasma cells
Terminally differentiated B cells
Produce antibodies
Eosinophils
Found especially at sites of parasitic infection or at allergic (IgE-mediated) sites
misc.
Which one of the following will increase the abrasive action of a polishing
agent?
Select all that apply.
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misc.
The purposes of periodontal dressings (packs) include all of the following:
2&C&{Jt ->
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ls otes
1. When selecting a polishing agent to remove generalized staining, consider the foilowing: tooth sensitivity, type of stain present, type of restorations present, and the
condition of the tooth surface. *** Not all surfaces should be polished.
2. Flexing the polishing cup into proximal areas increases its effectiveness.
misc.
Microorganisms that colonize the periodontal abscess have been reported to
be primarily:
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misc.
Gingival fibers consist of:
type 1 collagen
type II collagen
type III collagen
type IV collagen
ft
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iiim
, I, n
, u,-
^ i IIMHM
Mrammmit
As with a periodontal pocket, the chronic abscess is usually treated with scaling and root planing or surgical therapy.
The radiographic findings associated with this abscess are not specific. There may be no change radiographically in the early
acute lesion. However, often in a chronic abscess, there will be a localized discrete radiolucency lateral to the root or in a
furcation. Note: It can cause rapid alveolar bone destruction.
Note: Microscopically, an abscess is a localized accumulation of PMNs within the periodontal pocket wall. The
PMNs liberate enzymes that digest the cells and other tissue structures, forming the liquid product known as pus (exudate).
type I collagen
Notes
1. The connective tissue of the marginal gingiva is densely collagenous, containing a prominent system of collagen fiber bundles called the gingival fibers.
2. The gingival fbers are arranged in three groups: gingivodental, circular, and
transseptal.
3. The type I collagen of gingiva, however, is not the same biochemically as
found in other parts of the body, including the skin.
4. The collagen turnover in normal gingiva is not as rapid as in the periodontal ligament but significantly greater than in other tissues, such as the skin, tendons, and the palate.
5. The major components of the gingival connective tissue are collagen fibers
(about 60% by volume), fibroblasts (5%), vessels, nerves, and matrix (about
35%).
6. The three types of connective tissue fibers arexollagen,^reticular, anaplastic.
7. Collagen type I forms the bulk of the lamina propria and provides the tensile
strength to the gingival tissues.,,
8. Type IY... collagen (argyrpphilic reticulum fiber) branches between the collagen type I bundles and is continuous with fibers of the basement membrane and
blood vessel walls.
9. The elastic fiber system is composed of^ytalan, ejaunin, and elastin fibers
distributed among collagen fibers.
Remember: YiJgjnjnC is needed for hydroxylation oforoline and lysine essential for
collagen formation.
misc.
All of the following are contraindications to selective grinding in the natural
dentition EXCEPT one. Which one is the EXCEPTION!
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misc.
All of the following are clinical signs of bruxism EXCEPT one. Whichone is the
EXCEPTION!
TMJ symptoms
muscle soreness
periodontal pocket formation
cracked teeth or fillings
wear facets on teeth
widened PDL spaces on radiographs
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misc.
Which of the following statements regarding the assessment of tooth
mobility is false?
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misc.
Which of the following is not correctly matched with regards to a periodontal
treatment plan?
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Phase I
Reevaluatlon
misc.
Cellular cementum (contrasted with acellular cementum) is:
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misc.
All of the following statements concerning B cells are true EXCEPT one
Which one is the EXCEPTION!
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misc.
When trauma from occlusion results from reduced ability of the tissues to
resist the occlusal forces, it is known as:
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misc.
Which of the following is true of cementum?
Select all that apply.
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misc.
The most common indication to splint mobile teeth is to:
improve patient comfort and to provide better control of the occlusion if the anterior
teeth are mobile
improve oral hygiene
prevent a natural unopposed tooth from migrating
> prevent maxillary central incisors from separating after closure of diastema
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misc.
In combined endodontic-periodontic lesions, it is generally wise to treat:
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improve patient comfort and to provide better control of the occlusion if the anterior teeth are mobile
Splinting therapy may be applied with bonded external appliances, intracoronal appliances, or indirect cast restorations to connect multiple teeth, with the goal of improving tooth stability. Unstable teeth may be caused by a lack of periodontal support from bone loss, a lack of support from tooth
loss, or the need to splint abutment teeth to support pontics.
There is no reason for splinting nonmobile teeth as a preventive measure. Splinting is only one
measure used in the treatment of periodontal disease. Splinting should be used with other necessary measures, such as root planing, oral hygiene instructions, pocket elimination, and occlusal adjustment. Loose teeth splinted to adjacent teeth may become stabilized. When many teeth are
loose, adjacent sextants should be included in the splint. Teeth tend to loosen buccolinguallv yet may
remain firm mesiodistally. Even when teeth do not tighten, the splint serves as an orthopedic brace
that permits useful function of loose teeth. A variety of means may be utilized to achieve temporary stabilization. Whatever means are used, special attention should be paid to making the splint
amenable to oral hygiene procedures and instructing the patient on plaque control around the splint.
Notes
1. Indications for splinting are (1) mobility of teeth that is increasing or that impairs pacomfort, (2) migration of teeth, or (3) prosthetics where multiple abutments are
necessary.
2. Before considering splinting, the clinician must identify the etiology of the instability. Any inflammation of the periodontal supporting apparatus must be controlled before
making a decision on splinting because inflammation can produce mobility in the presence of normal occlusal forces and normal periodontal support.
3. Adequate crown length on the teeth being splinted is critical so that the interproximal
connectors do not impinge on the interdental papilla.
4. Adequate space must exist between the connector and the papilla for access with dental floss anteriorly and with an interproximal brush on posterior teeth.
tient
In patients with a dental abscess, the differential diagnosis between periodontal and endodontic origin can usually be established by the history, clinical examination, and radiographs. The true combined lesion results from the development and extension of an
endodontic lesion into an existing periodontal lesion (pocket)/Ttie pain from the loss of
pulpal vitality is the most common presenting complaint of patients with combined lesions. The "symptoms reported are those most often found with pulpal disease. Thermal
pulptesting provides information relative to the status of the pulp, and dental radiographs
can confirm the presence of apical changes and the extent of bone loss. Careful probing
confirms the presence and morphology of any periodontal pocket and permits location of
the communication with the apical lesion.
In combined endodontic-periodontic lesions, it is generally wise to treat the endodontic component first, because in many cases, this will lead to complete resolution of the
problem.
After successful endodontic treatment, the residual periodontal pocket that remains can
be more predictably treated. The periodontal therapeutic objectives vary with the extent
and configuration of the residual periodontal lesion.
Important: The long-term prognosis for a tooth with a combined lesion is closely related
to the extent and configuration of the periodontal attachment loss. With advanced horizontal bone loss, even an optimal endodontic result may not be sufficient to retain the
tooth. If the periodontal lesion is an advanced, multiwalled vertical defect, the success of
therapy likely depends on the ability to fill or regenerate attachment to obliterate the defect.
misc.
Trauma from occlusion can produce radiographically detectable changes in all
of the following EXCEPT one. Which one is the EXCEPTION!
lamina dura
' periodontal pockets
width of the PDL space
morphology of the alveolar crest
> density of the surrounding cancellous bone
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misc.
Extrinsic dental stains include:
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jeriodontal pockets
*** Periodontal pockets are not caused by occlusal trauma. A local irritant and inflammation are necessary to cause apical shift of the epithelial attachment.
The most common clinical sign of occlusal trauma is'tooth mobility. Other clinical signs
of occlusal trauma include^migration of teeth and the Itenderness of teeth to percussion.
Traumatic lesions manifest more clearly in the faciolingual aspects because, mesiodistally, the tooth has the added stability provided by the contact areas with adjacent teeth.
Radiographic signs of trauma from occlusion:
Widening of the periodontal ligament space
Thickening of the lamina dura
Angular bone loss and infrabony pocket formation
Root resorption
Hypercementosis
Note: Trauma from occlusion is reversible, that is, the body can repair the damage if
the excessive occlusal forces are eliminated.
Other findings associated with excessive occlusal forces:
Alternating areas of resorption and repair of the alveolar bone
Fibrosis of the alveolar bone marrow spaces
Cemental resorption leading to dentinal resorption
Cemental tears
Possible ankylosis
Occasional pulpal necrosis and calcification
Radiographic changes that may be seen on teeth that are no longer in function:
Reduced trabeculation of bone
Narrowing of the periodontal ligament space
oh
Abrasives:
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misc.
