Major Topic

Scaling/Root Planing/ Gingival Curettage Periodontal Ligament/ Gingiva

PERIODONTICS

FiGlS

Which statement regarding an eutogenous free gingival graft is not true?

. It

can be placed to prevent further recessron

. It can be used to effectively widen the attached gingiva

. lt retains its orvn blood supply
lessels

and is not dependent on the bed of recipient blood

. The greatest amount olshrinkage occurs within the first 6 weeks

. It

is also useful for covering non-pathologic dehiscences and fenestrations

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This is false; it retains none ofits own blood supply and is totally dependent on the bed ofrecipient blood vessels. In some instances. it can be used to cover a root surface with a narrow denudation. The procedure yields a high degree ofsuccessful results when used for increasing the width ofthe aftached gingiva. The free gingival gmft may be used therap€utic.lly to widen the gingiva after recession has occurred. It may be used prophylactically to prevent recession where the band ofgingiva is nanow and ofa thin, delicate
consistency. The liee gingival graft is an autogenous graft ofgingiva that is placed on a viable connective tissue bed cases, the donor site ftom which the graft is laken is an edentulous region or the palatal area. The gmft ePithelium undergo€s degenemtion after ir is placed. Then it sloughs, the epithelium is reconstructed in about a week by the adjacent epithelium and proliferation ofsurviving donor basal cells. In two weeks'time, the tissue appears to have rcformed, but matumtion is not completed until l0 to 16 weeks. The tim€ required is proportional to the thickness ofrhe graft. Note: The free gingival graft receives its nutrients liom the viable connective tissue bed'

***

*here initially buccal or labial rnucosa was present. In most

The procedure mry or may not yield a successful result when used to obtain root coverage; the result is nor highly predictable in such cases. The graft may be used to correct localized narrow recessions or clefu but nol deep, wide recessions, In these instarces, the later.lly 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 f"speciallyfacial).

Ililler classification

system for recession: . Class I: marginal tissue rec€ssion does rrot extend to the mucogingival junction. There is no bone

or soft tissue in the interdental arca. It can be narrow or wide. . Class II: maryinal tissue recession extends to or beyond the mucogingival junction. Therc is no loss ofbone or soft tissue in the interdental areas. It can be wide or narow. . Class III: marginal tissue recession ertends to or beyond the mucogingivaljunction. There is bone and soft tissue loss interdentally or malpositioning ofthe tooth. Therc is severe "Cless Iv: marginal tissuerecession extends to orbeyond the mucogingivaljunction. bone and soft tissue loss interdentally or severe tooth malposition. In general, th€ prognosis for classes I and II is good to excellent; whereas class III, only partial coverage can be expected. CIass IV has a very poor prognosis.

. Mandibular first and second premolars . Maxillary first and second molars . Maxillary canines . Mandibular molars with buccal and lingual class II or III furcation involvements

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. To cure periodontal disease

.

To eliminate the existing microflora

. To eliminate periodonlal pockets
. To change the existing microflora

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Hemisection refers to the vertical sectioning ofthe tooth through both crown and root. Most often, the technique is utilized in a mandibular molar region where the crown is divided through the bifurcation region. One-half ofthe tooth is extracted if one specific root has excessive loss in osseous support and the remaining half of the molar tooth now is treated as a premolar. Note: This process has been called bicuspidization or separation because it changes the molar into two sepamte roots. Root amputation refers to the separution ofan individual root from the crown structure ofthe tooth. Burs and diamond stones are utilized to sever the crown and root prior to extraction by root tip forceps. At the completion of the root amputation, the remaining apical area of the crown and furcation region are recontoured similar to the shape of a pontic so that maximal access is provided for oral hygiene methods. Most root amputations involve the maxillary first and second molars (tlrcse teeth are commonly involved periodon-

tal sites).
Root amputations or hemisections almost always result in irreversible pulpal damage that Demands endodontic therapy. Ideally the endo is done first which ensures patient comfort. Sometimes the decision to do a root resection cannot be made until flaps have been reflected and the periodontal status has been carcfully assessed. The RCT must be delayed until after the resection. Regardless ofthe sequence, consultation with both endodontist and periodonrist is required to ensure both aspects ofthe treatment can be performed.
root resection, molars with advanced bone loss in the interproximal and interradicular zones are not good candidates for hemisection.

\ote: As \\.ith

Important: Pontic design for crown and bridge: The sanitary and ovate pontics have convex undersurfaces, which makes them easiest to clean. The ridge-lap and modified ridge-lap designs have concave surl'aces, which are more diffrcult to access with dental floss. The sanitary pontic is mrely used because ofits unesthetic form. The ovate pontic is the ideal pontic form. The alveolar bone must be a minimum of2 mm from the most apical portion ofthe pontic.

It does not cure periodontal discase. The technique is performed in combination with apically positioncd flaps, and rhe procedure eliminates periodontal pocket depth and improves tissue contour to provide a more easily mainrainable environment. Before employing osseous resection or recontouring to treat an infrabony dcfect,
rhe rherapist should consider the following altemative trealments: . )laintenance with pcriodic root Note: Osseous resection surgery should not lte don€ until the . Bone grafts etiologic tlctors that resulted in the formation ofthe osseous Reettachment-fill procedures defects are arrested. Clinically detectable inflammation must ' . Hemisection or root amputation be eliminated by scaling and root planing and by thc patien!'s exercise of optimal plaque conlrol.

planing

Important: The most critical tactor in determirling whcther a tooth should be extraoed or have surgery per_ furmed on it is thc amount ofattachment loss (nhich is the apical nigration ofthe epithelia[ altachment).
\umerous therapeutic hard-tissue grafting materials for restoring periodontal osseous defects have been uscd. \faierial ro be grafted can be obtained from the same individual /drlog dr.s), from a dil]'erent individual ofthe *me species /d/1oglafsl, or from a different spectes (xenogralis).
Bone Srafting materials are genetally evaluated based on their osteogeni.

tl€\ bo e br cellt containe.l in

the

(abilil! to induce thelormation oJ graft), osteoindrrctive (abilit, ofmolecules conlained in the gruJi lo conto sen'e as a

\en neiEhboring cells inlo osteoblasts), or osteoconductiv€ (drilit! o/the grc-ft materitll
that tarors outside cells lo penetrate the graft . Aulog€nous bone grafts:

scalfold

andfom

netN

bone) polenti^1.

- Osseous coagulum: mixture ofbone dust from co(ical bone and blood. - Bone Blend: uses an autoclaved plastic capsule and pestle. Bone is rcmoved f.om a predetermined site, riurated in the capsul€ to a workable, plastic-like mass, and packed into bony defects. - Cancellous bone marrow transplants: bone obtained ftom the maxillary tuberosity oredcntulous ridges. - Cancellous bon€ from extraoral sites: fresh orpreserved iliac cancellous marrow bone. . Aflograft material: undecalcified freeze-dried bone allograft (FDBI [osteoconductive materialJ), decalcifiedFDBA, lDFDBA [osteoinductive mateial]). Note: DFDBA has a higher osteogenic potential fdae to the pretenee olbone morphogenetic prcteins IBMP9 than FDBA and is therefore preferred. . Xenografts: Bio-Oss has been used as a glaft material covered with a resorbable membmne lBro_Gude/ . Nonbone graft materitls: bioactive glass fPelioclas, Biocrun) and coal-derived materials.

. 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
and partial thickness periodontal flaps can be displaced

. Both full thickness

.Flaps flom the palate are considered easier to be displaced than any other region . Flaps should be uniformly thin and pliable

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. Gingivectomy
. Apically positioned flap

. Distal

rvedge

. Laterally positioned flap

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This is false; palatal flaps cannot be displaced (ouing to the absence ol unattached gingiva).

***

A periodontal flap is a segment ofmarginal periodontal

tissue that has been surgically separated coronally from its underlying support and blood supply and attached apically by a

pedicle of supponing vascular connective tissue. Flap procedures are the most commonly used ofall periodontal surgical techniques. The most commonly used flaps are full thickness mucoperiosteal flaps. These flaps include the surface mucosa (defned as epitheliunt, basement membrane, and connective tissue lamina propria) and the contiguous periosteum ofthe 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 the preparation ofrecipient sites for free gingival grafts or when a dehiscence or fenestration is present on a prominent root.

ofthe flap must be uniformly thin, usually about 2 mm thick. One determinant ofhow the flap will be raised, that is either as full thickness or as a panial thickness flap, is the thickness (amount) of the attached gingiva prior to surgerl'. Generally, a full thickness flap will be used where the attached gingiva is thin ) ntm or less in width), and a partral thickness flap may be used when the attached ginThe surgically created edge
(

ei

a ts thick (2 mm or more).

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 non-keratinized mucosa. Only ifsufficient space exists distal to the last molar, a band of attached gingiva may be present. In such a case a distal

s edge operation can be performed.
These procedures are also performed in the following areas

ofthe mouth:

. The maxillary tuberosity region . The mandibular retromolar triangle
ulous area

area
an edent-

. Distal to the last tooth in an arch, or mesial to a tooth which approxirnates

\{any- 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 ofthe wedge from the periosteal base and elimination ofthe tissues involved in the distal pocket region also reduces tissue bulk and allows for access to the underlvins bone.

. The need for bone surgery or examination ofthe bone shape and morphology

. Situations in which the bottom ofthe pocket is apical to the mucogingival junction
. Esthetic considerations, particularly in the anterior marilla . Elimination of gingival enlargements

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The primary objective and advrnhge of surgical flap procedures

in the treatment of periodontal disease is:

.

Reduce or eliminate periodontal pockets

. To provide access to root surfaces for debridement

. Regrowth ofalveolar bone
. Maintenance ofbiological width . Establishment ofadequate soft tissue contours

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Gingivectomy means cxcision of thc gingiva. By rcmoving thc pockct wall. gingivectomy provides visibility and accessibility lor complete calculr,rs removal and tho.ough smoothing of the roots, creating a favorable environment for gingival healing and restoration ofa physiologic gingival contour Abeveled incision is made apical to the pocket depth, the tissue is removcd, the area is debrided, and a surgical pack is placed. Note: The gingivectomy tcchniquc was widcly perfonned in thc past. Improved understanding ofhealing mechanisms and the development ofmorc sophisticated flap methods have rel€gated the gingivectomy to a lesser role in the current repertoire of available techniques.
The gingivectomy technique may be performed for the following indications: . Elimination of suprabony pockets, regardless of their depth, if the pocket wall is fibrous and

fimr

. Elimination of gingival enlargements . Elimination of suprabony periodontal abscesses Importanti An adequatc amount of attached gingiva must be present beforc done; otherw,isc the rcsult will be an area rvith minimal or no attached gingiva.

a

gingivcctomy is

Thc following factors should be considered when electing to perform a gingivcctomy rather than a periodontal flap: . Pocket depth fy'base of pocket is loc.tted at the mucogitlgiv.tljunction 01, apical to the alveolar crest, do not perfbt'm gingivectom)-)
r\-eed for access to bone (if osseou.s recontouritg is needed do not do gingiveclony) . r\rrrount ofexisting attached gingiva fy'lnadequate do not do gingivectotny) .\ gingivoplasty is directed towards reshaping the gingiva and papilla ofa tooth for corrcction of deformities and to provide the gingiva with normal and functional form. The overall objective is not to eliminate pcriodontal pockets, but rather to provide a more physiological tissue contour. \\'hile it is true that portions ofthc gingiva arc excised dudng thc gingivoplasty procedure, it is thc reshaping, not thc cxcision, of gingiva that defines gingivoplasty. Note: This procedure is conmonlv used to correct th€ tissue contours that result from ANUG.

.

provide Th. rcchniqucs vary with $c goal that is sought- However, thc common goal ofall flapltocedurcs is to
cess

ac_

for insir' rnentation. It glvcs

the

clinician thc opporlunity

1.,

visualizc thc rools so lhat calcul,s may bc rcmovcd

\\':rhout dircct visualizalion providcd by a 0ap, it is rarc that a clinician can cffectivcly root planc beyond 5mm of from thc rcgion of :r!.bing dcpth or into furcalions of Lcsscr dcpth. It also makcs rcmoval ofgranulomatous tissue to rcmovc this' duc to thc fact it contains epithelium and the poten:h: plriodontal dcfcct difficult. It is important tirl pres€ncc of bacterial infiltration. patient f'ails to dcnonstratc adcquate oral hygiclc durinS initial thcrapy 6'dliirg a'd tuot plannry)'

Important: If a surgen is contrainrlicated bccause aftcr surgcry thc incidencc ofdiscasc rccuncnce will bc greater iforal hygicne .".l3,ns noo. thc bcst.ourse ofaclion is to conlinuc to strcss oral hygiene and maintain sreas with scaling and rool
al.:nrn-r

is basic to most pcriodontal tlap proccdurcs. ll is thc incision from ll'hich a flap is reucctcd (l) it e\Folc rhc undcrlying bonc anal root The intcmal bevel incision accomplishcs thrcc imponant objcctivcsl (2) il conscrvcs the rclativcly uninvolved oute' surfacc ofthc gingiva which' ifapically ,c,,,or ls rlc p<*t cr iining: to thc bonc{ooth r.r:rroncrj. becomcs atta;hcd gingiva; and (3) il produccs a sharp, lbin flap margin for adaptation

Tlr internal bclel incision
ro

P.riot1onlolog,. I tl" .1.

A. Diagm oflfie inrem.lbevel incision /rxi ir.irtorl to reflecl l) full thjckness thu.opctiosteal) ttap. \ote that the itrcision ends on rfie bonc lo allow fo' dre re flection ofrhe entire flap. B Diagrm ofrhe inlemal bevel iicision to reflect a par tial-rhickness flap. Note thal rhe incision ends on dre mot surface to preser!e the
periosteun ofthe bone.

.In

addition to improving accessibility for instrumentation, removes the pocket wall, thereby reducing or eliminating the pocket

. Facilitates inslrumentation but does not attempt to reduce pocket depth

. Improves accessibility
. None ofthe above

and eliminates the pocket, but does the latter by apically positioning the soft tissue wall ofthe pocket

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A soft tissue graft that is rotated or oth€rwise repositioned to correct an adjacent defect is called a:

. Free gingival graft . Pedicle graft . Connective tissue graft . Frenectomy

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The modified Widman flap (MWF) facilitates instrumentation but does not attempt to reduce pocket depth. The reduction or elimination ofpocket depth is the main purpose of two flap techniques: the undisplac€d flap and tbe apically displaced flap. The decision of which to perform depends on two important anatomic landmarks:

.

Pocket depth

. Location ofthe mucogingival junction
These landmarks establish the presence and width ofthe attached gingiva, which is the basis for the decision.

***

The modified widman flap has been described for exposing the root sufaces for meticulous instrumentation and for removal ofthe pocket lining. This flap uses the three horizontal incisions but is not reflected beyond the mucogingival line. Note: It is not intended to eliminate or reduce pocket depth, except for the rcduction that occurs in healing by tissue shrinkage. The undisplaced ftnrepositioned) flap, in addition to improving accessibility for instrumentation. removes the pocket wall, thereby reducing or eliminating the pocket. This is essentially an excisional procedure ofthe gingiva. Note: Curently, the undisplaced flap may be the most frequently performed type ofperiodontal surgery. It differs from the modified Widman flap in that the soft tissue pocket wall is removed with the initial incision; thus it may be considered an "intemal bevel gingivectomy." The undisplaced flap and the gingivectomy are the two techniques that surgically remove the pocket wall. The apicallt- displaced flap also improves accessibility and eliminates the pocket, but it does the latrer by apically positioning the soft tissue wall ofthe pocket. Therefore, it preserves or increases the width of the attached gingiva by transforming the previously unattached keratinized pocket wall into attached tissue.

