Chapter 8

Question 1

what is periodontitis

Answer 1

• alveolar and supporting bone destruction
• can affect children and adults
• not based on age, but on clinical and radiographic findings

Question 2

what causes perio

Answer 2

• bacteria, causing:
• inflammatory/immune events
• microscopic changes in the connective tissue and epithelium
• development of perio

Question 3

what are the 4 stages of of histopathogenesis

Answer 3

• initial
• early
• established
• advanced

Question 4

what is the advanced lesion

Answer 4

• alveolar and supporting
• loss of connective tissue attachment
• the inflammatory infiltrate spreads in the connective tissue
• plasma cells (B cells) predominant

Question 5

what is a pocket

Answer 5

• a pathologically deepened gingival sulcus

- in disease, the junctional epithelium becomes pocket epithelium

Question 6

when is it a periodontal pocket

Answer 6

• when inflammation spreads into the body of the connective tissue – decreases collagen
• gingival fibers and connective tissue are destroyed, followed by apical and lateral migration of the junctional epithelium
• remember, a pocket refers only to soft tissue, not to bone. this is referred to as attachment loss
• as a consequence to destruction of the gingival fibres and apical migration of the JE there is bone destruction

Question 7

what will occur when the pocket depth increases in a periodontal pocket

Answer 7

• ideal for bacterial growth

- difficult to maintain

Question 8

what are the 2 types of periodontal pockets

Answer 8

• suprabony

- infra bony

Question 9

what cemental changes are seen in the root surface with disease

Answer 9

• surface is rough
• easily absorbs endotoxins
• and bacteria and their by-products
• called necrotic cementum

Question 10

how is bone destroyed with perio

Answer 10

• PMNs release prostaglandins. PGE2 destroys bone and PGs activate osteoclasts
• endotoxins destroy bone, which are released by gram negative bacteria
• B-cells
• release of IL-1, which stimulates PMN and collagenase
• cytokines from macrophages destroy bone, IL-1 also stimulates PGE2

Question 11

is the degree of bone loss correlated with the depth of pockets

Answer 11

• no

- radiographically, extensive bone loss can also be associated with shallow pockets, due to surgery or recession

Question 12

what does the pattern of bone loss depend on

Answer 12

• the route of the inflammatory infiltrate and route of tissue destruction

Question 13

what are the 2 patterns of bone loss

Answer 13

• horizontal

- vertical

Question 14

what is horizontal bone loss

Answer 14

• gingiva -> bone -> PD (principle fibers)
• bone is lost equally
• related to suprabony pocket
• bone resorption occurs from the outer aspect

Question 15

what is vertical bone loss

Answer 15

• inflammation travels directly from the gingiva into the periodontal ligament
• bone loss is more rapid on one side of the tooth than the other
• gingiva to PDL to bone
• base of the deepest portion of the bony defect is apical to the alveolar bone crest creating an infra bony defect

Question 16

what are the different types of infrabony defects

Answer 16

• vertical bone loss

- classified according to the number of osseous (bony) walls REMAINING around the defect

Question 17

what is a 3 wall defect with an infrabony defect

Answer 17

• 3 bony walls remain and one is missing (easiest to repair in surgery bc 3 walls to connect to)

Question 18

what is a 2 wall defect with an infrabony defect

Answer 18

• 2 bony walls remain and 2 are missing

- ‘crater’-M and D on adjacent teeth are missing, buccal and lingual walls remain (most common)

Question 19

what is a 1 wall defect with an infrabony defect

Answer 19

• one bony wall remains and 3 are missing

- ‘hemiseptum’ defect – only the buccal or lingual wall remains

Question 20

how far does the bone destruction process radiate

Answer 20

• 2 mm of the plaque mass

Question 21

what are some factors impacting the pattern of bone loss

Answer 21

• thickness and width of the interdental septum
• wider interdental septum (>2 mm) (posterior teeth) versus septal bone (anterior teeth)
• thus mandibular incisors - mostly horizontal loss
• greater than 2 mm – probably vertical

Question 22

how do we classify periodontitis

Answer 22

• extent
• severity
• grade

Question 23

what is the extent of periodontitis

Answer 23

• localized: less than 30% of sites involved

- generalized: more than 30% sites involved

Question 24

what is the severity of periodontitis

Answer 24

• stage I: CAL 1-2 mm
• stage II: CAL 3-4 mm
• stage III/IV: CAL greater than or equal to 5 mm

Question 25

what are some other factors that can affect periodontitis

Answer 25

- smoking - diabetes - genetics - HIV - stress - local factors (tooth related)

Question 26

what types of bacteria are often found at periodontitis sites

Answer 26

- P. gingivalis - T. forsythensis - E. corrodens

Question 27

when is periodontitis able to be diagnosed (what is present)

Answer 27

- apical migration of the JE - alveolar and supporting bone loss seen on x ray - soft tissue recession may be present

Question 28

what is rapid progressing periodontitis

Answer 28

- less common (1% of population) - replaces 'early onset and aggressive periodontitis' which included localized juvenile periodontitis, rapidly progressive periodontitis, and prepubertal periodontitis - can occur at any age not limited to patients under 35 - divided into localized and generalized (localized replaces localized juvenile periodontitis)

Question 29

what are common features of localized and generalized rapid progressing periodontitis

Answer 29

- patients are systemically healthy - rapid attachment loss and bone - familial predisposition other features may include - elevated levels of AA - abnormal functioning of phagocytes - elevated levels of PGE2 and IL-1 (note: not all features here must be present for diagnosis) - often occurs at age of puberty - min biofilm - high levels of antibodies - localized destructive sites

Question 30

what is molar/incisor presentation for localized rapid progressing periodontitis

Answer 30

- first molar/incisors with interproximal attachment loss on at least 2 permanent teeth - one of which is a first molar - and with no more than 2 teeth other than first molars and incisors - poor antibody response to the bacteria - generalized interproximal loss on at least 3 permanent teeth other than first molars and incisors

Question 31

what type of bacteria is often present with rapid progressive periodontitis

Answer 31

- AA - PG - P. intermedia - C. rectus - C. sp.

Question 32

what are defects of the PMNs and macrophages

Answer 32

- malfunctions in phagocytosis and chemotaxis - defect in either PMNs or macrophages but not both - seen in 70-80% of patients with aggressive perio - not seen in chronic periodontitis

Question 33

what is refractory periodontitis (old term)

Answer 33

- do not respond favourably to conventions therapy and are considered resistant to treatment 30% are smokers (AAP)

Question 34

what is peri-implantitis

Answer 34

- loss of bone that surrounds a functioning implant | - periodontitis on an implant

Question 35

what is peri-implant mucositis

Answer 35

- gingivitis on an implant - primary risk is bacteria - treatment is similar

Question 36

how can we treat periodontitis

Answer 36

- non-surgical start: - re-evaluate 4-6/8 weeks - determine surgery: pocket reduction or elimination. chronic -- this is best treatment - rapidly progressive perio: possible systemic antibiotics

Question 37

what type of bone loss is infrabony

Answer 37

- vertical

Question 38

what type of bone loss is suprabony

Answer 38

- horizontal

Question 39

what does localized aggressive periodontitis include

Answer 39

- first molar or incisor with no more than 2 other teeth besides first molar/incisor

Question 40

what does generalized periodontitis include

Answer 40

- generalized IP bone loss and destruction leaving at least 3 permanent teeth other than first molars/incisors