Water irrigation devices (oralirrigators) have beeni shown to:
eliminate plaque
clean nonadherent bacteria and debris from the oral cavity more effectively than
toothbrushes and mouth rinses
disinfect pockets for up to 12 hours
prevent calculus formation
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clean nonadherent bacteria and debris from the oral cavity more
effectively than toothbrushes and mouth rinses
Oral irrigators for daily home use by patients work by directing a high-pressure, steady
or pulsating stream of water through a nozzle to the tooth surfaces. Most often, a device
with a built-in pump generates the pressure. Oral irrigators clean nonadherent bacteria
and debris from the oral cavity more effectively than toothbrushes and mouth rinses.
When used as adjuncts to toothbrushing, these devices can have a beneficial effect on
periodontal health by reducing the accumulation of plaque and calculus and decreasing
inflammation and pocket depth.
Oral irrigation has been shown to disrupt and detoxify subgingival plaque and can be useful in delivering antimicrobial agents into periodontal pockets. Note: Daily supragingival
irrigation with a dilute antiseptic, chlorhexidine, for 6 months resulted in significant reductions in bleeding and gingivitis compared with water irrigation and chlorhexidine rinse
controls. Irrigation with water alone also reduced gingivitis significantly, but not as much
as the dilute chlorhexidine.
Important: Oral irrigators may be contraindicated in patients requiring antibiotic premedication prior to dental treatment since these devices have the potential for causing a
bacteremia. The patient's physician should be consulted.
Remember: The pathology associated with gingivitis is completely reversible with the
removal of plaque and the resolution of the inflammation.
oh
The effectiveness of toothbrushing is best measured by:
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oh
Which component of Super Floss" is most effective in cleaning around appliances and between wide spaces?
stiffened end
spongy floss
regular floss
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spongy floss
Super Floss is ideal for cleaning braces, bridges, and wide gaps between teeth. Its
three unique components - a stiffened end, spongy floss, and regular floss - all work
together for maximum benefits.
Three components:
Stiff-end threader so you can floss under appliances
Spongy floss cleans around appliances and between wide spaces
Regular floss removes interproximal subgingival plaque
Indications for use of Super Floss include plaque removal around the following:
-
Isolated teeth
Teeth separated by a diastema
Wide embrasures where interdental papillae have been lost
Fixed partial dentures (bridgework)
Orthodontic appliances
Implants
oh
Which of the following oral hygiene a ids is appropriate for cleaning a Class II
furcation?
stim-u-dent
interproximal brushes
interdental stimulator
perio-aid
oral irrigator
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oh
To date, the ADA has accepted two agents for treatment of gingivitis, these
are:
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r fw^erio_aidS
A tapered, round toothpick is inserted into the hole in the carrier and is then broken off.
The tip is left in and is used in a tracing motion along the gingival margins. It is also helpful in cleaning furcations that are accessible.
Stim-U-Dent (balsa wood wedges): these are of primary importance in gingiva]
igassage. They are also good for patients with interdental recession. These picks (triangular in cross section) are small enough to fit into most interdental spaces. As a supplement to brushing, they are useful for dislodging interproximal debris often missed
by meticulous brushing and for massaging the underlying interproximal gingiva.
Interproximal brushes (Proxabrush): are used for interdental cleansing when the
interdental space is wide. The brushes are replaceable.
Interdental stimulator: consists of a rubber tip of smooth or ribbed conical shape attached to a handle or to the end of a toothbrush. Its action massages and stimulates circulation of the interdental gingiva and may increase the tone of the tissue. It is not
recommended for areas in which the papillae are normal and fill the interproximal spaces.
It may cause injury to the gingival tissue.
Remember:
1. Nothing replaces brushing and flossing for removal of or disruption of plaque.
2. Frequent brushing and flossing helps to prevent calculus formation by breaking up
the matrix of plaque.
3. New plaque growth occurs shortly after brushing and flossing (starts interproximal and works its way around the tooth).
pdl/g
ie attachment apparatus is composed of all of the following EXCEPT one.
Which one is the EXCEPTION!
periodontal ligament
cementum
alveolar bone
gingiva
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10%doxycyclinegel
- * fo&\c&a&
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gingiva
The periodontium conists of the investing and supporting tissues of the tooth: gingiva,
periodontal ligament, cementum, and alveolar bone. It has been divided into two parts:
1. Gingiva: the main function of which is protecting the underlying tissues
2. Attachment apparatus: composed of the:
Periodontal ligament
Cementum
Alveolar bone
The cementum is considered a part of the periodontium because, with the bone, it serves
as the support for the fibers of the periodontal ligament.
The gingival fluid (sulcular fluid) contains components of connective tissue, epithelium,
inflammatory cells, serum, and microbial flora inhabiting the gingival margin or the sulcus (pocket). In the healthy sulcus, the amount of gingival fluid is very small. During inflammation, however, the gingival fluid flow increases, and its composition starts to
resemble that of an inflammatory exudate.
The main route of the' gingival fluid diffusion is through the basement membrane, through
the relatively wide intracellular spaces of the junctional epithelium, and then into the sulcus.
The gingival fluid is believed to:
Cleanse material from the sulcus
Contain plasm'a proteins that may improve adhesion of the epithelium to the tooth
Possess antimicrobial properties
Exert antibody activity to defend the gingiva
pdl/g
The gingival fibers are arranged in three groups. Which of the following is not
one of those groups?
circular group
gingivodental group
apical group
transseptal group
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pdl/g
Of the choices listed below, which one describes the boundaries that define
the attached gingiva?
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apical group
The connective tissue of the marginal gingiva is densely collagenous, containing a prominent system of collagen fiber bundles called the gingival fibers. They consist of type I collagen. The gingival fibers have the following functions:
1. To brace the marginal gingiva firmly against the tooth.
2. To provide the rigidity necessary to withstand the forces of mastication without being deflected away from the tooth surface.
3. To unite the free marginal gingiva with the cementum of the root and the adjacent attached gingivaThe gingival fibers are arranged in three groups:
Gingivodental group: these fibers are those on the facial, lingual, and interproximal surfaces.
They are embedded in the cementum just beneath the epithelium at the base of the gingival sulcus.
Circular group: these fibers course through the connective tissue of the marginal and interdental gingivae and encircle the tooth in ringlike fashion. They resist rotational forces.
Transseptal group: these fibers are located interproximally and form horizontal bundles that
extend between the cementum of approximating teeth into which they are embedded. They lie
in the area between the epithelium at the base of the gingival sulcus and the crest of the interdental bone. They are sometimes classified with the principal fibers of the PDL.
Notes
1. The attachment apparatus is a term used to describe these gingival fibers and the
epithelial attachment.
2. Some studies have also described two more gingival fiber groups: (1) a group of
semicircular fibers and (2) a group of transgingival fibers
3. Tractional forces in the extracellular matrix produced by fibroblasts are believed to
be the forces responsible for generating tension in the collagen. This keeps the teeth
tightly bound to each other and to the alveolar bone.
from the mucogingival junction to the free gingival groove (base of the sulcus)
In an adult, normal gingiva covers the alveolar bone and tooth root to a level just coronal to the CEI.
The gingiva is divided anatomically into marginal, attached, and interdental areas.
Marginal or unattached gingiva: is the terminal edge or border of the gingiva surrounding the
teeth in collarlike fashion. In about 50% of cases, it is demarcated from the adjacent attached gingiva by a shallow linear depression, the free gingival groove. Usually about 1 mm wide, the marginal gingiva forms the. soft tissue wall of the gingival sulcus.
Attached gingiva: is continuous with the marginal gingiva. It is firm, resilient, and tightly bound
to the underlying periosteum of alveolar bone. The facial aspect of the attached gingiva extends to
the relatively loose and movable alveolar mucosa and is demarcated by the mucogingival junction.
*** The width of the attached gingiva is an important clinical parameter. It is the distance between the mucogingival junction and the projection on the external surface of the bottom of the
gingival sulcus or the periodontal pocket. It should not be confused with the width of the keratinized gingiva because the latter also includes the marginal gingiva.
*** The width of the attached gingva on the facial aspect differs in different areas of the mouth.
It is generally greatest in the incisor region and narrower in the posterior segments.
*** Because the mucogingival junction remains stationary throughout adult life, changes in the
width of the attached gingiva are caused by modifications in the position of its coronal portion.
The width of the attached gingiva increases with age and in supraerupted teeth.
Interdental gingiva: occupies the gingival embrasure, which is the interproximal space beneath
the area of tooth contact. The interdental gingiva can be pyramidal or can have a "col" shape. The
shape of the gingiva in a given interdental space depends on the contact point between the two adjoining teeth and the presence or absence of some degree of recession.
Note: "Stippling" of the attached gingiva refers to the irregular surface texture of the attached
gingiva, similar to the surface of an orange peel. Stippling occurs at the intersection of epithelial
ridges that causes the depression and the interspersing of connective tissue papillae between these
intersections, giving rise to the small bumps.