The pedicle graft was the first periodontal plastic surgery procedure to be used for root coverage. lt 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.

\\'ith pedicle grafts, there is less concem 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 ofpedicle grafting include:
is possible, because the graft has an uninterrupted blood supply . Postoperative discomfort is usually minor . Since the color ofthe graft matches the adjacent gingiva, the procedure provides good

. Predictable correction ofgingival recession

esthetics

Indications include:

. To u'iden an inadequate zone ofattached gingiva . To repair an isolated area ofgingival recession
Contraindications include: . The prospective donor site lacks sufficient attached gingiva . The donor site has a fenestration or dehiscence of its supporting bone

\ote:

Pedicle grafts are not well-suited for repairing generalized recession defects. They rvere designed for repair of isolated recession. Many recession defects don't have a suitable adjacent donor site.

. A soft tissue graft used to correct mucogingival junction involvement

. Placement of nonresorbable barriers or resorbable membranes and barriers over
bony defect
. A free gingival graft used to increase the amount ofattached gingiva

a

. Placement of an autograft to treat a bony defect

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. Infection . Edema
. Disruption ofthe vascular supply before engraftment . The formation of scar tissue

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The method for the prevention of epithelial migration along the cemental wall ofthe pocket that has gainedwide attention is guided tissue regeneration fcfRr. This method is based on thc assumption that only the periodontal ligament cells have the potential for regeneration ofthe attachment appa.atus of the tooth. GTR consists ofplacing baniers ofdifferent types to covcr thc bone and periodontal ligamcnt. thus temporarily separating them from the gingival epithelium. Excluding the epithelium and the gingival connective tissue from the root surface during thc postsurgical healing phase not only prevents epithelial migration into the wound, but also favors repopulation ofthe area by cells from the periodontal ligament and the bone.
The initial membranes developed were nonresorbable (pobitetrulluotoethv"le e IPTFE]) and therefore required a second, although frequently simple, procedure to remove it. This second procedure was donc after thc initial stages ofhealing. usually 3 to 6 weeks after the first intervention. The second procedure was a significant obstacle in the utilization ofthis GTR tcchnique, and therefore resorbable membranes $ ere developed.

Resorbable membranes marketed in the United States include OsseoQuest aco,"e/, a combination of poly-glycolic acid, polylactic acid, and t methylene carbonate that resorbs at 6 to 14 months; Biocuide tOsteoHealth), abilayer porcine-derived collagen; Ahisorb fr1oc,( Dnlg), a polyactic gel; and Bio^cid \lend /Calcitech), abovine Achilles tendon collagen that resorbs in 4 to l8 weeks. Ofthese, Biocuide is easier to use and generally preferred.

Currenth. regenerative procedures are applicable and predictable under a certain set of circumstances: (l) The parient exhibits exemplary plaque control both before and after regenerative therapy, (2) The parient does not smoke, (3) There is occlusal stability ofthe teeth at the regenerative site, (4) Osseous detects are vcrtical in nature, with the mor€ walls ofbone remaining increasing thc likelihood ofrcgenetali\ e success.

\o&q' .. -' '-o--''

L A fienum becomes a problem ifthe attachment is too close to the marginal gingiva. Tension on the frenum may pull the gingival margin away from the tooth. 2. A fr€nectomy is complete removal ofthe frenum. 3. A frenotomy is incision ofthe frenum, this proccdure usually is suffice for most periodontal DurDoses.

***

The second most common reason is infection.

Tcchniques used to increase the width ofattached gingiva include the fiee gingival autogmft, fiee connecti|e tissue autograft, and the apically positioned flap. These techniqucs are used for widening the atrached gingiva apicat to the area ofrecession. Techniques used for gingival augmentation coronal to the recession (root coverage) include the free gingival and connective tissue autograft, as well as pedicle autografts (laterally and coronalll' positioned llaps), lhe srbeplthelial connective tissue graft (Langer) and guidcd lissue regeneration. Free gingival autografts jnvolve taking a section ofattached gingiva from another area of the mouth rusualh-the Inrd palate or an edentulous regionJ and suturing it to the recipient site. The success depends upon lhe graft being immobilized at the recipient site. Free gingival grafts arc used to create a widened zone of anached gingiva with the possibility ofgaining root coverage as well. The diflculty in getting complele root coveragc lies in the fact that an avascular graft is placed over a root surface also devoid

tria blood supply. Note: The ideal thickness for this graft is I to

1.5 mm.

Tte free connective tissue autograft technique is based on the fact that the connective tissue caries the genetic message for the ovcrJying epithelium to become keratinized. Thereforc, only connective tissue from a keratinized zone can be used as a graft. The advantage ofthis technique is that the donor tissue ji obraincd from the undersurface ofthe palatal flap, which is sutured back in primary closure; therefore, healing is by first intention. The apicrlly displaced flapi this technique uses the apically positioned flap, either partial thickness or full rhickness, to increase thc zone ofkeratinized gingiva. Rememberi Pos ition ed f7^ps (i.e., lalerully positioned fap, cotonally positioned Jlap, and apical4' positione.l.flap) are procedures in which the coronal portion ofthe flap is elevated from an atea adjacent to thc recipient sitc, and freed-up, but the base ofthe flap is still connccted to the underlying donor site tissue. In these procedures, the vascular supply to the llap is maintained, as opposed to the free gingival graft.

Important: Thcro is no necrotic slough ofpositioned flaps bccausc thcsc flaps take their vascular supply with them. In a free gingival graft, the healing involves revascularization ofthe graft. The top layers of the graft are thc last to be revascularized; therefore the epithelium dics off (degeneralion),
producing the necrotic slough.

. A coronally positioned flap
. A modified Widman flap . A double papilla flap

. A free gingival flap

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. Sharp
. Rounded . It doesn't matter whether the comers ofa periodontal flap are sharp or rounded

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Laterafly (horizontally) displaced flap: this technique was the standard technique for many years and is still indicated in some cases. The laterally positioned flap can be used
to cover isolated, denuded roots that have adequate donor tissue laterally and vestibular
depth.

Sliding partial-thickness grafts from neighboring edentulous areas (pedicle grafts) canbe
used to restore attached gingiva on teeth adjacent to edentulous spaces with denuded roots and a small, vestibular fomix, often complicated by tension from a frenum. The "double-

papilla flap" attempts to cover roots denuded by isolated gingival defects with a flap formed byjoining the contiguous halves ofthe adjacent interdental papillae. Results with this technique are often poor because blood supply is impaired by suturing the two flaps
over the root surface.

Indications include: . Traunra from incorrect toothbrushing (gingivql recessiotr) . Covering the exposed root surface with gingiva also helps to reduce or eliminate the
problem of hypersensitivity

. l. Deep periodontal pockets are often treated by flap surgery. These cases \otee will often result in reduced pocket depth by formation of a long junctional
epithefium (soft tissue reattachment), even ifthere is no change in the posil ion ofthe 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 alter flap surgery a fully epithelialized gingival crevice with a well-defined epithelial attachment is present. There is a beginning functional arrangement of the supracrestal fibers.

I

p€riodontal flap is a scction ofgingiva and/or mucosa surgically separated from thc underlying tisiues to provide visibiliry ofand access to thc bonc and root surfacc. The flap allows the gingiva to be displaced to a different location in patients with mucogingival involvement. Periodontal flaps can be classilied based on the following: . Bone exposure aftcr flap reflection: - full-thickness fmrcoperiosteal) Ilaps. allthe soft tissue, including the periosteum, are reflected to expose the underlying alveolar bone. - partial-thickness (mucosal) tlaps only thc cpithclium and a layer ofthe underlying connective !issue are reflected. Also called split-thickness flap. . Based on flap placemcnt aficr surgcry: - nondisplaced flaps: when the flap is retumed and sutured to its original position. - displaced flaps: which are p)aced apically. coronally, or laterally to their original position.
. Based on fianagement ofthe papilla: - conlenlional flapr thc interdental papilla is split beneath thc contact point ofthe two approximating teerh to allow reflection ofbuccal and lingual flaps. - papilla preservation flap: incorporates the entire papilla in one ofthe flaps.
The Four Basic Rules For Flap Design: L The base of the flap should be wider than the free margin in order to afford sufficient blood circulation ro the liee margin ofthe flap. l. The lines of the incision must not be placed over any defect in the bone to prevent delayed heal-

ing. 3. lncisions that traverse a bony eminence fcdr?ire/ should be avoided. The mucosa covering bony cminences is thin and healing is slow and may result in an ugly scar formation. ,1. All comers ofthe flap should be rounded. Sharp points will delay healing.

Important: . Healing should take place without complication if basic surgical principles are followed. .lncisions made in tissues that harbor uncontrolled infection may cause rapid spread ofthe infection. Do not do this. Most periodontal surgical procedures are perfomed only after anti-infective
therapy has been completed.

. Coronally displaced (positioned) flap
. Laterally displaced (positioned) flap

. Double papilla flap . Apically displaced (positioned) flap

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A free mucosal autograft (subepithelial connective tissue graf) differs from free gingival graft in that the transplant in a free mucosal grtft is:

. Connective

tissue with an epiftelial covering an epithelial covering

. Connective tissue without

. Epithelial tissue with its own blood supply . Epithelial tissue without its own blood supply

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An apically displaced (positioned) flap (APF) is a full-thickness, mucoperiosteal flap. It has a relatively high degree of predictability and is a "work-horse" ofperiodontal therapy. The objective ofthis tlpe offlap is to surgically eliminate deep pockets by positioning the flap apically while retaining the keratinized gingiva. Additionally, surgical access is obtained for osseous surgery treafinent of infrabony firtabony) pockets, and root planing. In the course of this flap surgery, after gaining access to the underlying osseous tissue and performing the required therapy, the flap is suhlred to place at a more apical level, sometimes exposing the alveolar bone margin. When this is done, additional attached gingiva grarulates from the periodontal ligament and covers the barely exposed bone. This additional tissuejoins the apically positioned attached gingiva to form a broader zone of gingiva. Note: On the palatal surface of maxillary molars you need to trim the flap margin to the proper length during the procedure. Indications for APF include:

. Moderate or deep pockets . Furcation-involved teeth . Crown lengthening
An APF is contraindicated if a patient is at risk for root caries. Excessive root surf-aces are ol'ten exposed after perfbrming an apically positioned flap. APF's are also conffaindicated
\\ here tooth exposure would be unesthetic.

Remember: For all mucogingival procedures, blood supply is the most significant concem. Biomodification ofthe root surface: the root surface ofthe pocket can be treated to improve irs chances ofaccepting the new attachment ofgingival tissues. Several substances have been proposed for this purpose, including citric acid, fibronectin, and tetracycline. Other agents used inciude growth factors (/. e., PDGE IGE bFGE BME and TGF) and one enamel matrix
protein dedvative obtained from developing porcine teeth (trade name is Emdogain).

free mucosal autograft (suhepithelial connective lissue graft) differs from a free gingival graft in that thc transplant in a frec mucosal graft is connective tissue without an epithelial covcring. Epithelial differentiation is induced by the underlying conncctive tissue, so that l'ree grafts of dense connective tissue taken from keratinized areas result in the formation of keratinized tissue even when transplanted to non-keratinized zones. This procedure is somewhat more difficult than fr.-e gingival grafling. This procedure is often used on canines where there is little keratinized gillgir a to create a band ofgingivalike tissue. Remember: During healing, the epithelium of free gingival grafts degenerates (necrotic slough), and re-epithelialization occurs by proliferation of epithelial cells from adjacent tissue and surviring basal cells ofthe graft tissue.

-\

\ote: Free gingival grafts are often used in conjunction with a frenectomy to prevent reformation ofhigh lrenal attachments.
Healing after flap surgeryl

. Immediately after suturing

hoarr. a connection between the flap and the tooth or bone surface is established by a blood clot. . 1 to 3 days after surgery: the space between the flap and the tooth or bone is thinner, and epithclial cclls nrigrate over the border ofthe flap, usually contacting the tooth at this time. . 1 week after surgery: an epithelial attachment to the root has been established by rneans of hemidesmosomes and a basal lamina. The blood clot is replaced by granulation tissue derived from the gingival connective tissuc, th€ bone manow, and the periodontal ligament. . 2 weeks alter surgery: collagcn fibers begin to appear parallel to the tooth suface. Union ofthe nap to the tooth is still weak because ofthe presence of immature collagen fibels. . I month after surgery: a fully epithelialized gingival crevice with a well-defined epithelial attachment is present. There is a beginning functional arangement ofsupracrcstal fibers.
(up lo 24

Note: Full-thickress flaps, which denude the bone, result in a superficial bone necrosis at I to resorption follows and r€aches a peak at 4 to 6 days, declining tberealler This results in a loss ofbone ofabout I mm: bone loss is greater ifthe bone is thin.
3 days; osteoclastic

.

Free gingival autograft

. Double papilla flap
. Modified Widman flap

. Laterally displaced (positioned) flap

16 Cop)righr O 201l-2012 - Dental Decks

. Ostectomy
. Osteoplasty . Positive architecture
. Negative architecture

Coplright Q 2011-2012 - D€nral Decks

(l) nondisplaced flaps, when the flap is retumed and sutured to its original position, or (2) displaced flaps: which arc placed apically, cororally, or laterally to their original position. Both full-thickness and partial-thickness flaps can be displaced, but to do so, the anached gingiva must bc totally separated from the underlying bone, thereby enabling the unattached po(ion ofthe gingiva to be movable. Howevcr, palatal flaps cannot be displaced because ofthe absence ofunattached gingiva. l. Apically displaced flaps have the important advantage ofpreserving the outer portion of the pocket wall and transforming it into artached gingiva. Therefore these flaps accomplish the double objectivc ofeliminating the pockct and increasing the width ofthe attached gingiva. 2. Laterally displaced flaps arc used to coffect or prevent recession by providing root coverage and crcating a broader band ofgingiva. It may be used in the absence ofrecession to widen the
Flaps are classified as zone ofgingiva. 3. Displac€d flaps are allphysically attached at their apical base by a pedicle
an

oflining mucosa and

int.ct blood supply,

Periodontal flaps use horizonlal and verticrl incisionsi Horizontal incisions: are directed along the margin ofthe gingiva in a mesial or a distal direction. .Int€rnal bevel incision: starts from adesignated area on the gingiva and is directed to an area at or near the crest ofthe bone. The starting point on the gingiva is determined by whether the flap is apically displ^ced 10.5- 1.0 nn fron the.free gingivol marg ,?/, not displaced r/rrl coronal to the base ofthe pocket), or used in the modified Widrn n ll^p (no more than I to 2 mm apical to the gingival morgin). Also called reverse the first incision /lrecduseil is lhe itial incision in lhe releclion ofthe periodonlal llap) ^nd.the bevel incision rhecalre its bevel is in relJerse directiofifrom that ofthe gingivectomv incision). . crevicualr incision (also termed the second inci.rial,/: is made from the base ofthe pocket !o the crest ofthe bone. Tle combination ofthe intemal bevel and crevicular incisions creates acollaroftissue around the teeth and contains most ofthe inflamed and granulomatous areas that constitut€ the lateml wall of thc pocker. as well as th€junctional epithelium and the connective tissu€ fibels. . Interdental incision incrsion): this incision separates the collar ofgingiva from the tooth.

i

tird

Tlese three incisions allow the removal ofthe gingiva around the tooth and visualization ofthe alvcolar bone. vertical or oblique releasing incisions: can be used on one or both ends ofth€ horizontal incision, depending on the pupos€ ofthe flap. They are used ifthe flap is to be positioned apically or laterally and must exte d beyond the mucogingival line, reaching the alveolar mucosa, to allow for thc rclease ofthc flap to be displaced. Note: Ifno vertical incisions are made, the flap is called an envelope flap.

Procedures used to corect osseous defects have been classified in two groups:

. Osteoplasty: refers to reshaping the bonc without removing tooth-supporting bone . Ostectotuy for orreoectotAi includes the removal oftooth-supporting bone
One or both ofthcse procedures may be necessary to produce the desircd results. \lorphologicafly descriptire tefins (these lenns all relale to d preconceit'ed slandard ol ideQl osseous

***

. Positive and negative architecture refer to the relative position ofinterdental bone to radicular bone. The architecrurc is said to be "positive" ifthe radicularbone is apical to the interdental bone. The bone is said ro have "negative" architecture ifthe interdental bone is more apical than the mdicular bone Flat architecture is the reduction ofthe interdcntal bone to the same height as the radicular bone \ote: Osseous form is considered to be "ideal" when the bone is consistently more coronal on the inrerproximal surfaces than on the facial and lingual surfaccs. The ideal folm ofthe marginal bone has simjlar interdental height, with gradual, curved slopes between interdental peaks.

Follol\ing ostectomy, peaks ofbone tJpically remain at the facial and lingual/palatal line angles ofthc reerh /rido\ i peak). Ifthese are not removed, periodontal pockets can recur Ostectomy to a positive architecture requires the removal ofthe line-angle inconsistencies (widow \ peak), as well as some of
the t-acial. lingual, and palatal and interproximal bone. The result is a loss ofsome attachment on the facial and lingual root surfaces but a topography that more closely resemblcs "ideal" bonc Terms ihat relate to the thoroughness ofthe osseous reshaping techniques include: . Definitive osscous reshaping: implics that further osseous reshaping would not improve the overall

result.
osseous reshaping: indicates a bone pattem that cannot be improved without signifiremoval that would be detrimental to the overall result. cant osseous \ote: The relationship between the depth and configuration ofthe bony lesionfs) to rootmorphology and the adjacentteeth determines the cxtent thatbone and attachment is removcd during resection. The technique ofostectomy is best applied to patients with early to moderate bone loss f2--t nrr) with moderate length root runks that have bony defects with one or two walls. These shallow to moderate bony defects can be effectively managed by ostcoplasty and ostectomy. In some surgical procedures, it is necessary to leave interradicular bone exposed, This usually results in bone loss ofno clinical consequence.

. Compromise

. One-wall intrabony defects
. Two-wall intrabony defects (osseous craters)
. Three-wall intrabony defects

. Through-and-tbrough furcation defects

1E

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. Bacteroides melaninogenicus
. Wolinella intermedius . Bacteroides gingivalis . Bacteroides intermedius

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disease. Thc bone is reduced in height, but the bone margin remains approximately perpendicular to the tooth surface. The interdental septa and facial and lingual plates are affected, but not necessadly to an equal dcgree around the same tooth.
a hollowed-out trough in the bone alongside the root; the base ofthe defect is located apical to the surrounding bone- In most instances, angular defects have accompanying intrabony periodontal pockcts; intrabony pockets, however, always have an underlying angular defectAngular defects are classificd on the basis ofthe number ofosseous 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 ponion, in which case the term combined osseous defect is used. Important: Surgical exposure is the only sule way to dctermine the presence and configumtion ofvertical osseous defects. The relative degree ofsuccess ofperiodontal bone grafting is reported to vary directly with thc number ofbony walls ofthe defect (rascularized, osseous surface area) and inversely with the surface area of the root against which the gmft is implaDted. Thus a nanow, three-walled angular defect usually yields the greatest success, a two-walled defect the next best, and a one-walled defect the least. l. Osseous grafting techniques and materials include: osseous coagulum, autogcnous inhaoral bone, autogenous iliac crest bone, freeze-dried bone allograft (FDBA, which is undecalcijied), decalcified freeze-dried bone allogftft @FDBA), FDBA or DFDBA combined

Horizontal bone loss is the most common pattcm ofbone loss in periodontal

Vertical or angular defects are those that occur in an oblique direction, leaving

with autogcnous bone.
2. Root resorption is the most common side effect ofosseous grafting.

3. An alfograft is a graft taken fiom one
4.

h[ma (donor) and placed in anothcr

human fre-

A dehiscence is a loss ofthe buccal or lingual bone overlaying thc root portion ofa tooth, leaving the area covered by soft tissue only. 5. The three-wall vertical defect was originally called an intrabony d€fect. Thc term intrabony was )ater expanded to designate ail vertical defects. 6. Thc onc-wall vertical defect is also called a hemiseptum. 7. Two-wall intrabony defects (osseous cralersl are best corected by rccontouring ofthe facial and linsual walls to restore normal intcrdental architecturc.

The purpose ofthis card is to hopefully clear up any confusion on the recent reclassifications ofa number ofperiodontal pathogens. The bacteria have stayed the same, but the names have changed. R€c.d Rcchisilic.tiod ofPetodoot Clrld6edor
alis l Patbogen'

Pr.r'lo0s

Porphyromonas eingilalis Baclereid€s

drlodo

Purphtrumondq cndodonirlis

Ba.lercidls

intrmaliu
Prcvotclla nelaninogenica

Ba€1eo'd6 relsinogenicN

. The first statement is true; the second statement is false . The second statement is true; the first statement is false

. Both

statements are true

. Both statements are false

20
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Mediators produced as a part ofthe host response that contribute to tissue destruction include all of the following EXCEPT one. Which one is the.EXCEPIION?

. Free radicals

.

Proteinases

. Prostaglandins . Cytokines

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Most investigations that evaluated the cffcct ofsmoking on nonsurgical therapy have demonsfated less reduction in probing depth and smaller gains in attachment levels in smokers compared with nonsmokels,

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 nonsmoken. Important point: Smoking is onc ofthc most signiricart risk factors currently available to predict the development and progressjon of periodontitis. Smokers:

. Demonstrate more orangc and rcd microbial complexes . Have an increase in Tannerella forsyhia levels

. Have

a depressed immunc system, smoking exefis a significant negative effect on the protective clcments of thc immune system. Studies show that smoking not only dampens the response of host defense cells such as neutrophils, but also leads to increascd release oftissue-destructivc enzl.mcs.

L Most systemic diseascs and conditions that may affect periodontal diseases generally alter host barrier and host defcnse mechanisms. Although many conditions cause gingival inflammation and ulce6, rtot all peop]e develop periodontal disease. Certain factors put individuals at higher risk than others. 2. Osteoporosis f/o.t.t of bone densitl) has been associated with periodontal disease in postmenopausal women. There is some evidence that some tleatments for osteoporosis, such as bisphosphonates, may reduce bone loss, including the bony structures that support the teeth.
3. Autoimmune conditions fe.g., Crohn's disease, rheutnatoid arthrilis, lupus er,-themalosus, CREST q,ndrone) have been associatcd with a higher incidence ofperiodontal discasc. Smokeless tobacco use has been associated with oral lcukoplakia and carcinoma. However, no generalized effects on periodontal disease prcgrcssion secm to occur, other than localized attachment loss and r€cession at the site oftobacco product placement. 5. Patients receiving radiation ther|py show periodontal aftachment loss and tooth loss to be greater on the radiated side compared with the nonradiatcd side. Periodontal health should be estabiished prior to beginning radiation therapy.1.

se (MMPs) are considered to be primary proteinases involved in periodontal tissue destruction by degradation ofextracellular matrix molecules MMPs are a family of proteolytic enzymes found in neutrophils, macrophages, fibroblasts, epithelial cells, osteoblasts, and osteoclasts that degrade extracellular matrix molecules, such as collagen, gelatin, and elastin. MMP-8 and MMP-1 are both collagenases; MMP-8 is released by infiltrating neutrophils, whereas MMP-1 is expressed by resident cells, including fibroblasts, monocltes/macrophages, and epithelial cells. Note: MMPs are also produced by periodontal pathogens P gingivalis and A. actinotherapeutics.

llatrix metafloprotein

Cltokines are important signaling molecules released from cells. lnterleukin-l f1Z-1), IL-8. and rumor necrosis factor alpha (TNFa), appear to have a central role in periodontal tissue destruction. The properties of these cytokines that relate to tissue destruction inr olr e stimulation ofbone resorption and induction oftissue-degrading proteinases. IL1 is a potent stimulant ofosteoclast proliferation (bone resorption), differentiation, and acrivation. IL-8 is important in attracting inflammatory cells and TNFCI, has similar effects as IL- I but is much less potent than IL-1. It is also imponant in activating macrophages. \ote: \Ionocytes/macrophages are very important in regulating the irnmune response tbrough the release of cytokines. \{acrophages are recruited to the area ol inflammation and are activated (foi binding to ZPt to produce prostaglandins (e.g., prostaglandin 82, PGE) Prostaglandins are biochemically synthesized from the fatty acid, arachidonic acid of cells membranes in response to cyclo-oxygenases (COX-l and COX-2). Cox-2 is upregulated by IL-1, TNF, and bacterial LPS and appears to be responsible for generating the prostaglandin (PGE) that is associated with inflammation. Note: The primary cells responsible for PGE2 production in the periodontium are macrophages and fibroblasts. Induction of MMPs and osteoclastic bone resorption is induced by PGE2.

. Bleeding upon probing . Gingival color . Pocket depths

. Stippling ofthe gingival

tissue

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In a clinically healthy periodontium, the microbial flora is largely composed of:.

\
o

. Gram-negative obligate microorganisms . Gram-negative facultative microorganisms . Gram-positive
obli gate microorganisms

. Gram-positive facultative microorganisms

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Inflammation, bleeding upon probing, and pocket depths are the most important diagnostic aids or signs of gingival or periodontal disease. Gingiva may or may not be stippled whether healthy or inflamed. The presence or absence ofstippling is not diagnostic.

Clinical criteria used for diagnosing gingivitis: . Color: normal gingival color ranges from coral pink to various stages ofpigmenration*** Erythema refers to an intense red color. Probably the most common color change notcd with p€iodontal disease is cyanosis (bluish-p rple hue).
. Contour: has
a mnge

ofnormal. This is influenced by missing teeth, posirion ofteeth, etc. Papillae should

fill the interproximal spaces. Gingival margins should be scalloped in lbrm. . Tone (or Consistenc)r: the normal consistency ofthe gingival tissue should . Siz€:

be resilient and fibrotic in nature from the free gingival groove apical to the mucogingivaljunction. Texture, stippling ofthe attached gingtra (the so-called orafige peel appearance) may or may not be present. the healthy gingival tissues should bc well-contoured to the und€rlying osseous architecnrre with the free gingival margin being ofsuch thinness to allow lor a "knife edge" thickness at the dentogingival

margin.

. Plaque, calculus:

the best way to evaluate the amount and distribution ofplaque is by the utilization disclosing solution. Remember: without bacterial plaque there would be no gingivitis.

of

are no nutritional deficiencies that by -there themselves can cause gingivitis or periodontitis. However, nutritional deficiencies ctn rlfect the condition ofthe periodontium. . \'itamin A d€ficiency: vitamin A may play an important role in protecting against microbial invasion by mainraining epithelial integrity. A deficiency can impact the barrier tunction ofepithelial cells. . \'itamin D deticiency: vitamin D is essential for the absorption of calcium liom the GI trao and the of the calcium-phosphorus balance. No human studies demonsfiate a rclationship between vitamin D deficiency and periodontal disease. Note: Vitamin D deficiency can contribute to osteoporosis ofalveolar bone rn voung dogs. . utamin B-complex d€ficiency: vitamin B complex includes thiamin, riboflavin, niacin, plridoxine, biorin. folic acid, and cobalamin- Deficiency ofthese as a group my contribute to gingivitis. . \'itamin C deficiency: severe deficiency of vitamin C results in scuny. Bleeding, swollen gingiva and loosened leeth are common features ofscuny,

Important: Tle impact of nutrition on periodontal disease

The gingival crevicc harbors bacteria in both health and disease. In a clinically healthy periodontium, the microbial flora is largely composed ofgram-positive facultative cocci and rods, predominantly species ofeenera such as Actinomyces and Streptococcus. Gram-negative species and spirochetal forms also ma! be found, but they are considembly less prevalent and occur in much smaller numbers The development ofgingivitis occurs in parallel with a tremendous incr€ase in the numbers ofbacteria present in plaquc. A distinct shift in the bacterial composition ofthe plaque also occurs, with increasing proponions ofgram-negative anaerobes. Note: Thehostresponse to plaque bacteria is fundamentally an

inflammatory response.

Desprte a remarkable diversity ofbacteria found in the periodontal microbiota, only a few species have been associated with Deriodontitis: These include:

. Porphlromonas gingivalis
. Tannerella fors),1hia . Prerolella intermedia . Campylobacter rectus

. Fusobacterium nucleatum
. Actinobacillus actinothempeutics

. Eikenella conodens

. Peptostreptococcus micros . Treponema denticola
are

Important: Decreases in the prcvalence and numbers ofP gingivalis, T. fors)'thia. and T. denticola
associaredv,ith successftrl clinical treatment of disease.

\onspecilic Plaque Hypothesis: maintains that periodontal disease results from the "elaboration of noxious products by the entire plaque flom." lnherent in this h)?othesis is the concept that control ofperiodontal disease depends on control ofthc amount ofplaque accumulation. This h)?othesis is contradicted by the finding that some patients with little plaque have severe periodontitis.
Specilic Plaque Hypothesisi states that only certain plaque is pathogenic, and its pathogenicity depends on the prcsencc ofor increase in specific microorganisms. This conccpt predicts that plaquc harboring spccific bacterial pathogens results in a periodontal disease because these organisms produce substances that mediate the destructio[ of host tissues.Note: Acceptance ofthis h]pothcsis was spurred by the recognition ofA. actinomycetemcomitans as a pathogen in localized aggressive periodontitis.

. Gram-positive bacteria
. Gram-negative bacteria

. Both gnm-positive

and grarn-negative bacteria

. Neither gram-positive and gram-negative bacteria

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. Minimal bleeding

.'?unched-out" papillae
. Painless . Periodontal pocket formation

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The cell wall ofGram-negative bacteria consists ofa lipopolysaccharide base, also krown as endotoxin, that has significant pathogenic potential. Typically, LPS containing Gram-

negative cell wall extracts are capable ofpromoting bone resorption, inhibiting osteogenesis, chemotaxis ofneutrophils, 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 ofgingivitis . Plaque bacteria produce enzyrnes (hyaluronidase, collagenase, chondroitin sulfatase, elastase and proteqses) that may initiate periodontal disease.

Antibodies or immunoglobulins are produced by plasma cells in response to oral bacteria or their byproducts. The most numerous are IgG which act to neutralize
bacterial toxins by enhancing phagocytosis. . The most likely source of bacteria fourd in diseased periodontal tissue is subging-

.

(v,hich is produced by Bacteroides species) catalyzes the degrad.a(hydrolysist of collagen. tion 2. Hyafuronidase (which is produced by Streptococcus mitans tnd salivarius) and chondroitin sulfatase (which is pt"oduced by Diphtheroids) may lead to the destruction ofthe amorphous ground substance.

l. Collagenase

ival plaque. . The likelihood that bacterial endotoxins play a major role in gingival inflarnmation is evidenced by the following: 1. A reduction in inflammation by the removal ofplaque. 2. A reduction ofthe inflammatory state with antibiotic treatment. Important: The predominant periodontal disease is gingivitis.

T\1o forms ofnecrotizing ulcerative periodontal diseases are necrotizing ulcerative gingivitis Qr'uc) and necrotizing uicerative p€riodontitis Qr'up). These conditions rcpre;enr acute rbrms ofperiodonr tal destruction typically associated with some form ofhost compromise.