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The principal fibers of the periodontal ligament are arranged in four groups.
The molecular configuration of collagen fibers in the periodontal ligament
provides them with a tensile strength greater than that of steel.
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Because of the high turnover rate, the connective tissue of the gingiva has a
remarkably good healing and regenerative capacity.
The reparative capacity of the gingival connective tissues is not as great as
that of the periodontal ligament or the epithelial tissue.
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Cervical line contours are closely related to the attachment of the gingiva at
the neck of the tooth. The greatest contour of the cervical lines and gingival
attachments occur on:
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*** The mesial surface of the maxillary central has the greatest curvature.
All teeth generally have a greater proximal cervical line (CEJ) curvature on the mesial
than the distal. Also, the proximal cervical line (CEJ) curvatures are greater on the incisors and tend to get smaller when moving toward the last molar, where there may be no
curvature at all.
The cementoenamel junction of all teeth curves in two directions:
Toward the apex on the facial and lingual surfaces
Away from the apex on the mesial and distal surfaces
In the absence of periodontal disease, the configuration of the crest of the interdental
alveolar septa is determined by the position of the CEJ on adjacent teeth.
The width of the interdental alveolar bone is determined by the tooth form present. Relatively flat proximal tooth surfaces call for narrow septa, whereas in the presence of an
extremely convex tooth surface, wide interdental septa with flat crests are found.
The junctional epithelium consists of a collarlike band of stratified squamous nonkeratinizing epithelium. It is three to four layers thick in early life, but the number of layers increases with age to 10 or even 20 layers. Also, the junctional epithelium tapers from its coronal
end, which may be 10 to 29 cells wide to one or two cells at its apical termination, located at
the CEJ in healthy tissue. These cells can be grouped in two strata; the basal layer facmg trie
connective tissue and the suprabasal layer extending to the tooth surface. Note: The length of
the junctional epithelium ranges from 0.25 to 1.35 mm (average is 0.97 mm).
The junctional epithelium is formed by the confluence of the oral epithelium and the reduced
enamel epithelium during tooth eruption. However, the reduced enamel epithelium is not essential for its formation; in fact, the junctional epithelium is completely restored after pocket
instrumentation or surgery, and it forms around an implant.
The junctional epithelium is attached to the tooth surface (epithelial attachment) by means of
an internal basal lamina. It is attached to the gingival connective tissue by an external basal
lamina. The internal basal lamina consists of a lamina densa (adjacent to the enamel) and a
lamina lucida to which hemidesmosomes are attached. Hemidesmosomes have a decisive
role in the firm attachment of the cells to the internal basal lamina on the tooth surface^ w
For a new attachment to form after periodontal treatment, the following must occur: ' | / \ t
1. Complete removal of calculus, altered cementum, diseased junctional epithelium, antral
pocket epithelium
2. Need undifferentiated mesenchymal cells
Important: The junctional epithelium in disease (which is referred to as a long junctional epithelium) is different from the junctional epithelium in health. In disease, migration of the
junctional epithelium occurs, along with degeneration in the connective tissue under the attachment; as the junctional epithelium proliferates along the root surface (gets longer), the
coronal portion detaches. Barrier membranes, which are often used to treat bony defects, help
to prevent this long junctional epithelium from forming.
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Which of the following types of oral mucosa is not keratinized under normal
conditions?
buccal mucosa
vermillion border of the lips
hard palate
gingiva
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The narrowest band of attached gingiva is found:
on the lingual surfaces of maxillary incisors and the facial surfaces of maxillary
first molars
on the facial surfaces of mandibular second premolars and the lingual surface of
canines
on the facial surfaces of the mandibular canine and first premolar and the lingual
surfaces adjacent to the mandibular incisors and canines
none of the above
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buccal mucosa
The three functional types of oral mucosa are lining, masticatory, and specialized mucosa. These
terms provide functional descriptions of the oral mucosa in specific locations.
Masticatory mucosa: covers the gingiva and hard palate.
- Epithelium: it has a keratinized or parakeratinized stratified squamous epithelium.
- Lamina propria: has two layers: a thick papillary layer of loose connective tissue and a deep
reticular layer of dense connective tissue.
Lining mucosa: covers all of soft tissue of the oral cavity except the gingiva, hard_rjalate, and
dorsal surface of the tongue.
- Ejplthelium: Generally, the epithelium of the lining mucosa is nonkeratinized. Qalfae^vermillipn.border of the lip, however, it is keratinized. If subject to unusual frictional stress, the
epithelium may become parakeratinized or keratinized. Other cells found in the epithelium of
the lining mucosa are Langerhans cells, melanocytes, and Merkel cells.
- Lamina propria: Under the epithelium of the lining mucosa, a loose connective tissue with
thin collagen fibers forms a papillary lamina propria that carries blood vessels, lymphatic vessels, and nerves.
- Submucosal Adistinct submucosa underlies the lining mucosa, except on the inferior of the
tongue. The submucosa contains large bands of collagen and elastic fibers that bind the mucosa
"trTtne underlying muscle. The submucosa also contains the larger nerves, blood vessels, and
lymphatic vessels that supply the neurovascular networks of the lamina propria throughout the
oral cavity. In the lips, tongue, and cheeks, the submucosa contains many minor slaivary glands.
- Specialized mucosa: is restricted to the dorsal surface of the tongue, and is characterized by
the presence of surface papillae of several types and by taste buds in the epithelium^ The epithelium is keratinized.
Important: All oral mucosa, whether keratinized, nonkeratinized, or parakeratinized, is of the
stratified squamous type of epithelium and the underlying central core of connective tissue. Although the epithelium is predominantly cellular in nature, the connective tissue is less cellular and
composed primarily of collagen fibers and ground substance.
on the facial surfaces of the mandibular canine and first premolar and
the lingual surfaces adjacent to the mandibular incisors and canines
*** Narrow gingival zones may occur also at the mesiobuccal root of maxillary first
molars, associated with prominent roots and sometimes with bony dehiscences, and at the
mandibular third molars.
The width of the attached gingiva is determined by subtracting the sulcus or pocket depth
from the total width of the gingiva (gingival margin to mucogingival line). This is done
by stretching the lip or cheek to demarcate the mucogingival line while the pocket is being
probed. The amount of attached gingiva is generally considered to be insufficient when
stretching of the lip or cheek induces movement of the free gingival margin.
The width of the attached gingva on the facial aspect differs in different areas of the mouth.
It is generally greatest in the incisor region (3.5-4.5 mm in maxilla, 3.3-3.9 mm in
mandible), and narrower in the posterior segments (1.9 mm in maxillary and 1.8 mm in
mandibular first premolars) ."*'*
Important: A "functionally adequate" zone of gingiva is defined as one that is keratinized, firmly bound to tooth and underlying bone,*about 2.0 mm or more in width, and
resistant to probing and gaping when the lip or cheek is distended.
Notes
1. The "attached" gingiva is structured to withstand frictional stresses of mastication and brushing.
2. The alveolar mucosa appears to be well adapted to permit movement but is
not able to withstand frictional stresses.
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. .
are the most common cells in the peridontal ligament and appear
as ovoid or elongated cells oriented along the principal fibers, exhibiting
pseudopodialike processes.
cementoblasts
osteoblasts
fibroblasts
macrophages
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Bone consists of:
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fibroblasts
Types of cells identified in the periodontal ligament:
Connective tissue cells fvflrjroblasts, cignientoblasts, and osteoblasts. Fibroblasts are the most
common cells; they synthesize collagen and possess the capacity to phagocytize "old" collagen
fibers. Note: Cementoclasts and osteoclasts are also seen in the cemental and osseous surfaces
of the PDL.
Epithelial rest cells: the epithelial rests of Malassez form a latticework in the PDL and are considered remnants of Hertwig root sheath, which disintegrates during root development. They are
distributed close to the cementum throughout the PDL of most teeth and are most numerous in
the apical and cervical areas.
^
^^
Defense cells: includeWrtrophils, lymphocytes, macrophages, mast cells, and eosinophils.
These cells, as well as those associated with neurovascular elements, are similar to the cells in
other connective tissues.
The functions of the periodontal ligament are categorized into:
Physical: attachment of the tooth to the bone via principal fibers and the absorption of occlusal
forces.
Formative: formation of connective tissue components by activities of connective tissue cells
(cementoblasts, fibroblasts, and osteoblasts).
Remodeling: by activities of connective tissue cells that are able to form as well as resorb cementum (cementoblasts or cementoclasts), the PDL (fibroblasts orfibroclasts),
and the alveolar bone (osteoblasts or osteoclasts).