The essential components ofNUG are: . Interdental gingival necrosis: oftcn described as ..punched_out papillae '

cheral microorganisms in advance ofthe region oftissue necrosis. NUG is usually associated with pre_ disposing host factors, including stress, smoking. immunosuppression (as see, t,ith HlIt infectin), and malnutrition.

*** \briable features include a fetid oris /oftzs ive otlor),lymphadenopathy, fever, and malaise. Predominant organisms associated with NUG include p intermedia, Fusobacterium species, and splroche*l microorganisms. Note: EM studies of NUG reveal a zonc oftissue infiltration ofspiro-

. Pain . Bleeding

\L-P is distinguished liom NUG by the ross ofclinical attachment and bone in affeued sites. but rbe clinical presenration and eriologic factors are similar ro that ofNUG in the absence of systemic disease. In the presence of systemic immunosuppression, exemplified by HIV infection, Nilp may resulr in .apid and extensive necrosis to the tissues and underlying alveolar bone.
and antibiotic rherapy aPer. I/) ifthere is systemic involvement /ln anifested byfever malaise, and lym_ phadenopathr). lmportant: Patients with Hlv-associated NUG require gentte debridement and an, timicrobial rinses.

The treatment ofNUG or NUP includes debridement, hydrogen peroxide (or chlothexidine) inses,

\ote: For patients with acute herpetic gingivostomatitis: . If diagnosed within 3 days of onset, acyclovir suspension should

times daily for 7 days . All patients, including those presenting more than 3 days alier disease onset, may recelve palliative care, including plaque removal, systemic NSAIDS. and topical anesthetics ' Patients should be informed that herperic gingivostomaritis is contagious at certarn stages, such as when vesicles are present

be prescribed, 15 mg/kg

five

. Actinobacillus actinomycetemcomitans and Tannerella forsythia

. Slreptococcus

and Actinomyces species

. Treponema and Capnocytophaga species

. Prevotella intermedia and Porphl,romonas gingivalis

CopltiSht O 201l-201? - Dental Decks

Early microbiologic studies of localized aggressive perio dontitis (LllP) provided clear evidence of a strong associatlon between disease and a unique bacterirl microbiota dominsted byr

. Tannerella forsythia
. Prevotella intermedia . Porphyromonas gingivalis . Actinobacillus actinomycetemcomitans

fla)

27
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*** Gram-positive
aburdant in
a

cocci (Streptococci) and filamentousbacteria (Actinonflces) are most

healthy sulcus.

Normal inhabitants of the oral cavity: Gram-positive:

.

Streptococcus

Gram-negative: . Veillonella

. Corynebactenum

. Actinomyces

. Campylobacter
. Fusobacterium

. Peptostreptococcus

. Lactobacillus

. Eikenella
consist ofa variety ofalpha-hemolytic streptococci, including

*** Viridans streptococci

S. salivarius, mutans, sanguis, and mitis, all common

oral flora.

Important information: LThe oral cavity is usually sterile at birth. Microorganisms appear about l0-12
hours after birth. 2. After one year, the following bacteria are present: . Streptococci

- S. salivarius is most abundant - S. mutans and sanguis do not appear until teeth are present

. Staphylococci
. Neisseria
. Achnomyces

. Fusobacterium

***

By the age of4-5, the oral flora resembles that ofan adult.

Important: The new classific|tion system for periodontitis is more descriptive and not as temporal as was th€ previous system. The terms adult,juvenile, early onset, and prcpubertal have been replaced with various
l'orms ofchronic and aggressive diseas€. The majority ofpalients wilh chronic periodontitis are successfully managed with coDventional treatment reg_ imcns. Horvcver, a small proportion ofpatients do not rcspond to treatment and demonstratc conlinued clini_ cal periodonial desiruction. These individuals are referred to as "refractory periodontitis patients." In chronic periodontitis the bacteria most often cultivated at high levels include P gingivalis, T. fors)'thia, P intemedia, C. recos. E. corrodens, F. nucleatum, A. actinotherapeutics f,4d), P micros, and Trepon€ma and Eubacterium species. Dctectable levels ofP gingivalis, P intermedia, T. forsyhia, C. rcctus and A.actinotherapeuiics fldl are associated *'ith diseasc progression and their elimination by therapy is associated with improved clinical reipons.. \ote; Recent studies have documented an association between chronic periodontitis and viral mi_ .roorganisms of the herpesvirus group, most notably Epstein-Ban virus-1 and human c)4omegalovirus. The presence of these subgingival viruses is associated with putative bactcrial pathogens, including P gingivalis, T.

Ibr.!thra. P Intermedia. and f. denticola.

\ primary characteristic ofaggressive periodontitis that differentiates it fiom chronic periodontitis is lbe rapid progression ofattachment and bonc loss that is evident. Aggessive periodontitis may be localized or generalized, The classic form oflocalized aggressive periodontitis was initially referred to as "periodontosis" and then as 'local ized j uvenile periodontilis (lJP,. Localized aggressive periodontids fZ,4P,) is the new classification designated to replace LJP"
LAP is defined by several distinguishing characteristics: onset around the time of puberty, aggressive peri_ odontal destnrction localized almost exclusively to the incisors and filst molars, and a familial pattem ofoc_ curence. Aa is the dominant bacteria in LAP, other micrcorganisms that have been associatedwith LAP include P gingivalis, E. conodens, C. rectus, F. nucleatum, Bacillus capillus, Eubacterium bmchy, and Capnocltophaga species and spirochetes. Important The one outstanding negative featurc is the r€lative absence oflocal fac_ lors (plaque) to explailn the severe periodontal desfiuction which is present. ceneralized aggressive periodontitis (GlP) is differentiated from the localized form by the extent of involvement around most ofthe permanent teeth, and it is considered to include rapidly progressing periodontitis. Patients with GAP frequently have subgingival gram-negative rods, including P gingivalis, and exhibit suppressed neutrophil chemotaxis.

. Lichen planus
. Pemphigoid . Pemphigus vulgaris . Leukemia

. Chronic ulcerative stomatitis

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. Periodontitis does not always begin with gingivitis . Gingivitis and periodontitis cannot be induced without bacteria . There are no radiographic features ofgingivitis . The presence ofpockets cannot be determined from radiographs

. Chronic gingivitis

does not always lead to periodontitis

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The following diseases also present as desquamative gingivitis: Linear IgA disease, Dermatitis herpetiform, Lupus erythematosus and Erythema multiforme. Desquamative gingivitis lDG) is only a clinical term that describes a peculiar clinical picnrre. This term is not a diagnosis per se, and once it is rendered, a series of laboratory procedl[es should be used to arrive at a final diagnosis. lt is important to be aware ofthis mre clinical entity so as to distinguish desquamative gingivitis from plaque induced gingivitis which is an extrernely 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, affects the buccal/labial gingiva predominantly, frequently spares the marginal gingiva but can involve the whole thickness ofthe attached gingiva and its clinical appearance is not significantly altered by traditional oral hygiene measrres or conventional periodontal thenpy alone. \ote: The role ofplaque is vague in desqr.ramative gingivitis.

lmportant point: The multiplicity ofcauses ofdesquamative gingival lesions with a focus on
dermatologic disease makes it imperative that clinicians develop diagnostic skills and good communication with physicians such as intemists and dermatologists. Because microscopic evaluation is the foundation lor diagnosis ofdesquamative gingival lesions, clinicians must rake the responsibility to biopsy all desquamative lesions. The majority ofcases ofDG are now known to be due to mucocutaneous conditions, in parricular lichen planus, pemphigoid and pemphigus. DG can be mistaken for plaque induced gin-

siritis and this can lead to delayed diagnosis and inappropriate treatment of
dermatological diseases such as pemphigoid or pemphigus.

serious

Remember: Histologically, where non-ulcerated areas are found, the stratified squamous epirheliunr is significantly atrophic. Rete pegs are short or absent. Inflammatory cells, mainly plasma cells, may be found on the basal layer.

Periodontitis always begins as a gingivitis which is usually due to local initation, pdmarily plaque, and rhe inflammation then spreads from the gingiva and soft tissues into the underlying sfuctures. GingiviIjs and periodontitis cannot be induced withortbactetia (plaque). Periodontitis is inflammation that affects and destroys thc attachment apparatus. The clinical fcature thar djsringuishes periodontitis fiom gingivitis is the presence ofclinically detectable attachment loss. This often is accompanied by periodontal pocket formation and changes in the density and height of sub,iacent alveolar bone. Important: The progress ofperiodontitis may be arrested with proper the.apy.

Remember: lhere are do radiographic featurcs ofgingivitis. In periodontitis, radiographic changes are noted. \\hich may includc thc lollowing: . Ioss of lamina dura

. horizontal or vertical bone resorption . thickening lrlllerlng) ofthe periodontal ligament

space

Clinicai signs of inflammation, such as changes in color, contour, and consistcncy and bleeding on probine. ma! not always be positive indicators ofongoing attachment loss. However, the prescnce ofcontinucd blecding on probing at sequcntial visits has provcd to be a reliable indicator of thc presence of
rntlammation and the potcntial for subsequent attachment loss at the bleeding site.

L Importantr The prescncc ofpockets cannot be determined from

the cvaluation

ofra-

\ote.

diographs.
does not always lead to periodontitis. Chronic gingivitis may exist for long penods without advrncine to oeriodontitis. 3. Severe periodontal Jisease may be seen in patients with Chediak-Higashi syndrome, Papillon-Lefevre syndrcme, Down syndrome or?c/edsed letels ofP intermedia have been.found), lazy leukoclte syndrome, and leukocfe adhesion deficiency (LAD) 4. Chronic stress appears to have effects on the periodontium. The most notable example is the documented rclationship between stress and acute necrotizing ulcerative gingivitis /NUG/. 5. Hypophosphatasia, congenital heart disease, tetralogy ofFallot, and Eisenmenger's syndromc may be associated u.ith increased severity ofperiodontal disease. 6. Ingestion ofheary met^ls (i.e., hismuth, lead, and nercury) may result ill changes in the periodontium.

:. Cingiviris

. Gingivitis
. Occlusal trauma

. Early periodontitis
. Acute necrotizing ulcerative gingivilis

30
CopFighr
@ 201

1,2012 - Dental Decks

\ )
. Pocket depth
. Attachment loss

. Anatomical crown length

. Bleeding upon probing

31

CopriSht O

201 I,2012 - Dmtal Decks

Radiographic Changes in Periodontal Disease: . Early periodontitis: areas of localized erosion ofthc alveolar bone crest (hfuntihg oJ the crest in anleriol regiotis ahd a rounding ofthe ju ctio benreen the clest a d lanina dura in the poslerior
regions).
the destruction of alveolar bone extends beyond e.rly changes in the alveolar crest and may includc buccal or lingual plate rcsorption, generalized horizontal erosion or localized vertical defects and possible clinical evidence of tooth mobiliry. .Advanced periodontitis: thc bone loss is so extensive that thc rcmaining teeth show excessive mobility and drifting and are injeopardy ofbeing lost. There is usually extensive horizontrl bone loss or ertensive bony defects. L In gingivitis, the radiographic appearance ofthe bone will be normal. 2. The crest ofthe alveolar bone is affected in oeriodontal disease. In health. it lies l-2 mm

. Moderate periodontitis:

below the level ofthe CEJS ofadjacent teeth. 3. A reduction of only 0.5 or 1.0 mm in the thickness of the cortical plate is sufficient to permit radioeraohic visualization of destruction ofthe inner cancellous tmbeculae.
a periodontal standpoint. It is a complex metabolic disease characterized by chronic hyperglycemia. Individuals with diabctcs havc a highcr prevalence and severity ofperiodontal disease than do those without diabetes. Diabetes does not cause periodontal disease but studies show that it alters the response ofthe pcriodontal tissues to bacrerial plaque- Poorly controlled diabetics often have:

Important: Diabetes mellitus is an extremely important disease fiom

. Enlarged gingiva, sessile or pedunculated gingival polyps, polypoid gingival proliferations,

abscess

formation. and loosened teeth . Pol! morphonuclear leukocyte deliciencies resulting in impaired chemotaxis, defective phagocyrosis. or impaircd adherence . The chronic hyperglycemia adversely affects the sj'llthesis, maturation, and maintenancc ofcollagen and extracellular mat x. Numerous proteins and matrix molecules undergo a nonenrymatic glycosylation, resulting in accumulated glycation end products (,46tt.This inc.ease in AEGS affects how colJagcn is normally repaired or replaced and may play a roJc in the progression ofperiodontal
dlsease.

Afiachment loss is much more significant than periodontal pocketinB fuclualb it is the most signllicant fac' aor"/ because with attachment loss supportive structur€s are being destroyed. Pocket depth is lhe distance between the base ofthe pocket and lhe gingival margin. The level ofattachment on lhe other hand. is lhe disla.ce betwecn the base ofthe pocket and a fixed point on the crown, such as the CE-I. Changcs in the level ofattachment can be caused only by gain or loss ofattachmeni and thus providc a belter indicstion of the degree of periodontal destnrction.

Important: The rwo most critical parametets for thc prognosis ofa periodontally involved tooth are attach_ ment loss (most crilical/ and mobility. I. pe.iodontics, factors often considered in the generation ofa prognosis include, but are not Iimitcd to, tooth JFe. fufcation involvcment, bone loss, pocketdepth, toolh mobiliry occlusal forcq, patient's home care, preserce ofststemic disease, and cigarette smoking. Tle progrosis is usually classified as excelleft (no bone loss. gingival heallh. good patient cooperalion, no ;etondan svstenic or enri ronn ental .factors), good (adequate bone suppor| good patient cooperdtion. no errtronmental factors, and well-controlled systemic fadols). Jair (less han adequate bone supporl, mobiliry-,
g,d.1e I./itrcation inyol,-emenl, g(,.)d patient cooperation, and limited enircnmenlal and/or syslemiclactors), poor rnoderate lo atlvance bone lo.\s, mobilit! gade I an.l Illurcation inrolremenl, queslionable patient coLtperdtio . and presence of en$rcnmenlal and/or .\)-stemic factors), qu.estioa ble (adwnced bone loss, grade I on,l II fun:ation int'ol|ements, mobilitt', and presence o.f environmental and/or s),stemic factors), and hopeless tudwnced bone los.r, inahility to establish maintainable siluation. and the presence ofunco trolled envi,onntentol and,tor st,sten ic factors extr^.tion(s) is/are indicated/.

\otli: .].... 1,

I - Pockeling can incrcasc or decrease, depending on the amount ofinflammation without attachment loss. On the other hand, extensive attachment loss and gingival recession may be accompanied by shalfow pockets (poor progtlosis oJ tooth). 2. When thc gingival margin is located on the anatomic crown, the level of attachm€nt is determined by subtracting from the depth ofthe pocket the distance from the gingival margin to the CEJ. Ifboth are the same. the loss ofattachment is zero. 3.When the gingival margin coincides with the CEJ, the loss ofattachment equals the pocket

-

deprh. 4. When the gingival margin is located apical to the CEJ, the loss ofaftachment is grcater than thc pocket depth, and therefore the distance between the CEJ and the gingival margin should be added to the Docket deDlh.

. A hormonal imbalance . Inadequate oral hygiene

. Occlusal trauma . A vitamin deficiency
. Aging

32
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201 1-201 2

- Dmial Decks

Which of the folloring needs to be evident in order to make a diagnosis of periodontitis?

. Bleeding . Pocket depths of5 mm or more . Radiographic evidence ofbone loss
. A change in tissue color and tone

copyriSht O 20ll-2012 - Dental Decks

The initial microbiota ofacute gingivitis consists of glam-positive rods, gram-positive cocci. and gramnegativc cocci. The transition to gingivitis is evident by inflammatory changes and is accompanied first by the appearance ofgram-negative rods and filaments, then by spirochetal and motile organisms. Thc microbiota ofchronic gingivitis consists ofapproximately equal proportions ofgram-posttive (56%o) and gram-negative (ll%o/ species, as well as facllltative (59o/o) and.anaerobic fllZoJ microorganisms Predominant gram-positive species include S. sanguis, S. mitis, S. intermedius, S. oralis, A viscosus, A naeslundii, and P micros. The gram-negative microorganisms are predominantly F. nucleatum, P intermedia, and V panula, as well as Haemophilus, Capnocltophaga, and Campylobacter species.

Comparing the microbiota in hcalth, gingivitis, and periodontitis, thc following microbial shifts can be seen: . From gmm positive to gram negative 'From facultative anaerobes to obligate anaerobes . From fermenting to proteolytic spccies . From cocci to rods . From nonmotile to motile organism

All surfaces ofthe oral cavity (both hard and soft lis re.s, are coated with a pellicle (initial phase of plaque development). Within nanoseconds aftcr a vigorously polishing the teeth, a thin, saliva-dcrived later. called the acquired pellicle, covers the tooth surface. This pellicle consists ofnumerous components. including glycoproteins fmrcirsl, proline-rich proteins, phosphoproteins (e.g., .tldthetin),histidinerich proteins. enrymes (e.g., alpha-amtlase), and other molecules that can ftinction as adhcsion sites for
bacteia (receptors). BadBrelth (oral malodor). At]east 85yo of breath malodors have an oral source. Gingivitis, periodonritis and tongue coating are the predominant causes ofbad breath. The gram-negative anacrobic bacteria associated with gingivitis and periodontitis cause bad breath by their proteolysis, which produces foul-smclling volatile sulfide compounds fflcsl. is a very characteristic shift dental plaque - L The overall pattem obse ed ingram-positive developrnentmicroorganisms to the later facultative from the early predominance of Ioa{i-.:_ ..,r.t1.i predominance of gmm-negative anaerobic microorganisms.

't@'t::"

2. The major factor in determining the different bacteria is oxygen. The redox potential the gingival sulcus greatly influences thc bacterial composition.

of

to be most accurate in asscssing alveolar bonc resorption lfextensive bone loss has occurred, vertical bitewings should be taken. They will reveal more of the periodontium. Bone loss may be horizontal or vertical. AIso remembcr that more than 3070 ofthe bone mass al the alveolar crest must be lost for a change in bone height to be recoglized on radiographs Rcmember: The clinical feature that distinguishcs periodontitis from gingivitis is thc presence ofclinically detectable attachment loss.

\ote: Bitewing x-rays tend

Other cfinical criteria that should be evaluated during dnll \i:e o-/ gitlgila):

a

periodont^l e\^tn

(besiales

color' tone cotttour

. Level of the free gingival margin in relation to the CEJ:

the normal levcl ofepithelial aftachment should be on enamel or at the CEJ. This would place the hee gingival margin 2 to 3 mm coronal to this rulcuLar base. on enamel. . Periodontal pocket d€pth: all measurements in cxcess of3 mm are rccorded for sulcular deplh, as *** The loss \\ eli as any reading rvhich locates thc free gingival crcst 2 mm or more apical to the CEJ. is determined by measuring the distance between the CEJ and the base ofthe attachment ofatlachmenl . Bleeding: physiologically, bleeding from the gingival sulcus should not be caused by gentle provocation. Bleeding in the absence oflocal irritants may indicate a systemic disease. . Exudate: the presence ofexudatc, sp€cifically suppuration /wrlc h is due to the presence oJ larye numbet's al neutrophils it1 the pocket) is evaTuared by digital pressure on the buccal and lingual ofcach tooth. . )lucogingival complications: this term indicates the involvement ofnot only the gingival componenl in the disease state, but also the presence of imminent involvement ofthe alveolar mucosa

Tte follo\\'ing should

also be noted:

. Erosion:

usually found on lhe cervical area oflhe facial surlace ofa toolh . Abrasion: loss oftooth structure by mechanical wear horizonlal toothbrushing with a hard toothbrush and abrasive dentifrice is the most common cause. . Attrition: occlusal wear due to functional contacts with opposing tecth. Results in wear facets on the occlusal surfaces of teeth. . Abfraction: occlusal loading resulting in tooth flexure, mechanical microfractures, and tooth structule loss in the cervical area. . Hyp€rsensitivify of roots: duc to exposure ofdentinal tubules to thermal changes following rccession and removal ofcementum by toothbrushinS, root decay, or scaling and root planing.

. Grade 0 . Grade I
. Grade II . Grade III

34
Cop).righr C 201 l-2012 - Dental D€cks

. Subgingival

and/or overhanging margins ofrestorations

. Carious lesions that extend subgingivally
. Calculus . Furcations exposed by loss of attachment and bone . Crowded and mal-aligned teeth . Root grooves and concavities

CoplriBnt O 201 I -20 l2 - Denbl Decks

The degree ofgingival enlargement can be scored as follows: . Grade 0: no signs ofgingival enlargement . Grade I: enlargement confined to interdental papillae . Grade II: enlargement involves papilla and marginal gingiva . Grade III: enlargement covers three quarten or more ofthe crown

Using the criteria oflocation and distribution, gingival enlargement is designated as follows: . Localized: limited to the gingiva adjacent to a single tooth or group ofteeth . G€n€raliz€d: involving the gingiva throughout the mouth . Marginal: confined to the narginal gingiva . Papillary: confined to the interdental papilla . Diffuse: involving the urarginal and attached gingivae and papillae . Discrete: an isolated sessile or pedunculated, tumorlike enlargement Gingival enlargement may result from chronic or acute inflammatory changes; chronic changes are much more common.Chronic inflammatory gingival enlargement odginates as a slight ballooning ofthe interdental papilla and marginal gingiva. In the early stages it produces a life presener-shaped bulge around the involved teeth. This bulge can increase in size until it covers part

ofthe crowns. The enlargement may be localized or generalized and progresses slowly

and painlessly.

\ote:
as

Chronic inflammatory gingival enlargement is caused by prolonged exposure to denas irritation by anatomic abnormalities and improper restorative and orthodontic ap-

tal plaque. Factors that favor plaque accumulation and retention include poor oral hygiene,

$ell

pliances.

lmportant: A pseudopocket is a pocket formed by gingival enlargement without apical migration of the junctional epithelium. It does not involve the loss ofbone. Pseudopockets are also referred to as gingival, false, or relative pockets. All pseudopockets are suprabony (ie base of the pocket is coronal to tlrc crcst o;f the alveolar bone).

Djsringuishing between the effccts of calculus and plaque on thc gingiva is difficult because calculus is always covcred with a nonmineralized layer ofplaque. The nonmineralized plaque on the calculus surface is the principal irritant, but the underlying calcified portion may bc a significant contributing factor. It does not initate the gingiva directly but provides a fixed nidus for the conrinu.d accumulation ofplaquc and retains it close to the gingiva. Plaque iniriates gingjval inflammation. which starts pocket formation, and the pocket in tum providcs
a :helrered area for plaque and bacterial accumulation. The increased

flow ofgingival fluid associated

\

irh gingival inflammation provides the mincrals that convert the continually accumulating plaquc into subging!\al calculus. Calculus /xric, i.s rrineralized bucterial plaqreJ plays an important role in maintaining and accentuating periodonlal discase by keeping plaque in close contact with the gingival tissue and creating areas \\here plaque removal is impossible. O!her contnburing or complicating factors in periodontal disease includc:

.

iared $ ith lood impaction or rctcntion.
ease.

Food impaction or retention: overlapping, malposcd, tiltcd or drilled teeth arc frequently assocIfnot removed. this will lead to inflammatory periodontal dis-

. Open and loose contacts: leads to food impaction and possible retcntion. . Overhanging margins of restorations and improperly designed prostheses: can contribute to
the initiation ofperiodontal disease. There is a direct correlation between surface roughness or mariginal inegularitics ofa restoration and the retention ofplaque. . Soft or sticky consistency of dieti food debris tends to collect between the tecth and along the gingiva and can be a prominent causc ofinflammation. . \'iolation of the "biologic width": if margins of a restoration infringe upon thc biologic width (ju ctional epilhelium and con ectite ti.tsue attachmenl), gingival inflammation, pockct formation, and alveolar bone loss may occur. Note: The average biologic width is approximately 2 mm fapprormatcly 0.97 no for thejunclional epitheliuln and L03 mmlbr the connective tissue atlachment).
has been shown to increase plaque retention and to result in increases in thc melaninogenica, P intermedia, and A. odontolyticus.

. Occlusal traumatism . Orthodontic therapy:
numbers

ofP

During pregnancy there is an increase in levels of both
progesterone and €strogen. The so-called pregn|ncy tumor is not a neoplasm.

. The first statement

is hue; the second statement is false is true; the first statement is false

. The second statement . Both . Both

statements are true statements are false

Copyrighl O 20ll'2012 - Denbl Decks

.I .II
.

III

37 CoplriShi C 20ll-?012 - Dental Dects

Pregnancy gingival enlargement may be marginal and generalized or may occur as single or multiple tumorlike masses. During pregnancy there is an increase in levels of both progesterone and estrogen. Tlese hor-

monal changes induce changes in vascular permeability, leading to gingival edema and an incrcascd inflammatory response to dental plaque. Note: The subgingival microbiota may also under changes, including an increase in Prevotella iniermedia. These bacteria cmve steroid homlones for their o\r.n metabolism.
The enlargement is usually generalized and tends to be more prominent interproximally lhan on the facial and lingual surf'aces. The enlarged gingivia is bright red or magenta, soft, and tiiable and has a smooth, shiny surface. Bleeding occurs spontaneously oron slight provocation. Note: Usually appears in second or third month.

Thc so-called pregnancy tumor is not a neoplasm; it is an inflammatory response to bacterial plaque and is modified by the pateint's condition. h usually appears after the third month ofpre!$ancy but may occur carlier. The lesion appears as a discrete, mushroomlike, flattened spherical mass that protrudes from the gingival margin or more often from the interproximal space and is attached by a sessile or pedunculated base.

Important: Most gingival disease during pregnancy can be prevented by the removal ofplaque and calculus,
as

well

as the

institution offastidious oral hygiene at the outset.

Cingival diseases modified by systemic factors: endocrine changes during pregnancy, puberty, and diabetes. Blood dyscrasias fi.e., leukemia) may itltp ct lhe immun€ response as wellGingival diseases modified by medications: anticonvulsants, antih''peftensive calcium channel blockers, and immunosuppressant drugs are known to cause gingival enlargement.

\on-Plaque-lnduced Gingival Lesions:
. Gingi!al diseases ofspecific bacterial origin: Neisseria gonorrhoeae, treponema pallidum, streptococcus
species.

. Gingi\al

discases of viral origin: Herpesvirus infections (Prinary, herpetic gingivostomalilis, Recurreht oral herpes, I/aricella toster) ' cingival diseases offungal origin: Candidiasis (caused bv Candida albicons) . Gingi\al discases ofgenetic origin: Hereditary gingival fibromatosis ' Gmgival manifestations ofsystemic conditions: may appcar as desquamative lesions, ulcerations ofthe gingi\ a or both . Traumatic lesions: may be factitious f']rr'rrtentionally produced) as in the case oftoothbrush trauma, ianagenic linduced by the dertlrtl as in the case ofrestorative car€ that may lead to traumatic injury ofthe gingiva, or accidental, as in lhe casc ofdamage to the gingiva through minorbums fiom hot foods or drinks.

and rhcse cclls phagoc)'tose and

\eutrophils, or polymorphonuclcar lcukocles fPMNr), prcdominatc in the carly stagcs ofgingival inflammation, kill plaque bactcria. Bacterial killingbyPMNS involvcs both intraccllular mcchanisms tlttier phago.llosis ofbacteriu within nenbrune-bound stntdurcs i side rre.€//) and cxtracc]lular mechanisms /]-r

,lrorncdl/, such

.eled\e o/ PMN eitzlnes and oxvgen radicals outside the cell). Tl,csc cnzymcs include the MMPs fd ahx metanoras collagcnascs (MMP-8 and MMP-.,, which b.cak down collagcn fibcrs in the gingival and pcrirdonralrissues Note: oxygcnradicals buperotide and btlroge peroide) ptodnccdby PMNS and macrophagcs arc ro\rc as q cll ro ccll s of thc periodontium having a dircct cffcct on ccll functions and DN A.

e

Erfthema Bleeding on probing
Same as stage Il, plus blood shsis

R+rdiu.ed

u nh

nemission, from Ncwman MC, Tak.i HH,

K

lok*elold PR, CaranaFA . Cafta":d

\ Clntal P.riodoatob$, I tl'

..1. Else-

Stage I v Gingivitis Thc advanced lesion : cxtcnsion of thc lesion into ,lveolar bone charactcrizcs a fourth stagc knoNn as thc advanccd lcsion or phase ofperiodontal brerkdown. Microscopically, lhcrc is fibrosis ofthc gingiva and $idcsprcad manifcstations ofinflammatory and immunopathologic tissuc damagc. In gcncral at this advanccd stagc. plasma cells continuc to dominatc thc conncctivc tissues, and ncutrophils continuc to dominatc thcjunctional cpithclium and gingival crcvice.

i\-otcr Abno.malities in ncutrophil funclion found in paiicnts with neutropcnia, agranuloq4osis, Chcdiak-Higashi syndromc, Papillon-Lefevre syndrome, leukocyte adhcsion deiicicncy t)?c 1 (LAD-1), andletkoctae adhesion deficicncy rypc 2 (l,AD-2) make the patient more susceptible to aggressive periodontitis. Remember: Thc four stagcs ofthe periodontal lesion are: initiali €arly! €stablished and advanced.

. Coronary Heaxt Disease . Atherosclerosis

.

Stroke

. Cirrhosis ofthe liver
. Diabetes mellitus . Low-birth-weight delivery
38 Copright O 20ll-2012 - De alDeks

. On whether or not the patient feels that frequent visits will help maintain his/her
periodontiun . On the appearance and clinical condition ofthe gingival tissues

. On the amount of attachment . On the ability

loss prior to the periodontal treatment

and performance in home care

Copyrigh O2011,2012, Dental D€cks

Although the potential impact ofmany systemic disorders on the periodontium is well documented, reccnt evidcncc suggcsts that periodontal infection may significantly enhance the risk for certain diseases or alter fhe natural course ofsystemic conditions (see chart belov). Org'n
Systems snd Conditions Possibly Influenced

bv Periodon.al lnfeciion Cardiovrscrlrr
/

C€rcbrovlscuh. SystcD
Repmduced \nh pemision. from Newnra. MC. T.kei HH. Kloklerold PR. CamnTa F,\. Clrtun:d s Cliht.al Perialo,/o/o!pr //" P/ Elscvicr. 2(J06

Coronary hean diseasc (CHD)

Angrna Myocardial infarcrion (Mt) Ccrcb'ov&ular accident (siroke)

Endo.rln€System

Reprodrctive System
Preiern low-birth-weishl (LBw) infatts

R$pirltory Systcm
Chronic obshr€live pulmonary dis€as€ (COPD) Acutc bactcrial pncumonia

\oaes

1. The relationship between diabetes mellitus and periodontal disease has bccn cxtcnsivcly examined. lt is clear that diabetes increases the risk for and severity of periodontal diseases. Thc incrcased prevalence and scvcrity ofpcriodontitis typically scen in patients with diabelcs, especially those with poor metabolic conhol, led to ihc dcsignation of periodontal discasc as the "sixth complication of diabet€s." The others are retinopathy, nephropathy, neuropathy, macrovascular disease, and ahered wound healing. jt 2. Whcn considering f'actom that increase an individual's risk for developing periodontitis (e.g., tohocco use), and acquired risks factors has bccn rccognized that genetic, environmertal le.g., ststetric disease) can increasc a patient's susc€ptibilitl to dcvcloping this disease Risk factors can affect onset, ratc ofprogression, and severi!v ofperiodontal disease, as well as .esDonse to theraDv.

and patient is the maintenance ofgood Thc main goal of the \\ ill prevent the recurrence of disease, which is the rnain objective of the maintenance phasc of peritrdonral therapy. The primary cause ofrecurrence ofdisease is the dental team's failurc to motivatc thc parient Io practice effectivc plaque control.