Nutritive: through blood vessels that maintain the vitality of its various cells.
Sensory: carried by the trigeminal nerve, proprioceptive and tactile sensitivity is imparted
through PDL (sensation of contact between teeth).
Note: The PDL also contains a large proportion of ground substance, filling the spaces between the
fibers and cells. It consists of two main components: glycosaminoglycans, such as hyaluronic acid
jmd proteoglycans, and glycoproteins, such as/ibronectin and laminin. The PDL may also contain
calcified masses called cementicles, which are adherent to or detached from the root surfaces. These
develop from calcified epithelial rests.
0.002 mm
0.2 mm
2.0 mm
20 mm
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The principal fibers of the peridontal ligament are composed mainly of collagen type III.
The amount of collagen in a tissue can be determined by its glycine content.
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0.2 mm
***The periodontal space is diminished around teeth that are not in function and in
unerupted teeth, but it is increased in teeth subjected to hyperfunction.
The periodontal ligament is composed of a complex vascular and highly cellular connective tissue that surrounds the tooth root and connects it to the inner wall of the alveolar
bone. It is continuous with the connective tissue of the gingiva and communicates with
the marrow spaces through vascular channels in the bone.
The PDL is abundantly supplied with sensory nerve fibers capable of transmitting tactile,
pressure, and pain sensations by the trigeminal pathways. Nerve bundles pass into the
PDL from the periapical area and through channels from the alveolar bone that follow the
course of the blood vessels. The bundles divide into single myelinated fibers, which ultimately lose their myelin sheaths and end in one of four types of neural termination:
1. Free endings, which have a treelike configuration and carry pain sensation.
2. Ruffini-like mechanoreceptors, located primarily in the apical area.
3. Coiled Meissner corpuscles, also mechanoreceptors, found mainly in the midroot
region.
4. Spindlelike pressure and vibration endings, which are surrounded by a fibrous
capsule and located mainly in the apex.
AJ *
Note: Orthodontic treatment is possible because the PDL continuously responds and
changes as a result of the functional requirements imposed on it by externally applied
forces.
Notes
1. Less regularly arranged collagen fibers are found in the interstitial connective
tissue between the principal fiber groups; this tissue contains the blood vessels,
lymphatics, and nerves.
2. Although the PDL does not contain mature elastin, two immature forms are
found; oxytalan and eluanin. The so-called oxytalan fibers run parallel to the
root surface in a vertical direction and bend to attach to the cementum in the cervical third of the root. They are thought to regulate vascular flow.
3. The principal fibers are remodelled by the PDL cells to adapt"to physiologic
needs and in repsonse to different stimuli.
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of the saliva causes precipitation of calcium phosphate
salts by lowering the precipitation constants.
decrease in the pH
increase in the pH
decrease in the viscosity
increase in the viscosity
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The sulcular epithelium is a:
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increase in the pH
The theoretic mechanisms by which plaque becomes mineralized can be grouped into two main categories:
1 .Mineral precipitation results from a local rise in the degree of saturation of calcium and phosphate ions, which may occur through the following mechanisms:
An increase in the pH of the saliva causes precipitation of calcium phosphate salts by lowering the precipitation constants. The pHaaajUje_devated by the losjof carbon dioxide and
the fojaaation of ammonia by dental plaque bacteria.
Colloidal proteins in saliva bind calcium and phosphate ions and maintain a supersaturated
solution with respect to calcium phosphate salts. With stagnation of saliva, colloids settle out,
and the supersaturated state is no longer maintained, leading to precipitation of calcium phosphate salts.
Phosphatase liberated from dental plaque, desquamated epithelial cells, or bacteria precipitates calcium phosphate by hydrolyzing organic phosphates in saliva, thus increasing the concentration of free phosphate ions.
2. Seeding agents induce small foci of calcification that enlarge and coalesce to form a calcified
mass. This concept is referred to as the epjtactic concept, or more appropriately, heterogenous
jjLUcleation. It is suspected that the intercellular matrix of plaque plays an active role as the seeding agent. The carbohydrate-protein complexes may initiate calcification by removing calcium
from saliva (chelation) and binding with it to form nuclei that induce subsequent deposition of
minerals.
Note: Mineralization of plaque starts extracellularly around both gram-positive and gram-negative organisms.(^acderion^^fsvd.yeillonella species have the ability to form intracellular hydroxyapatite crystals.
Remember: Materia alba is a concentration of njjcroorganisms, dgsquamated epithelial cells,
leukocytes, and amixture of salivary proteins and lipids, with few or no food particles, and it lacks
the regular internal pattern observed in plaque.
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>ental plaque is composed primarily of:
microorganisms
water
minerals
tissue cells
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The source of mineralization for supragingival calculijsis:
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microorganisms
Dental plaque is defined clinically as a structured, resilient, yellow-grayish substance that adheres tenaciously to the intraoral hard surfaces, including removable and fixed restorations.
Plaque is primarily composed of bacteria in a matrix of salivary glycoproteins and extracellular polysaccharides. The micoroorganisms exist within an intercellular matrix that also contains a few host cells,
such as epithelial cells, macorphages, and leukocytes.
Dental plaque is broadly classified as:
\Supragingival plaquejfis found at or above the gingival margin; when in direct contact with the gingival margin" it is referred to as marginal plaque. Gram-positive cocci and short rods predominate at
the tooth surface, whereas gram-negative rods and filaments, as well as spirochetes, predominate in
the outer surface of the mature plaque mass.
..Subgingival plaque: is found below the gingival margin, between the tooth and the gingival pocket
epithelium. In general, the subgingival microbiota differs in composition from the supragingival
plaque, primarily because of the local availability of blood products and the low oxidation-reduction
(redox) potential, which characterizes the anaerobic environment.
Cervical plaque:
- Tooth associated: gram-positive rods and cocci
- Tissue associated: gram-negative rods and cocci, filaments, flagellated rods, and spirochetes
Deeper parts of the pocket:
- Tooth associated: gram-negative rods
- Tissue associated: gram-negative rods, flagellated rods, and spirochetes. Filamentous organisms become fewer.
Key point:The composition of the subgingival plaque depends on the pocket depth. The apical part is
dominated by spirochetes, cocci, and rods, whereas in the poronaLpart, more filaments are observed.
Important: The overall pattern observed in dental plaque development shows a shift from the early aerobic environment characterized by gram-positive facultative species to a highly oxygen-deprived environment in which gram-negative anaerobic microorganisms predominate.
saliva
Calculus is dental plaque that has undergone mineralization. It forms on the surfaces of
natural teeth and dental prostheses. Saliva is the source of mineralization for supragingival
calculus, whereas the serum transudate called gingival crevicular fluid furnishes the minerals for subgingival calculus.
Supragingival calulus: is located coronal to the gingival margin. It is usally white or pale
yellow in color and is hard with a claylike consistency. It is easily removed by a professional
cleaning. The two most common locations for supragingival calculus to develop are the
buccal surfaces of the maxillary molars and the lingual surfaces of the mandibular anterior
teeth. Saliva from the parotid gland flows over the facial surfaces of the maxillary molars
through Stensen duct, whereas the orifices of Wharton duct and Bartholin duct empty onto
the lingual surfaces of the mandibular incisors from the submandibular and sublingual
glands, respectively.
Subgingival calculus: is located below the crest of the marginal gingiva. It is typically
hard and dense and frequently appears dark brown or greenish black (due to exposure to gingival crevicular fluid) while being firmly attached to the tooth surface.
Differences in the manner in which calculus is attached to the tooth surface affect the relative
ease or difficulty encountered in its removal. It has been shown that calculus can attach to
tooth surfaces through four modes:
L Attachment by.means of an organic pellicle on enamel: most common mode
2. Mechanical locking into surface irregularities
3. Close adaptation of calculus undersurface depressions to the gently sloping mounds of
the unaltered cementum surface
4. Penetration of calculus bacteria into cementum
Important: A reduction in gingival inflammation and probing depths with a gain in clinical
attachment can be observed after removal of subgingival plaque and calculus.
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Specific bacteria are implicated in periodontal disease and are commonly
found at the site of infection. The Red complex bacteria consist of the following.
Select all that apply.
porphyromonas gingivalis
tannerella forsythia
treponema denticola
eikenella corrodens
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Nearly all human oral bacteria exhibit,
genetically distinct cell types.
j cell-to-cell recognition of
adhesion
pleomorphism
coaggregation
organization
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porphyromonas gingivalis
Rzditannerella forsythia
Treponema denticola
Recent sudies of plaque samples looking for 40 subgingival microorganisms using a DNA hybridization
methodology, defined "complexes" of periodontal microorganims. The composition of the different complexes
was based on the frequency with which different clusters of microorganisms were recovered. The early (primary) colonizers are either independent of defined complexes (Actinomyces naeslundii, A. viscosus) or members of the yellow (Streptococcus spp.) or purple complexes (Actinomyces odontolyticus).
The microorganisms primarily considered secondary (late) colonizers fell into the green, orange or red complexes. The green complex includes Eikenella corrodens, Actinobacillus actinomycetemcomitans serotype a,
and Capnocytophaga species. The orange complex includes Fusobacterium, Prevotella, and Campylobacter
species. The green and orange complexes include species recognized as pathogens in periodontal and nonperiodontal infections. The red complex consists of Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia. This complex is of particular interest because it is associated with bleeding on probing,
which is an important clinical parameter of destructive periodontal diseases.
Plaque as a biofllm: The dental plaque biofilm has a similar structure to all biofilms (composed of microcolonies encased in a polysaccharide matrix). It is heterogenous in structure, with clear evidence of open fluidfilled channels running through the palque mass. These water channels permit the passage of nutrients and
other agents throughout the biofilm, acting as a primitive "circulatory" system. The intercellular matrix consists of organic and inorganic materials derived from saliva, gingival crevicular fluid, and bacterial products.
Important: In a biofilm, bacteria have the capacity to communicate with each otherfcalled quorum sensing).:
This involves the regulation of expression of specific genes through the accumulation of signaling compounds
that mediate intercellular communication. When these signaling compounds reach a threshold level (called
quorum cell density), gene expression can be activated.
Note: The high density of bacterial cells in a biofilm also facilitates the exchange of genetic information among
cells of the same species and across species and even genera. Conjugation, transformation, plasmid transfer,
and transposon transfer have all been shown to occur more easily in a biofilm.
Remember: Following a prophy, plaque is most likely to accumulate on the interproximal tooth surfaces
first.
coaggregation
The process of plaque formation can be divided into three major phases:
1. The formation of the pellicle on the tooth surface: all surfaces of the oral cavity are coated
with a pellicle (the initial phase of plaque development). Within nanoseconds after vigorously
polishing the teeth, a thin, saliva-derived layer called the acquired pellicle, covers the tooth surface. This pellicle conists of numerous components, including glycoproteins (mucins), prolinerich proteins, phosphoproteins (e.g., statherin), histidine-rich proteins, enzymes (e.g.,
'atpha-amylase), and other molecules that can function as adhesion sites for bacteria (receptors).
Note: The mechanisms involved in enamel pellicle formation include electrostatic, van der
Waals, and hydrophobic forces.
2. Initial adhesion and attachment of bacteria:
- Phase 1: Transport to the surface: involves the initial transport of the bacterium to the
tooth surface.
- Phase 2: Initial adhesion: results in an initial, reversible adhesion of the bacterium, mediated through van der Waals and electrostatic forces.
- Phase 3: Attachment: after initial adhesion, a firm anchorage between bacterium and surface will be established.
- Phase 4: Colonization of the surface and biofilm formation: read #3 below
3. Colonization and plaque maturation: When the firmly attached microorganisms start growing and the newly formed bacterial clusters remain attached, mjcrofipjonies or a biofilm can develop. From this stage forward, new mechanisms are involved because new intrabacterial
connections may occur. At least 18 genera from the oral cavity have shown some form of coag., greagation (cell-to cell recognition, of genetically distinct partner cell types). Essentially all oral
bacteria (but especially Fusobacterium nucleatum) possess surface rnplecules that foster some
type of cell-to-cell interaction. This process occurs primarily through the highly specific stereochemical interaction of protein and carbohydrate molecules located on the bacterial cell surfaces, in addition to the less specific interactions resulting from hydrophobic, electrostatic, and
van der Waals forces.
magnesium whitlockite
brushite
octcalcium phosphate
hydroxyapatite
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filaments
cocci
rods
vibrios
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brushite
Supragingival calculus consists of inorganic (70%-90%) and organic components. The inorganic portion consists of 76% calcium phosphate, 3% calcium carbonate, and traces of magnesium phosphate, and other metals. The principal inorganic components are calcium (39%);
phosphorus (19%); carbon dioxide (1.9%); magnesium (0.8%); and trace amounts of sodium,
zinc, strontium, bromine, copper, manganese, tungsten, gold, aluminum, silicon, iron, and fluorine. At least two-thirds of the inorganic component is crystalline in structure. The four main
crystal forms are as follows:
Hydroxyapatite (58%)
Magnesium whitlockite (21%)
Octacalcium phosphate (12%)
Brushite (9%>)
Generally, two or more crystal forms are typically found in a sample of calculus. Hydroxyapatite and octacalcium phosphate are detected most frequently (in 97% to 100% of all
supragingival calculi) and constitute the bulk of calculus. Bjrai&hjte is more common in the
mandibular anterior region and magnesium whitlockite in the posterior areas.
The organic component of supragingival calculus consists of a mixture of protein-polysaccharide complexes, desquamated epithelial cells, leukocytes, and various types of microorganisms.
The composition of subgingival calculus is similar to that of supragingival calculus, with
some differences. Subgingival calculus has the same hydroxyapatite content, more magnesium whitlockite, and less brushite.and octacalcium than supragmgival"calculus. The ratio of
calcium to phosphorus is higher subgingivally, and the sodium content increases with the depth
of periodontal pockets. Salivary proteins present in supragingival calculus are not found subgingivally.
Note: Calculus (both supragingival and subgingival) located on interproximal surfaces can be
seen on bite-wing radiographs as interproximal spurs.
COCCI
Bacterial plaque is the primary etiologic factor for the initiation of periodontal disease. Plaque formation begins immediately after a tooth surface is cleaned. The rate of plaque formation is affected by diet, age, salivary
flow, oral hygiene, tooth alignment, systemic disease, and host factors. Changes in the types of organisms
occur within plaque as the plaque matures.
Days 1 to 2: young plaque consists primarily of cocci (i.e., Streptococcus mutans and sanguis)
Days 2 to 4: cocci still dominate but there are increasing numbers oifjJamgrtous forms and slender rods.
Gradually the filamentous forms replace many of the cocci.
Days 4 to 7: filaments increase in numbers, and a more mixed flora begins to appear with rods, filamentous forms, and fusobacteria.
Days 7 to 14: vibrios and spirochetes appear, and the number of white blood cells increases. More gramnegative and anaerobic organisms" appear. The signs of inflammation are beginning to be observable in the
gingiva.
Days 14 to 21: vibrios and spirochetes are prevalent in older plaque, along with filamentous forms. Gingivitis is evident clinically.
As plaque ages:
The number of cocci decreases and the number of rods, fusiform, filaments, and spirochetes increases
The number of aerobic bacteria decreases and the number of anaerobic bacteria increases
The number of gram-positive organisms decreases and the number of gram-negative organisms increases
Key point: As the biofilm (plaque) matures, there is a shift from a predominance of facultative, gram-positive bacteria to gram-negative, anaerobic bacteria.
The transition from gram-positive to gram-negative microorganisms observed in the structural development of dental plaque is paralleled by a physiologic transition in the developing plaque. The early colonizers (e.g., Streptococci, Actinomyces species) use oxygen and lower the redox potential of the
environment, which then favors the growth of anaerobic species. Gram-positive species use sugars as an
energy source and saliva as a carbon source. The bacteria that predominate in mature plaque are anaerobic and asaccharolytic and use amino acids and small peptides as energy sources.
1. The organic constituents of plaque include polysaccharides (dextran), proteins (i.e., albumin),
Notes glycoproteins (from saliva), and lipid material.
2. The inorganic components of plaque are predominantly calcium and phosphorus, with trace
amounts of other minerals, including sodium, potassium, and fluoride.
3.The source of inorganic constituents of supragingival plaque is primarily saliva.
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When evaluating an osseous defect, the only way to determine the number off
walls left surrounding the tooth is by:
periodontal probing
radiographs
exploratory surgery
> testing for mobility
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Angular defects are classified on the basis of:
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exploratory surgery
*** This is because a dense buccal and/or lingual plate of bone will tend to mask the defect,
blocking it out on the radiographs. This information can only be determined by exploratory
surgery.
Important: Radiographs will not show:
1 The.number ofwajlsjeft surrounding the tooth
2. The exact configuration of the defect
3. The location of the epithelial attachment
Remember: The two most critical parameters for the prognosis of a periodontally involved
tooth are mobility and attachment loss (which is most critical). Angular defects are classified on the basis of the number of osseous walls. Angular defects may have one, two, or three
walls. The number of walls in the apical portion of the defect may be greater than that in its
occlusal portion, in which case the term "combined osseous" defect is used.