Th. first !ear after treatm€nt is a critical period, since the patient has alrcady demonst.ated susceptl-

b.ilil

ro pc.rodontal disease, the cause ofwhich tends to be persistent and recurrent. The appearance and condition ofrhe gingival tissues rvill detemine ifthe patient is maintaining adequate plaquc control.

L Bleeding during circumferential probing indicates that the crcvicular epithelium is ulcer-

\or€,s ated due to active periodontal disease' l- Aiier periodontal treatment the first recall visit should bc scheduled at three months. with ' c\cellent plaque control and maintenance ofperiodontal health. thc inter'"al may be lengthencdto4-6months.
Rem€mberi

l. Pubertr- is oftcn accompanied by an cxaggerated response ofthe gingiva to plaque. Gonadotropic homones dudng pubcrty may lead to increased levels ofP intemedia and Capnoc)'lophaga species
in rhe denral plaque.
a general rulc, the nenstrual cycle is not accompanied by motable gingival changes, however, increased gingival bleeding is often seen during this timc. l. Hormonal contraceptives aggmvate the gingival rcsponse to local factors similar to that sccn in pregnancy. 4. Oral disfurbances are not a common featurc ofmenopause. Some females may develop gingivos_ IOmatltls. [a, e lrcpenia, agrrlnuloc]losis, lfuonboc\' 5. Patients with blood dyscrasias fi.e., leukemia, a topenic put'purd, €1c./ often demonstratc disturbances to the gingiva and periodontium.

:. As

e

ofyour implant restoration is rttaching an analogue to the impression post and then seating them both lnto the set impression material, you have made a/an:

If

one of the steps in the fabrication

. Open-tray impression
. Closed-tray impression

. Either ofthe above
. Neither ofthe above

40
CopFighr O 2011,2012, Dental Decks

An "impl|nt level impr€ssion' merns that;

. The impression

c

oping (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 . None ofthe above

41

Copldghr O

201

l'2012 - Dental Deck!

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 is removed lrom the mouth after setting, the impression coping remains in the mouth, still attached to the implant or abutment. The copin g (also called the impression post) is removed from the mouth, joined to an implant analogue (also called qn 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 is placed into the mouth. After the impression material has set, the retaining screw is released /azscrewed) 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.

Note: A pick-up impression may be used with divergent implants. The master impression should accurately relate the implants and/or abutments to each othe( the opposing occlusion and adjacent teeth. For the impression to be accurate, all of the components must be properly seated at the time ofthe impression. Verification ofthe proper seating ("down") of the abutrnents is difficult if the junction or the impression coping-to-implant interface is subgingival. Radiographic verification of seating is reouired before the imoression is made.

The impression coping (or impression post) was atrached to the implant at the time ofthe impression, thus recording the implant position at the "implant level". Ifthe impression coping was instead attached to the abutment (which was attached to the implant) the impression is termed an "abutment level impression."

Ifthe impression is made ofthe already seated abutment without the use ofan impression coping. just as a standard crown and bridge impression ofa prepared abutment, it is a direcr impression of the abutment.
is manufactured as an "external hex" design, this means that the antirotational component is part ofthe implant and seats into the abutment.

lfan implant

If the antirotational feature is a part of the abutment and seats into the implant body \\'hen the abutment is seated, the implant is an "internal hex" design. Aprosthesis which is anached to only one implant abutment (e.g., a single crowy' requires an antirotational component between the abutment and the implant, and between the restoration and the abutment, to prevent prosthetic component loosening secondary to the forces ofocclusion.

. The crown is retrievable

. The residual cement excess in the sulcus is avoided . The occlusal surface ofthe crown is left intact
. A shorter abutment may be used

12 Coprighr O
201 1-201 2

- Denial Dects

an implant restoration is to:

. Check on healing progress . Remove the implant for cleaning . Uncover the implant and place an abutment

. Determine which components will frt
. All ofthe above

43 Coplriglr O 20ll-2012

- Denral Decks

Access to the retaining screw that holds the restoration onto the abutment requires an access hole through the crown. This access hole must be restored after the final torque is applied to the retaining screw. This restoration is subject to failure and may need replacement periodically. In addition, this restoration is sometimes in the area ofthe crown that is in occlusion. The hole and restoration in the occlusal surface can be undesirable because of the esthetic compromise that results.

An abutment retaining screw should be tightened to a specified torque to minimize the possibility of future loosening ofthe screw or the components. A torque wrcnch (or torque controller) measures and controls the amount offorce or torque applied to the screw This
torque force applied to a screw is called preload. Implant manufacturers provide recommended torque values that are optimal for their particular components, materials and design.

Remember: In implant dentistry, ar 6'open tray" impression is used because the abutment retention screw must be unscrewed after set.
The abutment retaining screw must be unscrewed after the impression material sets, but before the tray is removed from the mouth, thus releasing the abutment from the implant. Before the impression procedure, a hole is cut in the tray, usually directly occlusal to the abutment retention screw, to allow access ofa hex driver or screwdriver to the head ofthe scren'. This feature makes the tray an'6open tray" rather than a "closed tray" (no hole). After the abutment retention screw is released, the tray is removed from the mouth with the abutment still encased in the set impression material. This is also called a "pick up" rmpresslon.

ln two stage implart syslems (also refefted to as two piece or submerged,rystans) the first stage surgery is placement ofthe implant in the bone. Then a period of time is allowed for healing, meaning osseointegration and healing ofthe gingiva over the top ofthe implant. After this healing, the second stage surgery is performed to uncover the implant, make sure there is access to it, and place an abutment e.g. a healing abutment. Another period of healing is allowed for healing and maturation ofthe gingiva. ln one stage systems (also called one piece or non-submerged r.l,s/ems), the implant is left panly or completely exposed at the time ofsurgical placement and the second stage surgery is avoided.

. Flaring or enlarging the coronal end ofthe osteotomy . Reversing the engine to remove the implant . Placing the implant in
a counterclockwise rotation

. Torquing the abufinent to place

4
Cop''righr O20ll-2012 - Dental D€cks

. .

Screw or cylinder shape Surface texture

. Alloy composition

. Surface coatings
. None of the above

45 Copright O 20ll-2012 - Dental Deck

As one ofthe final steps in creation ofthe osteotomy to receive the implant body, a special bur is activated and inserted into the occlusal end of the osteotomy in order to increase the diameter ofthe opening slightly or to otherwise shape it. This step is referred to as "countersinking." Countersinking the implant osteotomy is called for by some manufacturers to compensate for very dense cortical bone or to prepare the bone for a particular implant shape (e.g., a flared implant shape at the coronal end). Another ofthe final steps in the creation ofthe osteotomy is to place a threaded bur into

ofthe osteotomy. This groove is placed so as to receive and guide the threads on the side of the implant during surgical placement and thus minimize the torque required and to minimize heat. This process of creating the groove on the inside ofthe osteotomy wall is referred to as "tapping" the osteotomy.
the osteotomy so as to create a spiral groove on the wall the osteotomy are used at relatively slow speeds (xp.m.) lo prevent injury to the bone, especially overheating ofthe bone. Also, water or saline irrigation is used to cool the burs and the bone during drilling.

All ofthe burs used to create

Dental implants are manufactured in several categories ofdesign and shape such as blades and root form implants. Root form implants are produced as a straight cylinder or as a basic screw design having threads. This basic overall design is the macrostructure ofthe implant. A cylinder shaped implant is pressed into a tight fitting osteotomy (pressJit). A. screrv shaped implant is screwed into the bone and this provides added stability. Screw shaped implants can be tapered. Implant macrostructure is also referred to as "implant

geometry'." The microstructure of the implant is descriptive of the surface quality or surface alteration. Implant surfaces can be described as "machined" which is a relatively "smooth" surface as produced by the original milling process. It is not as smooth as a "polished" surface such as the polished collar prepared lor gingival soft tissue attachment. Implant surface alterations are secondarily incorporated to produce surface roughness which has been shon'n to be more advantageous thar smooth surfaces for promoting osseointegrarion. Sandblasting, acid etching, and titanium plasma spray processes are examples ofthe roughening techniques. Chemical additives can be applied to enhance bone apposition k. g., htdroxyapatite surface coatings).

. Established by keratinized mucosa
. Established by non-keratinized mucosa . Dependent on hemi-desmosomes

. Comparable with the interface on teeth
. All ofthe above

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The advantage ofusing a screw-shaped implant instead ofa straight cylinder implant wlthout threods is:

. Easier osteotomy preparation . lncreased initial stability . Less force required to insert the implant
. No antirotational components are necessary

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The irnplant or the abutment must pass through the gingiva to be utilized in the mouth. The epithelial attachment to titanium cal be formed by keratinized gingiva or by nonkeratinized mucosa and is comparable to the analogous attachment of long junctional epithelium to the tooth. The epithelial attachment is composed of hemidesmosomes and a basal lamina. In addition, a sulcular epithelium forms. Between the junctional epithelium and the bone, a zone ofconnective tissue is present.

Implants have a "biologic width" of 3 to 4 mm. Connective tissue fibers are present as circular fibers oriented parallel to the implart or abutment surface, but no connective tissue fibers insert into

titanium.

Note: Epithelium forms apically to approximately
around the imDlant.

I to 1.5 mm from the crestal

bone

A screw shaped implant engages the walls ofthe osteotomy and is therefore more likely to be stable. The osteotomy preparation might be more difficult to accomplish if tapping the site is required. ("Tapping" in this conte means producing thread grooves inside the osteotomy that are meant to receive the threads of the inplant.) The clinician's control over the vertical positioning of the implant is increased when using a threaded "screw" implant as opposed to a "press lit" implant that relies more on precise preparation and sizing ofthe osteotomy for frictional holding ofthe implant.

Jote: Antirotational elements are incorporated to prevent rotation ofthe attached abutment or the restoration, not the implant itself.

. CEJ
. Apical end ofthe implant

. Ball tip ofthe probe

. Implant shoulder or other permanent physical structure . Radiograph

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. ...\ lmplants -)

Ifthe implant to abutment interface consists ofa permanent extension on the top ofan lmplant and a receptacle inside the abuiment, the impl|nt connection is categorized as:

. An intemal connection

. An extemal connection . A cone in a socket connection . A non-engaging connection . A rotational element

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When detemining the attachment level on teeth, the CEJ is used as the landrnark to determine attachment level. Because an irrplant and its restoration have no CEJ, another permanent and accessible structure must be selected to be the landmark. This is often the shoulder of the implant or the restoration margin, The correct terminology for this meas[rement becomes "relative attachment level," relative to the selected landmark, instead of "clinical attachment level" on a tooth. Probing depths around implants are determined with a standard shaped periodontal probes, with plastic probes generally recommended instead of metal orobes.

The junction ofthe abutment and the implant is important from an engineering standpoint and a biological standpoint. The restorative platform ofthe implant forms an interface, or a joint with the abutment. This area is also referred to as the microgap. The precision of

fit between these components influences how much movement will occur between these pans and how well the associated screws will remain tightened over time. Precision fit. internal or external connection, and antirotational elements are part of this juncrhe

iion and all require close manufacturing tolerances.
The closeness of the fit ofthe components plays a significant role in how much bacterial contamination occurs at the interiace. The term microgap emphasizes the space bet\\.een the components and the space available for bacterial growth and the resultant inflammation at the location. Achieving a precise fit ofthese 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.

The healing reaction of the bone surrounding the microgap is determined by the macrostructure of the implant, the precision of the fit, and the location of the microgap.
Bone remodels and adapts to different configurations and locations ofthe interlace 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, in the order of0.2 mm per year.

Which of the following occlusal conditions would exert the lowest amount dfbiting force under normal conditions?

. Complete dentures resting on soft tissue . Complete dentures supported by implants
. Fully dentate occlusion . Maxillary complete denture opposing natural teeth

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. Occlusal overload
. Bacterial plaque . Micromotion during healing . Excessive cantilevering ofthe prosthesis
. All ofthe above

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al Decks

Patients having complete denhrres supported by soft tissue only tend to apply about one sixth ofthe occlusal force compared to the fully dentate occlusion or a complete denture opposing natural dentition. Occlusal forces produced by full arch dentures supported by implants produce about the same force as fully dentate occlusal schemes.

The two most common causes of peri-implantitis are considered to be plaque and occlusal overload. Excessive cantilevering of an implant-bome prosthesis will result in excessive occlusal force on the implant as well as off-axis loading. Occlusal forces that are within the long axis ofthe implant are best tolerated by implants. Lateral forces are less-w€ll tolerated and can be harmful ifexcessive. Lateral forces on implants magnif the amount of stress on the crestal bone surrounding the implant. Off-axis loading ofthe implant is a term used to describe this situation. Inplants $'hich have beenjudged to be a failure because ofinfection, bone loss and/or mobility must be removed. Ifan implant is mobile, it can probably be extracted fairly easily. Ifan implant needs to be removed but is not mobile, it is still osseointegrated to some degree. Extraction may be possible, with effort, or the implant must be removed with a special drill called a trephine drill. A trephine drill is a cylindrical, hollow, open ended bur desigrred to fit over the implant and cut down the sides ofthe implant to release the implant from the bone. This may cause a significant amount ofbone damage or bone loss and a bone graft is sometimes placed following removal ofthe implant.

Ifan implant isjudged to be unusable from a prosthetic st^ndpoint (e.9., poor angulation or location) but is not otherwise failing, it may be covered with soft tissue and allowed
to remain unused in the bone for an extended period of time. This is referred to as a "sleep-

ing" implant.

. Primary stability of the implant . Limited micromotion during healing

. Minimization of surgical trauma
. Uncontaminated implant surfaces

.All ofthe

above

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"Site development" for implants includes all ofthe following techniques l9XCl9PI one. Which one the EXCEPTIOM

. Guided

tissue regeneration

.

Socket grafting

. Bone grafting with cow bone . Bisphosphonate supplementation for bone density

. Onhodontic tooth movement

Coplright O 20ll-2012 - Dental Decks

At the completion of surgical placement ofan implant, the implant must not be movable in the osteotomy. This condition is termed "primary stability of the implant." If the implant is not protected from excessive forces during healing (e.g., occlusion) the implant experiences movement relative to the surrounding bone. Ifthis "relative motion" or "mi-

cromotion" persists, osseointegration will be prevented.
Surgical trauma can prevent the formation of osseointegration by damage to bone cells, often because ofexcessive heat generated during drilling procedures. Sharp burs, intermittent drilling pressures, ard irrigation for cooling of the burs and site prevent or limit this injury to the bone. The limit ofheat is 4? C for less than one minute.
The implant is sterilized by the manufacturer and protected with packaging to preserve the oxide layer @O) which is apassivization layer and critical for osseointegmtion. These

conditions must be maintained before the implant is placed into the osteotomy.