Pocket depth is the distance between the base of the pocket and the gingival margin. The
level of attachment, on the other hand, is the distance between the base of the pocket and a
fixed point on the crown, such as the CEJ. Changes in the level of attachment can be caused
only by gain or loss of attachment and thus provide a better indication of the degree of periodontal destruction.
Pocket formation causes loss of attachment of the gingiva and denudation of the root surface.
The severity of the attachment loss is generally, but not always, correlated with the depth of
the pocket. This is because the degree of attachment loss depends on the location of the base
of the pocket on the root surface, whereas the pocket depth is the distance between the base
of the pocket and the crest of the gingival margin. Pockets of the same depth may be associated with different degrees of attachment loss and pockets of different depths may be associated with the same amount of attachment loss.
~$^2
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The principal differences between intrabony and suprabony pockets are the
relationship of the soft tissue wail of the pocket to the alveolar bone, thepattern of bone destruction, and the direction of the transseptal fibers of the
periodontal ligament.
In intrabony pockets, the base of the pocket is apical to the crest of the alveolar bone, and the pocket wall lies between the tooth and the bone.
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Which type of pocket is formed by gingival enlargement without destruction
of the underlying periodontal tissues?
gingival pocket
periodontal pocket
suprabony pocket
intrabony pocket
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Intrabony pocket
4. On facial and lingual surfaces, periodontal ligament fibers follow angular pattern of adjacent bone. They
extend from cementum beneath base of pocket along
alveolar bone and over crest to join with outer periosteum.
Reproduced with permission, from Newman MG, Takei HH, Klokkevold PR, Carranza FA. Carranza's Clinical Periodontology,10th
ed. Elsevier, 2006.
gingival pocket
Deepening of the gingival sulcus may occur by coronal movement of the gingival margin, apical displacement of the gingival attachment, or a combination of the two processes.
Pockets can be classified as follows:
Gingival pocket. (pseudopocket): this type of pocket is formed by gingival enlargement without destruction of the underlying periodontal tissues. All gingival pockets are
suprabony (the base of the pocket is coronal to the crest of the alveolar bone). The sulcus is deepened because of the increased bulk of the gingiva.
Periodontal pocket: this type of pocket occurs with destruction of the supporting
periodontal tissues. Progressive pocket deepening leads to destruction of the supporting periodontal tissues and loosening and exfoliation of the teeth.
Two types of periodontal pockets exist:
Intrabony (infrabony, subcrestal, or intra-alveolar): in which the bottom of the
pocket is apical to the level of the adjacent alveolar bone
Suprabony (supracrestal or supra-alveolar): in which the bottom of the pocket is
coronal to the underlying alveolar bone.
Clinical signs that suggest the presence of periodontal pockets include a bluish red, thickened marginal gingiva; a bluish red, vertical zone from the gingival margin to the alveolar mucosa; gingival bleeding and suppuration; tooth mobility, diastema formation; and
symptoms such as localized pain or "pain deep in the bone." The only reliable method of
locating periodontal pockets and determining their extent is careful probing of the gingival margin along each tooth surface.
poc/fur
Furcation involvements have been classified as grades I, II, III, and IV according to the amount of tissue destruction. Grade II is:
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poc/fur
In intrabony pockets:
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in the furcation, and involvement of the pulp via lateral canals in the furcation. Definitive diagnosis of furcation involvement is made by careful clinical probing. X-rays are helpful but
only as an adjunct to the clinical examination.
The major principle of treatment of involved furca is to eliminate the involvement whenever
possible. A variety of methods are available for treatment. Not all of them provide for elimination of the furcation; some provide only for increased accessibility for plaque removal. Bone
grafts have relatively little effectiveness in treating furcations. However, guided tissue regeneration is used to treat Grade II furcations with good success. Note: Furcation involvement
i r of
r maxillary second molars have the poorest prognosis following therapy- f-f^'
Important: Microscopically, furcation involvement presents no unique pathologic features. It
is simply a phase in the rootward extension of the periodontal pocket.
poc/fur
Drug-induced gingival enlargement consists of a pronounced hyperplasia
of the connective tissue and epithelium.
Drug-induced gingival enlargement may occur in mouths with little or no
plaque and may be absent in mouths with abundant deposits.
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When using the periodontal probe to measure pocket depth, the measurement is taken from the:
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> it should be parallel to the long axis of the tooth at the point angle
it should be parallel to the long axis of the tooth at the contact area
it should touch the contact area and the tip should angle slightly beneath and beyond
the contact area
it should be perpendicular to the long axis of the tooth in front of the contact area
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prob
How should the periodontal probe be inserted into the sulcus?
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it should touch the contact area and the tip should angle slightly
beneath and beyond the contact area
*** The periodontal probe may be angled approximately 10 on each interproximal surface so that the tip of the probe is placed apical to the contact point of adjacent teeth and
may detect any interdental crater, but, in most instances, the direction of the probing is parallel to the long axis of the tooth.
Periodontal measurements are taken by inserting the probe under the marginal gingiva
and gently moving it down to the junctional epithelium (feels soft, elastic, and resilient).
In a healthy site, the tip of the probe stops within the junctional epithelium and, in a diseased site, it penetrates into the connective tissue. In severe disease, the probe tip may penetrate to the alveolar bone.
1. The clinical probing depth is always greater than the histologic sulcus or
Notes pocket depth. Probing accuracy is only within +/- 1 mm.
2. The calibrated periodontal probe should have a tapered shaft approximately
0.5 mm in diameter at the tip. It is important to have uniform instruments
throughout the practice to ensure as much standardization as possible.
3. Furcation areas can be best evaluated with the curved #2 Nabers probe.
t%/Yh& periodontal probe can also be useful in the detection of subgingival deposits.
Notes
1 .The most important reason for using the periodontal probe is that it determines the loss of attachment. These measurements are taken both before and
after scaling and root planing procedures to evaluate the tissue response and
the effectiveness of treatment.
2. Probing is performed with firm, gentle pressure. The correct probe force (approximately 10 to 20 grams) depresses the thumb pad approximatelyJ_mmJo
2 mm.
prob
If you should meet resistance after inserting the periodontal probe into the
sulcus, you should:
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prob
Which of the following is the most common error when performing periodontal probing?
excessively angling the probe when inserting it interproximally beyond the long
axis of the tooth
forgetting to also probe the lingual of every tooth
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lift the probe away from the tooth and attempt to move it apically
Often when probing, the passage of the probe may be blocked by a hard, unyielding
ledge. This is usually calculus. Gently lift the probe away from the tooth, placing it
against the tissue wall of the pocket and attempt to proceed apically again. If the obstruction was indeed calculus and it has now been bypassed, then the probe should now
move deeper into the pocket until the junctional epithelium is reached. The tip of the
probe should be placed back against the tooth once the obstruction has been bypassed.
Remember: The probe should be inserted parallel to the vertical axis of the tooth and
"walked" circumferentially around each surface of each tooth to detect the areas of
deepest penetration.
1. Recession is the measurement of the migration of the free gingival margin
Notes apical to the CEJ of the tooth. Recession is measured as a positive value. The
recession measurement added to probe depth at a particular site indicates the
amount of periodontal attachment that has been lost at that site. When the gingival margin is coronal to the CEJ, the recession measurement has a negative
value.
2. To measure the amount of attached gingiva: (1) Place the probe on the external surface of the gingiva and measure from the mucogingival junction to the
gingival margin to determine the width of the total gingiva. (2) Insert the probe
and measure probing depth. (3) Subtract the probing depth from the total gingival measurement to get the width of the attached gingiva.
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rt sens/rec
The most accepted theory as to the cause of root sensitivity is the:
bayer's theory
1
chemiosmotic theory
hydrodynamic theory
quantum theory
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hydrodynamic theory
The Hydrodynamic theory postulates that the pain of root sensitivity results from indirect innervation
caused by dentinal fluid movement in the tubules, which stimulates mechanoreceptors in the pulp.
Root hypersensitivity is a relatively common problem in periodontal practice. It may occur spontaneously when the root becomes exposed as a result of gingival recession or pocket formation, or it may
appear after scaling and root planing and surgical procedures. The primary symptom is cold sensitivity. Plaque and food debris, if allowed to remain on exposed root surfaces, often lead to increased sensitivity. Note: To reduce the sensitivity to thermal change after removal of a periodontal dressing, it is
best to keep the roots free of plaque.
The most common agents used by the patient for oral hygiene are dentifrices. Although many dentifrice
products contain fluoride, additional active ingredients for desensitization are strontium chloride, potassium nitrate, and sodium citrate. The ADA has approved the following dentifrices for desensitizing purposes: Sesodyne and ThermoDent, which contain strontium chloride; Qgst Sensitivity Protection,
Denquel, and Promise, which contain potassium nitrate; and Protect, wfcrhcontams sodium citrate.
Important: Desensitizing agents act through the precipitation of crystalline salts on the dentin surface,
which block dentinal tubules.
Various office treatments for the desensitization of hypersensitive dentin:
Cavity varnishes
Antiinflammatory agents
Treatments that partially obturate dentinal tubules
- Fluoride compounds
- Burnishing of dentin
Sodium fluoride
- Silver nitrate
Stannous fluoride
- Zinc chloride-potassium ferrocyanide
- Iontophoresis
- Formalin
- Strontium chloride
- Calcium compounds:
- Potassium oxalate
Calcium hydroxide
- Restorative agents
Dibasic calcium phosphate
- Dentin bonding agents
rt sens/rec
it
The most important factor in the control of hypersensitive roots among patients with periodontal disease after gingival recession has exposed the cervical portions of teeth is:
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When extensive scaling and root planing must be performed, the best approach would be:
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,1
I I
Sometimes these areas will become sensitive if the root is exposed. The patient will complain
of cold sensitivity. The hypersensitivity will sometimes subside in time with daily plaque
removal using a soft brush (this will help desensitize the root surface by allowing remineralization of the root surface). Remember: Gingival recession can also occur secondary to periodontal therapy. This may have additional significance in the older patient, namely, increased
risk for cervical abrasion and dentinal sensitivity, and most importantly, predisposition to root
caries.
The acids and toxins produced by the plaque organisms are very irritating to the pulp by way
of the odontoblastic processes. This irritation of the pulp heightens its sensitivity to other stimuli. No attempt to reduce hypersensitivity will be successful unless the roots are consistently
kept free of plaque.
Desensitizing agents can be applied by the patient at home or by the dentist or hygienist in the
dental office. The most likely mechanism of action is the reduction in the diameter of the dentinal tubules so as to limit the displacement of fluid in them. This can be attained by:
formation of a smear layer produced by burnishing the exposed surface
topical application of agents that form insoluble precipitates within the tubules
impregnation of tubules with plastic resins
sealing of the tubules with plastic resins
The hygienist or dentist should evaluate the brushing technique and monitor hard and soft tissue conditions at each recall visit. Faulty placement, overaggressive movement or pressure, or
the use of a hard toothbrush can lead to hard and soft tissue damage.
The most common cause of gingival recession is tooth injury (abrasion). This type of recession is common on the left canines of right-handed persons (or right canines of left-handed persons).
1. There is potential for abscess formation in a deep pocket when only a suNotes perficial scaling is performed.
2. OHI may be more effective if a patient can see healing tissue in an area
that has been completely debrided and compare it to tissue in an untreated
area.
3. A patient who has had a gross debridement will see a marked visual improvement of the oral cavity and may not understand the importance and necessity of the deep scaling and root planing appointments. This may cause
the patient to not follow through with the scheduled treatment, and the patient's periodontal condition will be allowed to deteriorate further.
4.Important: Clinical evaluation of the soft tissue response to scaling and root
planing, including probing, should not be conducted earlier than 2 weeks postoperatively. Reepithelialization of the wounds created during instrumentation
takes 1 to 2 weeks. Until then, gingival bleeding on probing can be expected,
even when calculus has been completely removed because the_so_ft tissue wound
is not epifheliaiized.
T . l f any bleeding or swelling is noted in localized areas of the mouth during
the reevaluation appointment, check for and remove any residual calculus
deposits that might remain.
6. In root planing, ideally, the working stroke should begin at the apical
edge of the junctional epithelium (the base of the pocket).
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scal/rp/gc
Some degree of curettage is done unintentionally when scaling and root planing are performed; this is called inadvertent curettage.
Curettage accomplishes the removal of the chronically inflamed granulation
tissue that forms in the lateral wall of the periodontal pocket.
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scal/rp/gc
The main objective of root planing is:
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Maximum shrinkage after gingival curettage can be expected from tissue that
is:
fibrotic
edematous
fibroedematous
formed within an intrabony pocket
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edematous
Indications for curettage are very limited. It can be used after scaling and root planing for the
following purposes:
1. Curettage can be performed as part of new attachment attempts in moderately deep intrabony pockets located in accessible areas where a type of "closed" surgery is deened advisable.
2. Curettage can be done as a nondefmitive procedure to reduce inflammation before pocket
elimination using other methods or when more aggressive surgical techniques (e.g., flaps)
are contraindicated.
3. Curettage is also frequently performed on recall visits as a method of maintenance treatment for areas of recurrent inflammation and pocket depth.
Contraindications of gingival curettage as a definitive procedure include:
***^Acute periodontal inflammation
Firm, fibrotic tissue
Intrabony pockets
Mucogingival involvements
When the lateral gingival wall is extremely thin
1. Patients with edematous and granulomatous inflammation respond better to
Notes curettage than do those with conditions of fibrous hyperplasia.
2. For a new attachment to occur: (1) An adequate number of undifferentiated
mesenchymal cells must be present. (2) Complete removal of junctional and pocket
epithelium must be accomplished. (3) The complete removal of calculus and/or altered cementum must be accomplished.
Important: It is recommended that all students read The American Academy of Periodontology Statement Regarding Gingival Curettage.
This can be found on the Internet at:
http://www.perio.org/resources-products/pdf/38-curettage.pdf
scal/rp/gc
Ultrasonic instrumentation is accomplished with a:
heavy touch and light pressure, keeping the tip perpendicular to the tooth surface
and constantly in motion
light touch and heavy pressure, keeping the tip parallel to the tooth surface and stationary
light touch and light pressure, keeping the tip parallel to the tooth surface and constantly in motion
heavy touch and heavy pressure, keeping the tip perpendicular to the tooth surface
and stationary
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scal/rp/gc
Which of the following is the instrument of choice for removing deep subgingival calculus, for root planing altered cementum, and, for removing the
soft tissue lining the periodontal pocket?
curette
sickle scaler
hoe
<
file
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curette
Each working end of a curette has a cutting edge on both sides of the blade and a rounded toe. The curette
is finer than the sickle scalers and does not have any sharp points or corners other than the cutting edges
of the blade. Therefore, curettes can be adapted and provide good access to deep pockets, with minimal
soft tissue trauma. In cross section, the blade appears semicircular with a convex base. The lateral border of the convex base forms a cutting edge with the face of the smemicircular blade. There are cutting
edges on both sides of the blade. There are two basic types of curettes:
Universal curettes: have cutting edges that may be inserted in most areas of the dentition by altering and adapting the finger rest, fulcrum, and hand position of the operator. The blade size and the
angle and length of the shank may vary, but the face of the blade of every universal curette is at a 90degree angle (perpendicular) to the lower shank when seen in cross section from the tip. The blade
of the universal curette is curved in one direction from the head of the blade to the toe.
Area-Specific curettes: Gracey curettes are representative of the area-specific curettes, a set of several instruments designed and angled to adapt to specific anatomic areas of the dentition. The Gracey
curettes also differ from the universal curettes in that the blade is not at a 90-degree angle to the lower
shank. The term offset blade is used to describe Gracey curettes, because they are angled approximately 60 to 70 degrees from the lower shank.
Notes
1. Using curettes with short, even working strokes followed by longer ones is the most effective and efficient way of performing root planing. The correct cutting edge can be seen as
a larger, outer curve.
2. Final root planing strokes are longer and lighter than scaling strokes.
3. Root planing strokes become lighter as the cementum becomes smoother.
4. Exploratory scaling and root planing strokes differ in angulation, pressure, length, and
direction.
Remember: To establish the correct working angle once a curette is inserted subgingivally, the shank
must be moved away from the tooth to open the angle of the blade to the tooth surface. At proper
working angulation (less.than.90 but more than 45), the lower shank of a.Gracey curette is parallel
to the tooth surface being scaled. The lower shank of a universal curette would be tilted slightly toward
the tooth.
scal/rp/gc
In magnetostrictive ultrasonic units the pattern of vibration of the tip is linear.
In piezoelectric ultrasonic units the pattern of vibration of the tip is elliptical.
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If a patient experiences sensitivity while being scaled with an ultrasonic scaling device, all of the following actions will be appropriate to counter this
problem EXCEPT two. Which two are inappropriate?
proceeding to another tooth and then returning to the sensitive tooth later in the
appointment
moving the instrument slower
making necessary adjustments to the water spray
turning up the power of the device
using less pressure
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scal/rp/gc
Air is used to deflect the free gingival margin to detect:
the CEJ
smooth root surfaces
subgingival calculus
inflammation
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The primary function of which instrument is to fracture or crush large deposits
of tenacious calculus?
hoe scalers
files
chisel scalers
quetin furcation curettes
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subgingival calculus
One of the uses of the air syringe is to detect calculus, both supra- and subgingival.