Bisphosphonates (e.g., alendronate) are used to treat osteoporosis and cancer Bisphosphonate therapy, especially a history of I.V. bisphosphonate therapy is one of the few absolute contraindications for implant placement. BONJ, or bone osteonecrosis ofthe .jau. is a serious complication and is difficult to manage successfully. It can occur folIorr ing dental surgery such as extractions and dental implant placement. Guided tissue regeneration techniques have been adapted for bone augnentation in edentulous areas and the techrique has become klown as guided bone r€generation. Several bone graft materials, and combinations ofthese 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 which is transplanted to the recipient from a member ofanother species. It can be combined with an autograft fo r autogenous bone) from lhe 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 ofteeth to bring bone volume occlusally with the tooth and thus increase bone volume at the site ofthe planned imDlant Dlacement.

. Prevent rotation of multiunit restorations
. Prevent rotation ofthe implant . Prevent rotation ofthe abutment in the implant

. Prevent over-torquing ofthe abutment screw
. All ofthe above

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Coprighr O 20ll-2012 - Denral Decks

. At the end ofthe surgical procedure

. Following the final torque application to an abutment
. Anytime the fit or seating ofa component must be verified

. Intraoperatively to verify implant position
. Al1 ofthe above

Coplright C 201 I -2012 - Dmtal Decls

The antirotational element is designed to prevent rotation ofthe abutment, and tlus prevent loosening ofthe abutment screw which holds the abutment to the implant.

Antirotational elements between the implant and the abutrnent are described as "external" or "internal." The extemal type consists ofa permanent extension ftom, as part of, the implant which fits into a receptacle in the abutment. An "intemal" antirotational element has the extension as a part ofthe abufinent which fits into a receptacle in the implant. Antirotational elements are also added to abutments to prevent the rotation ofattached single unit restorations such as a single crown. Multiunit restorations do not require antirotational features to prevent them from rotation on the abutment since they are connected to two or more imDlants or abutments.

Radiographic verification that the desired anatomic placement ofthe implant or implants has been achieved is desirable at the completion ofthe surgery to make sure the implant and any vital structures nearby are separated as planned. Also, positioning of the implant/s/ from a prosthetic standpoint can be assessed and corrections made at this time necessary. In addition, the surgeon should have documentation ofthe successful implant

if

placement before the patient is dismissed. The surgical placement radiograph is an imponant baselin€ record that will be used for comparison at multiple time points during
rhe life

ofthe implant.

During the surgical procedure in which the implantfs) are placed, radiographs can be taken of depth gauges, the drills, the implant itself or other markers in order to judge whether the proper depth or anatomic location has been achieved before further drilling or implant
ad\ ancement is accomplished.

Alier the final torque is applied to a long-term healing abutment, an impression coping /posr, or the final restoration, verification ofthe proper mating ofthe components is necessary. Impressions for fabrication of prostheses and the subsequent laboratory procedures that rely on the impressions cannot be accomplished accurately if any of the components are not joined together completely, also referred to as being "down." Inaccuracy during the fabrication ofa restoration will prevent the prosthesis from fitting passively to all ofthe implants involved. This non-passive fit can lead to implant failure.

. Osteotomy . Bone channel

. Smokestack
. Callus core

. Chimney

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PERIODONTICS

Which of the following was/were included in the 1986 Albrektssou et al criteria for functional implant success?

. Implant is immobile and has no peri-implant radiolucency . Bone loss is less than 0.2 mm./year after the first year of service
. Absence ofpersistent and/or irreversible pain, infection, paresthesia or violation ofthe mandibular canal

.
.

Success rates

ofat least 85olo at year 5 and 80%

at year 10

All of the above

Copyrigbr O 20ll'2012 - Dental Decks

The osteotomy is prepared with precision in order 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. Ifthe 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. A drill designed as a "thread tap" is used for this purpose. Many implants are designed to be "self+apping," meaning that tapping ofthe bone as a separate step is not necessary because the threads ofthe implant are designed to engage the bone and guide the implant forward.

Ifthe osteotomy is too large for the implant diameter, or ifthe osteotomy is over-prepared or poorly-prepared, the implant will lack primary stability, an unacceptable result which rvill cause osseointesration 10 fail.

This s€t ofcriteria is often quoted to help define or determine whether or not an implant is successful.

Implant rnotrility indicates loss of osseointegration and irnplant failure. Implants with only partial loss of osseointegraiion will still be stable. A peri-implant radiolucency indicates that bone is not in contact with the implant and it suggests loss of osseointegration. A peri-implant radiolucency often has the appearance of a distinctly widened periodontal ligament on a natural tooth. Persistent pain, infection, or paresthesia are not normal implant outcomes and indicate definite complications of implant placement. -{ radiographic appearance of violation of the mandibular canal by an implant could be misleading and would not, by itself, define failure. Radiographic confirmation ofthe implant malposition, particularly in combination with persistent pain, infection or paresthesia u'ould mean failure. Success rates are generally higher than 80-85% today, with 95% and higher being expected.

. Pain

. Mobility

. Loss of osseointegration

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. A cold weld
. Ankylosis

. Osseointegration . Metal callous formation

59 Copyright O 201 I -20
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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 ofbone, 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, ifpossible. Note: "Black triangle disease" refers to an absence ofone or more papillae following implant therapy and restoration.

Osseointegration means direct bone-to-implant contact with no intervening periodontal Iigament or any other tissue. There is no insertion ofconnective tissue fibers into titanium meaning there cannot be a fi.rnctional periodontal ligament. Connective tissue presence around an implant means failure ofosseointegration 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 oxrde (TiO) which is biologically inert and prevents host tissue access directly to titanium itself, and allows osseointegra-

tion.

-\t the light microscopy level, there is an intimate association of bone to the titarium. \\'ithin a few weeks ofplacement ofthe implant, woven bone is laid down at the bone implant interface, Woven bone is characterized by a very random orientation ofits collagen fibrils and it is the first bone to be established on the implant. Within a few more weeks,
rhe \I'oven 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.

)r{ote: Roughened implant surfaces, for example those created by sandblasting and acid etching etc. encourage ald accelerate the bone formation at the titanium surface.

. Relatively

soon after surgical implant placement

. Relatively late, following placement ofthe prosthetic restoration . Either of the above . None ofthe above

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'..1'-.,r...

PERIODONTICS

Implant

. True . False

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lmplant 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 ofthe prosthetic restoration on the implant. Early failur€s are related to surgical trauma ard/or implant instability at the time ofplacement. Late failures are most often related to microbial plaque accumulation equivalent to periodontal disease and/or to excessive occlusal forces

"Peri-implant mucositis" denotes inflammation ofthe soft tissues surrounding the implant but with no loss of bone. "Peri-implantitis" refers to this inflammation but with accompanying loss of implantsupporting bone. Both conditions require treatment.

Implants are essentially ankylosed structures and do not erupt or move physiologically rrithin bone. If the growth ofthe individual has not been completed, the original positioning ofthe implant in the jaws may become increasingly unfavorable due to changed shape or size of the surrounding tissues. Early successlul esthetic outcomes can be lost. The implant may also prevent normal development ofthe jaws.

. Type I bone . Type 2 bone . Tlpe 3 bone . Type 4 bone

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.35%

.50-60%
.74% .
90

-

95o/o

.100%

Copfight €,

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Bone quality is categorized according to its cortical plate thickness and cancellous/trabecular density. The thicker the cortical plate and the higher the cancellous density, the higher the quality ofthe bone in terms of implant stability and support. Type I 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 ofa thin layer ofcortical bone surrounding a dense core of cancellous bone. Type 4 bone is characteristic ofthe 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: . Cigarette smokers . Poorer "quality" bone . The ma,rilla than in the mandible . Uncontrolled diabetics

Risk factors for implant failure or complications include metabolic diseases which can influence systemic healing. Uncontrolled diabetes is one of these conditions as are bone metabolic diseases, history of head and neck radiation therapy and immunosuppressive medications. Implant failures are recognized to be more frequent in smokers. Failure rates are highest where the bone is ofthe poorest quality, such as D4 bone quality bone in the posterior maxilla.

In patients with normal healing capabilities, especially good bone healing capabilities, and sufncient bone olgood quality, implant success rates are often quoted in the range of
90 - 95%.

Diminished healing capacity would possibly be encountered in patients with r.rncontrolled or poorly controlled Diabetes mellitus, irrmunocompromised states, radiation treaftnents 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 ofdental implants, however, failure rates are higher in smokers. The failure rate is related to the amount of smoking on .r daill ba'is and the paclvyears history for the patient. Rememb€r: Implants should not be considered for children who are still experiencing
sro\r'th.

. High smile line, thick periodontal biotype . Low smile line, thin periodontal biotype . Low smile line, thick periodontal biotype

. High smile line, thin periodontal biotype

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. Do not move in
. Do not have
a

response to orthodontic forces

periodontal ligament
and later removed

. Can be placed

. Can be located to gain force advantage
. All ofthe above

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A low smile line indicates that the patient does not lift the lip upwards when smiling to
the extent that the gingival-restorative interface can be seen by the observer. Consequently, esthetic compromises may be more acceptable to the patient because they are not routinely visible. A thick periodontal biotype indicates that the patient has thicker, denser gingiva with a less pronounced scallop. This type oftissue is more resistant to recession caused by restorative procedures and materials, a lower chance of "show-through" of

the implant or abutment ald a lower chance ofloss ofthe papillae adjacent to the implant.

Abutments can be made from metal or ceramic materials. Aluminum oxide and zirconium ceramic abuhnents can be fabricated by CAD/CAM (Co mputer Aided Desigtr/Computed Aided Manufacture) methods and milled by machine. Note: Ceramic abutments
may be more subject to fracture than titanium or other metal abutments under heavy occlusal loads.

Inplants do not move in response to orthodontic forces because they do not have a periodontal ligament. Thus, bone carnot be resorbed and replaced at the bone-implant interface, as around teeth, to make implant movement possible. Certain types of implants
can conveniently be placed for anchorage on a temporary basis and then removed later

fol-

lowing completion of the orthodontic treatment.
The periodontal ligament is responsible for proprioception around natural teeth. The lack ofthe periodontal ligament around implants results in a much reduced tactile sense of $ here the implants are in relation to the opposing occlusion. There is a phenomenon thar develops with time called osseoperception which gives the patient a certain amount of tactile sense regarding the implants in the bone.

. Direct palpation of the bony ridges

. Determination of any limitations of mouth opening . Cross-sectional imaging

.

All ofthe above

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Deck

. Circular

course

ofthe intemal maxillary artery

. Maxillary sinus extension towards the canine tooth

. Course of the inferior alveolar nerve anterior to the mental foramen
. Necessity for angled abutments . None of the above

Coplright O 20ll-2012 - Dental Decks

The assessment ofthe prospective implant patient should include direct palpation of the bone contours in the area ofthe planned implant tojudge for adequate bone volune. It is particularly important that the lingual contours ofthe mandible and any possible concavities such as the submandibular fossa be explored since surgical encroachment on such areas can lead to life-threatening complications for the patient. Cross sectional imaging is not absolutely r€quired but it is far superior to two-dimensional radiography and will be considered the standard of care in many locations. Defense ofthe omission ofcross-sectional imaging analysis would seem difiicult in the event of a surgical complication.

Note: Limitations of any mouth opening ability on the part of the patient can preclude placement ofan implant due to the inability to accommodate the handpiece and drills.

When treatment planning mandibular implant locarions, 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 identifu the canal ofthe inferior alveolar nerve as it approaches the mental foramen, the implant location should be planned to be at least 5 mm or more anterior
Io the foramen.

The inferior alveolar nerve also courses from lingual to buccal as it moves anteriorly. \&'tren planning implant position, the osteotomy preparation should be planned to end a minimum of 2 mm vertically away flom the mandibular canal, and 2mm away from ary
other vital structure.

\ote: Ifan implant system is designed to be surgically placed with part ofthe implant body exposed to the oral cavity after flap closure, it is a one-piece or non-submerged imnlant.

. True . False

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The heafing abutment placed at the stage Il (uncovering) strrgery for a two-piece implant system should be:

. Approximately one to two mm "taller" that the height ofthe tissue

. Out ofocclusion
. Radiographically confirmed
as seated

. Designed to shape or mold the tissue
.

All ofthe

above

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This concept was adhered to in the early techniques for surgical placement oftwo-piece (or tu)o-stage, or "submetged") implant systems. Two-piece systems typically involve initial osseous placement ofthe implant ard coverage with primary closure ofthe gingival flaps. Current surgical placement techniques for two-piece systems also include leaving the attached abutrnent exposed to the oral cavity at the time of implant placement. One-piece systems (also called one-stage or non-submerged systems) are typically placed with the implant exposed to the oral cavity, also called "transgingival" placement. A "radiographic stent'or guide: . Identifies proposed implant sites in the radiograph . Positions opaque markers in the radiograph . Correlates information on the radiographs, cast, & wax-up . Can help identif distortion in the radiograph

It is possible for an implant that was surgically placed with primary stability and given adequate time to osseointegrate can subsequently be found to rotate in the osteotomy at the time of the second stage surgery. This rotation is sometimes detected when the healing abutment is attached to or torqued onto the implant. Although mobility ofan implart is considered a sign of implant failure in other circumstances, the rotation ofthe implant at second stage surgery may possibly be overcome by replacing the cover screw. covering rhe implant with soft tissue and allowing the site to heal for an additional 3 months. The irnplant is taken completely out of function for this period of time.

. Cone beam computed tomography . Panoramic radiography

. Conventional linear tomography
. Cat scars

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.

Soft tissue observation

. Radiographic assessment . Probing

. Visual inspection of implant components
. All ofthe above

71 Copyright @ 20ll-2012 - D€ntal Decks

Cone beam computed tomography is a 3 dimensional imaging modality that produces digital data that can be reformatted to produce multiple cross-sectional slices and other views ofthe jaws. Cone-Beam CT exposes the patient to a relatively low dose of radiation when compared to medical grade computed tomography. "Cat Scan" refers to computed tornography. 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 bluned out in the image. Image quality oflinear tomography is ofsignificantly lower quality than Cone-Beam CT.

Tissue observation around implants is based on many of the same parameters that are used when assessing natural teeth. Bleeding on probing, or absence ofbleeding on probing, are useful indicators of inflammation. Purulence, edema, erythema, and loss ofattachment 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 probhg depths tend to harbor a more pathogenic flora. Probing depths can be difficult to measure due to the size and access limitations of implart restorations. Changes in attachment level around an implant are useful in recognizing progression ofperi-implantitis.

Remember: The term '6relative 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 scratch-

ilg

of titanium cornponents.

. A minimum of3 mm of space between adjacent implants

. At

least 2 mm ofbone remaining between the implant and vital structues

. At least one mm ofbone surrounding the implant in all dimensions . A minimum of l6 mm of implant length for stability . Placement ofthe restorative platform apical to the CEJ's ofadjacent teeth

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Which of the following factors determine(s) which abutment the restorrtive dentist should select:

.

Soft tissue (mucosal or gingival) height
space

. Interarch

. Implant angulation
. Esthetic requirements . All ofthe above

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Implants of10 to 14 mm length are routinely used successfully and achieve adequate primary stability. 16 mm ofavailable bone height (plus a 2 mm margin of safety from adjacent vitql structures) is not usually available or required. 10 mm implants are generally considered the minimum recommended length, although 8 mm and shorter implants are available. The term

"vital structure" refers to any structure that the surgeon should avoid contact-

ing during implant placement (e.g., the inferior alveolar nene, the maxillory sinus, roots of nearby teeth qnd blood vessels, especially on the lingual aspect ofthe mqndible). A2 mm margin of safety is usually allowed between the limit of the osteotomy and any vital structure. Less than 3 mm ofbone between adiacent imDlants risks bone loss in the area
and esthetic consequences.