Supragingival calculus is often seen more easily when it is dry (saliva often conceals it),
and deflecting the free gingival margin slightly makes subgingival calculus easier to detect.
When using the explorer to detect calculus, a light instrument grasp should be utilized to
increase tactile sensitivity. The lateral side of the tip of the instrument should be placed
in contact with the tooth surface when exploring for calculus. Dried calculus is easier to
detect than wet calculus with the explorer because it is less slippery.
files
The five basic scaling instruments are as follows:
>
(Curette) the curette is the instrument of choice for removing deep subgingival calculus,
root planingVrtered cementum, and removing the^stoft tissue lining the periodontal pocket.
Each working end has a cutting edge on both sides of the blade and a rounded toe. The
curette is finer than the sickle scalers and does not have any sharp points or corners other
than the cutting edges of the blade. Therefore, curettes can be adapted and provide good access to deep pockets with minimal soft tissue damage.
- Sickle sc&ler&supragingival scalers): have a flat surface and two cutting edges that converge in a sharply pointed tip. The shape of the instrument makes the tip strong so that it will
not break off during use. The sickle scaler is used primarily to remove supragingival calculus.
r- * Files: have a series of blades on a base. Their primary function is to fracture or crush large
deposits of tenacious calculus or burnished sheets of calculus. Files" can easily gouge and
roughen root surfaces when used improperly. Therefore, they are not suitable for fine scaling and root planing.
'Chisel scalers:, are designed for the proximal surfaces of teeth too closely spaced to permit the use of other scalers and are usually used in the anterior part of the mouth. They are
double-ended instruments with a curved shank at one end and a straight shank at the other;
the blades are slightly curved and have a straight cutting edge beveled at 45 degrees. The
chisel is inserted from the facial surface. The instrument is activated with aEushnujtion,
while the side of the blade is held firmly against the root.
|jT.oe scalerp are used for scaling.ofled^esjjrringsof calculus. The blade is bent at a 99degree angle; the cutting edge is formed by the junction of the flattened terminal surface with
the inner aspect of the blade. The cutting edge is beveled at 45 degrees. Note: McCall's #3,
4, 5, 6, 7, and 8 are a set of six hoe scalers designed to provide access to all toomsurfaces.
Each instrument has a different angle between the shank and handle.
scal/rp/gc
While scaling subgingivally, the tip of the curette breaks off. All of the following are appropriate actions to take to try and remove this tip EXCEPT one.
Which one is the EXCEPTION!
scal/rp/gc
While scaling subgingivally, the tip of the curette breaks off. All of the following are appropriate actions to take to try and remove this tip EXCEPTone.
Which one is the EXCEPTION!
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scal/rp/gc
It is impossible to carry out peridontal procedures efficiently with dull instruments.
A sharp instrument cuts more precisely and quickly than a dull instrument.
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Gracey Curette
Universal Curette
Cutting Edge
Use
Curvature
Curved in two planes; blade curves Curved in one plane; blade curves up, not to the
side
uEandiaJJSJMe
Blade angle
Offset blade; face of blade beveled Blade not offset; face of blade beveled at 90
at 60 degrees to shank
degrees to shank
scal/rp/gc
When sharpening, a wire edge is produced:
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A curette designed to scale and root plane anterior teeth with deep pockets
will have a:
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when the last stroke of the stone is drawn away from the cutting edge
Avoid formation of a "wire edge," which is produced when the direction of the sharpening stroke
is away from, rather than into or toward, the cutting edge. When back-and-forth or up-and-down
sharpening strokes are used, formation of a wire edge can be avoided by finishing with a down
stroke toward the cutting edge.
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The cutting edge of an instrument is formed by the angular junction of two surfaces of its blade.
The cutting edges of a curette, for example, are formed where the face of the blade meets the lateral surfaces. When the instrument is sharp, this junction is a fine line running the length of the cutting edge. As the instrument is used, metal is worn away at the cutting edge, and the junction of the
face and lateral surface becomes rounded or dulled. Thus, the cutting edge becomes a rounded surface rather than an acute angle.
Sharpening stones can be categorized by their method of use:
Mounted rotary stones: these stones are mounted on a metal mandrel and used in a motordriven handpiece. They may be cylindrical, conical, or disc-shaped. These stones are generally
not recommended for routine use because they (1) are difficult to control precisely, (2) tend to
wear down the instrument quickly, and (3) can generate considerable frictional heat, which may
affect the temper of the instrument.
Unmounted stones: come in a variety of sizes and shapes. Unmounted stones may be used in
two ways: the instrument may be stabilized and held stationary while the stone is drawn across
it, or the stone may be stabilized and held stationary while the instrument is drawn across it.
1. The optimal internal angle between the face of the Wade and the lateral surface of
Notes a universal curette and a Gracey curette is 70 to 80. fSg$*i>***
2. An instrument whose cutting edge is 90 or more will slip over calculus deposits and
requires heavy lateral pressure to remove calculus deposits.
3. The best grasp to use when holding an instrument to be sharpened is the palm grasp.
How an instrument shank is designed influences the intended use of the instrument. It is recommended that an instrument with a rigid shank be used for removal of heavy calculus deposits. *** Straight shames are used in the anterior areas and contra:angled shanks a r e j a ^ m
the posterior areas.
Rigid, thick shank:
Stronger
Less flexible
Provides less tactile sensitivity
Stronger instruments are needed for heavy calculus removal
Less rigid, more flexible shank:
Provides more tactile sensitivity
Used for removing fine calculus and for root planing
Important: The Gracey curettes differ from the universal curettes in that the blade is not at a
90-degree angle to the lower shank. The term offset blade is used to describe Gracey curettes,
because they are angled approximately 60 to 70 degrees from the lower shank. ^ /
^ttgulatinn}efers to the angle between the face of the bladed instrument and the tooth surfaceltJtnayalso be called the tooth-blade relationship. During scaling and root planing, optimal angulation is between 45: and 90 degrees. With angulation of less than 45 degrees, the
cutting edge will not bite into or engage the calculus properly. Instead, it will slide over the
calculus, smoothing or "burnishing" it. If angulation is more than 90 degrees, the lateral surface of the blade, rather than the cutting edge, will be against the tooth, and the calculus will
not be removed and may become burnished.
Q ^
Note: When gingival curettage is indicated, angulation greater than 90 degrees is deliberately
established so that the cutting edge will engage and remove the pocket lining.
scal/rp/gc
are used selectively on line angles 01
negotiated with other strokes.
vertical strokes
oblique strokes
horizontal strokes
circular strokes
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horizontal strokes
There are three basic strokes used during instrumentation. Any of these basic strokes may be activated
by a pull or a push motion in a vertical, oblique, or horizontal direction. Vertical and oblique strokes are
used the most frequently. Horizontal strokes are used selectively on line angles or deep pockets that cannot be negotiated with vertical or oblique strokes. The direction, length, pressure, and number of strokes
necessary for either scaling or root planing are determined by four major factors: (1) gingival position
and tone, (2) pocket depth and shape, (3) tooth contour, and (4) the amount and nature of the calculus or
roughness.,
Exploratory stroke: is a light, "feeling" stroke that is used with probes and explorers to evaluate
the~dimensions of the pocket and to detect calculus and irregularities of the tooth surface. The instrument is grasped lightly and adapted with light pressure against the tooth to achieve maximal tactile
sensitivity.
Scaling stroke: is a short, powerful pull stroke that is used with bladed instruments for the removal
of both supragingival and subgingival calculus. The scaling motion should be initiated in the forearm
and transmitted from the wrist to the hand with a slight flexing of the fingers. The scaling stroke is
not initiated in the wrist or fingers nor is it carried out independently without the use of the forearm.
Root planing stroke: is a moderate to light pull stroke that is used for final smoothing and planing
of the root surface. With a moderately firm grasp, the curette is kept adapted to the tooth with even,
lateral pressure. A continuous series oflong, overlapping shaving strokes is activated. As the surface
becomes smoother and resistance diminishes, lateral pressure is progressively reduced.
1. "Pulling" strokes are safer than "pushing" strokes because the push stroke may force calNotes cuius into the supporting tissues. The push stroke, especially in an apical direction, is not
t recommended.
2. Probing stroke: upward and downward movement within a periodontal pocket.
3. The modified pen grasp is the most useful grasp for periodontal instrumentation.
4. The lower third of the working end, which is the last few millimeters adjacent to the toe
or tip, must be kept in constant contact with the tooth while it is moving over the tooth.
5. For subgingival insertion of a bladed instrument such as a curette, angulation should be
as close to 0 degree as possible. During scaling and root planing, optimal angulation is between 45 and 90 degrees.