Primary stability is a primary objective at surgical placement ofthe implant. It depends on the overall shape or geometry of the implant including the presence of threads, the precision olthe osteotomy preparation and the quality ofthe bone at the site. For the implant to achieve osseointegration, primary stability must be achieved at th€ time ofsurgical placement.

Ideally, the abutment t)?e is selected during the treatment planning process for the implant and restoration. "Stock" abutments (made in standard sizes) can be selected to accommodate a cemented or a screw-retained restoration. Abutments can be used to compensate lor an irnplant angulation which must be different from the desired restoration angulation or position. The abutment should be long enough to provide adequate retention, but short enough to allow the combined abutment and restoration to fil into the space available benveen the occlusal aspect ofthe implant and the opposing occlusion. This space is refened to as the "interarch space" or "restorative space." Different material compositions of abutments can be selected for ootimum color effect.

. The abutment to implant connectlon . The shape ofthe abutment's restorative paxt
r Prcs<-fif imnlrnic

. Threads on

a screw implant

. An implant milling machine

71 cop)righl C 20ll-2012 - Dental Decks

A "polished collar," or the smooth polished exterior surface ofthe closest to or in the oral cayity is designed to:

impl|nt

. Provide

a location for epithelial attachment

. Make the exposed surface cleansable . Keep plaque from gaining access to deeper sh:rrchlres . Inhibit biofilm formation
.

All ofthe above

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A Morse taper is a cone in socket type ofconnection design for the fitting ofthe abutment into the implart. As the cone is forced (tightened) tnto the socket, the connection becomes increasingly tight and resistant to movement ofthe abutment. This stability can be incorporated as an antirotational element to keep the abutment from rotating in the implant. The cone in socket fit can also produce a very closejoining ofthe metal components which inhrbits bacterial contamination ofthe ioint.

The soft tissue interface can be keratinized gingiva or non-keratinized mucosa, both seem clinically acceptable. ln early implant designs, it was thought that the polished surface of the collar would allow for an epithelial attachment that would keep plaque form reaching the non-polished or roughened surface in the bone. Plaque is less likely to form olr a smooth surface than on a rough surface. Epithelium can also form an attachment on
a roughened surface.

Remember: The interface between epithelial cells and titanium is composed of
hemidesmosomes and a basal lamina. The epithelial attachment is identical to a natural rooth. \\ ith a long junctional epithelial attachment. A sulcus forms lined by sulcular epithelium rvhich then transitions into oral epithelium

\ote:

of connective tissue with

Interposed between the epithelial attachment and the marginal bone is a dense zone a somewhat limited vascularity.

. Cemenled crown to the abutmenL

.

Screw-retained crown on the abutment

. Restoration which fits to the implant with no abutment
. Abutment with a ball extension for a removable prosthesis

Coplrigh O 20ll-2012 - Dental Decks

. Powered toothbrushes . End-tufted brushes . Plastic curettes . Conventional ultrasonic tips
. Floss, especially multifilament varieties

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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 which are designed to fit directly to the implant with no intervening abutment.

Titanium

as a

metal is relatively "soft" and can be scratched on the surface fairly easily. Plas-

tic curettes. mther than metal curettes, are recommended for titanium surfaces on implants
and abutments, particularly subgingivally. The same applies in the case ofplastic periodontal probes instead of metal probes on titanium. Powered toothbrushes have been shown to be acceptable on titanium surfaces. Floss is not harmful to titanium surfaces, nor are conventional roorhbrushes and end-tufted brushes,

Conventional metal ultrasonic tips should not be used because they do significant damage to rianium components. However, specially designed ultrasonic tips having plastic or other softer coatings are available and these are acceptable. The underlying principle is that whatever is selected to clean titanium surfaces must not scratch or pit those surfaces.

.\ll ofthe following

products can be used on implants and other titanium surfaces:

. Chlorhexidine mouth dnses

. Phenolic compound mouth rinses . Water jet irrigators . Rubber cup polishing with fine pumice
The reaction to plaque by the tissues surrounding an implant is very much like the tissue reaction to plaque by the tissues around teeth. Implant maintenance is based an the principles of periodontal maintenance and patients ate thus instructed in cleaning methods to personally remove plaque on a consistent basis. Patients are also advised to retum for cleaning ofthe surfaces ofthe implant system that are exposed to the oral environment. Titanium surfaces are subject to the formation ofplaque and calculus. A suggested interval for implant maintenance appointments is every thr€e months for cleaning ofthe surfaces and inspection of the pans

ofthe system which

can become loose with

flnction.

Peri-implantitis can form around implants in response to plaque. This process is very sitnilar to that ofperiodontitis with many ofthe same organisms involved in etiology.

. Diminished healing capacity ofthe patient's

tissues

. Current chemotherapy for the treatrnent of cancer
. History ofradiation therapy to the maxillofacial complex

. Dysmorphophobia
. Advanced patient age

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. Replacing the implant to get a better abutment selection . Changing to a wider abutment for molar contours
. Changing to
a shorter abutment to hide margins

. Matching

a smaller diameter abutment

with

a

wider diameter implant

. Converting a round abutment to triangular

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Advanced patient age is not a contraindication to implant treatment. The ability of the patient to withstand surgical treatrnent, etc. is a decision resting on the systemic health

ofthe patient. Any condition that causes an impairment ofthe patient's ability to heal should be considered as a contraindication to implant treatment. Serious psychiatric conditions such
as psychoses should be considered a contraindication to implant treatment. Dysmorpho-

phobia is

al extremely irrational

fear ofbeing disfigured by treatment. Psychiatric com-

plications can make the patient change his or her opinion about the acceptability
treatrnent which is difficult for the clinician to overcome.

of

Platform switching refers to combining an abutment ofa particular diameter with a nonmatching diameter implant. Typically, this is a smaller diameter abutment connected to a larger diameter implant. This combination is advantageous in terms of reducing the amount ofbone remodeling and bone loss that normally occurs following placement of the abutment and the restoration on the implant.

Different designs of implarts have typical patterns of bone remodeling following final placement ofthe abuftnent. The physical location and the design ofthe abutment to implant connection play a role in localization of inflammation in the adjacent bone and the remodeling outcome. This connection has commonly been in the form ofa butt joint befir'een an abuhnent and an implant ofthe same diameter. This physical combination, even under the best circumstances, allows some degree ofbacterial activity between the components, and ifthis abutment-to-implant interface (or "microgap") is located at or under the bone crest, increased bone loss or remodeling can occur By combining the smaller diameter abuftnent with the larger diameter implant, this interface is moved slightly away ftom the bone resultins in less crestal bone remodeline.

. The patient will have difiiculty cleaning the area . Bone loss will probably occur between the implants . The presence ofa normal papilla is unlikely

. Optimum esthetic contours will
. All ofthe above

be prevented.

EO

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. Plasma cells . Red blood cells . Leukoc).tes

. Sertoli cells

81 Cop,'righr O 20ll-2012 - Dental Decks

When adjacent implants are treatment planned, there should be sufficient space for a minimum of 3 mm of bone remaining between the implants. This distance will prevent or limit the amount ofbone loss that occurs between the implants during the normal osseous remodeling that occurs after abutment placement. If the implants are closer than 3 mrr, bone loss is likely as the two remodeling processes coalesce. In addition, if subsequent bone loss occurs due to peri-implantitis on one of the implants, this can affect the bone on the adjacent implant ifthey are too close together The amount ofspace required to successfully position, restore and maintain the implant(s) must be calculated with the planned implant diameters considered. If adjacent implants are too close to one another, oral hygiene efforts by the patient are compromised due to lack of access for hygiene measures. Peri-implantitis can result.

Maintaining or creating an esthetic papilla between two adjacent implants is a major challenge, and bone loss behveen the implants makes formation ofa full papilla even more unlikely. An unesthetic open space can easily result and is commonly referred to as a "black triangle." The shape ofthe matured new papilla is dependent on the distance between the implants. the bone remaining, the depth of the implant placement, ard the shape of the restorations. Vertically, only 2, 3 or 4 mm ofsoft tissue height can be expected to form ben\ een two implants.

Implant placement adjacent to a natural tooth should allow a minimum of1.5 mm ofremaining bone between the implant and the tooth. To allow for an esthetic emergence profile. an implant should be surgically positioned 2 to 3 mm apical to the adjacent tooth CEJ. The presence of a papilla between the implant and the natural tooth is largely dependent on the bone level remaining on the natural tooth.

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
.,A.cute

***

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 leukocltes found in tissues. Among the most important resident leukocytes are mast cells, peripheral dendritic cells, and monoc)'te derivatives such as dermal dendrocyes /iilrrio.y/es). These resident leukocrtes transmit information that initiates the process of immediate inflammation.

Irnnediate inflarnmation is followed within minutes by a short-lived period /ap to seleral lorasl ofacute inflammation that is characterized by an influx ofneutrophils to the area after they exit the blood. Ifthe problem is not resolved, acute inflammation gives way to a potentially unending period ofchronic inflammation dominated by the migration of lvmphocytes and macrophages to the local tissues. Cells ofthe inrnune system that are important in inflammation and host defenses include mast celfs, dermal dendrocytes (ft istiocytes),peipheral 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 ofthe innate immune response (li'om birth). Lymphocytes (T cells, B cells, and plasma cel/s/ are considered to be part ofthe specific immune response and develop antigen-specifi c responses throughout life.

\ote:

. plasma cells, basophils, eosinophils
. macrophages, eosinophils, lyrnphocyes . macrophages, lymphocy.tes, basophils . lymphocytes, macrophages, eosinophils

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ERIODONTICS

Z\ '

.

Which cells of the immune system possess rsceptors for the complement component C3q by which they participate in immediate inflammation?

. Peripheral dendritic cells

. Dennal dendroc)tes (histiocytes)
. Monocytes . Natural killer (NrKl cells

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Stages of Acute

Inflammation: injury there is a briefperiod oflocalized vasoconstict-

l. Vascular

Phase of Inflammation . Vasoconstriction - Immediately following tissue

ion. . Complement activation and mediator rel€Nse -Tissue injury, or the presence ofbacteria, activates complemcnt. C3b mofeculcs formcd in this process bind to microbes and injl]Jed.tissve (opsonizatior.). C3a and C5a (chemotaxins) trrggcr thc release ofhistamine and serotonin from nearby mast cells. Tissue injury also triggers the formation ofbradykinin and initiates the slnthesis ofpros€glandins alrd leukotrienes. . Vasodilation - Ilistamine, and the other vasoactive mediators of inflammalion, then cause relaxation of smooth muscle in arteriolar and capillary walls. Vcssels dilate increasingblood flow to injured tissues. This is manifested by r€dness (hlperemia) andheat near the site ofinjury . lncreased vascular perm€ability - With vasodilation, the endothelial cells lining blood vessels contract slightly creating gaps behveen the cells that allow plasmato escape into surrounding tissues. Plasma delivers antibodies and othcl antimicrobial substances to thc site ofinjury. Fibrinogen from plasma also clots and serves as a tcmporary barrier to bacterial invasion.
2.

Cellular Phase oflnflammation

. Adhesion - As blood vessels dilate, the velocity of blood flow slows allowing circulating white blood cells to accumulate on the inner surface ofvessel walls. This process is called margination, . Diapedesis end chemotaxis - The wBC's then begin to squeeze between the contracted endothelial cells and migrate in an amebalike fashion into the extravascular space fd process called diapedesis). Once in tissue, the WBC'S are attracted by activated complement and begin to migrate towards the site ofinjury or infection. wBC's (specifically PMNs) apparently have surface recepto$ for chemotactic agcnts fi.e., CJd, TIE IL-8, LtB4.IL-1, IFN-I) which cause them to move in the direction ofincreasing concentrations ofthe chemotactic substanc€ /?rocess is called chemora.nrr. Initially, the first group ofcells to arrive at the site of injury are neutrophils fPMNs/. Latq macrophages become more numerous. In certain parasitic infections. eosinophils predominate. In viral infection, lymphocytes rather than neutrophils usually predominate.

. Phsgocytosis - wlen wBC's (specificalb, PMNS) anive

at the sitc oftissue injury or microbial invasion they become very active and begin engulfing bacteria forming a phagosome which combines .r.ith lysosomal granules to form a phagolysosome, in which digestion ofthe engulfed particle occurs.

cells ofthe immune system originate from a hematopoietic stem cell in the bone marrorv, which a myeloid progenitor cell and a lymphoid progenitor cell. These two progenitors give risc to the myeloid cells f/ro, ocytes, macrophages, dendritic cells, meagakaryocytes and granLlooles) andlJl|4phoid cells (T cells, B cells a d hatural killer (NK) cel/t, respectively. Theses cells make up the cellular components ofthe innat. (non'specilic) and adaptive (.tpecifc) lrl.,rfline systems. Cells possess receptors, which are molecules on the cell surfaces that enable the cell to interact with orher molecules or celis. Receptom reflect and dictate the function ofcells. . \Iast c€ffs: are important in immediate inflammation fanaphylatis and allergic rcsponses). They possess receptors fot complement components (C3a and C5a) aswell as receptors for the Fc portion ofrhe antibody molecules IgE and lgc. They feature prominent c,'toplasmic granules, termed lysosomes. \r'hich store inflammatory mediators such as histamine and heparin. . Dermal dendrocytes (histiocyres)t these cells are distributed near blood vesscls and possess receptors for the complement component C3a, by which they participate in immediate inflammation. . Periph€ral dendritic cells (DCs,): are leukocytes with dendritcs. Langerhans cells are DCs that reside in the suprabasilar portion s ofsquamous epithelium. DCs are important in antigen processing and presentarion to cells ofthe specific immune response. . \eutrophils and Mononcytes/macrophages: are phagocytic leukocyes. Neutrophils ate the predominant leukocyte in blood. Because neutrophils do not need to differentiate substantially to function, they are suited for rapid responses. They possess receptors for metabolites ofthe complement molecule C3. Nlonocytes are referred to as macrophages when they leave the blood. They present anrigen to T cells. Together, macrophages and lymphoc,'tes orchestrate the chronic immune response. . Lymphocytes: the three main tlpes of lymphoc)'tes are distinguished on the basis oftheir receptors for antigens: T lymphocytes, B lymphocytes, and natural killer (NK) cells. - T cells: recognize diverse antigens using a low-affinity transmembnnous complex, the T-cell antigen receptor alCR/. T cells are subdivided based on whether they possess the co-receptors CD4 (?: helper cells) or CD8 (T-cytotoxic cells). -B cells: help control extracellular antigens such as bacteria, fungal, yeast, and virions. B cells recognize diverse antigens using the B-cell antigen receptor frcRl. After antigen exposure, some B cells differentiate to form plasma cells which secrete IgM. Others differentiate into memory B cells. - Natural killer (Nf) cells: recognize and kill certain tumor and virally infected cells.
-4.11

giles rise to two major lineages,

. Plasma cells

. Mast cells
. Neutrophils . Macrophages

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The

has emerged as a unique immune cetl thst could be activated by many non-immune processes, including rcute str€ss rnd

could par,icipate 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

85 Cop"ighr O 201I-2012'Dental D€cks

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 jn chronic infection are mrcrophages and lymphocytes. With the aid ofchemical mediators such as l),rnphokines, macrophages do an excellentjob ofengulfing and neutralizing or killing foreign antigens. Llanphocytes are the predominant cell in chronic inflammation. Note: Macrophages and lymphoc)'tes are intcrdcpcndent in that thc activation ofone stimulates the actions ofthe othcr. Chronic inflammation:

. Lymphoc],te, macrophage, and plasma cell infiltration . Tissue destruction by inflammatory cells
. Aftempts at repair with ftbrosis and angiogenesis (nev vessel lormation) . wlen acute phase cannot be resolv€d
- Persistent injury or infection (ulcer TB) - ProJonged toxic agent exposure fsllr.llJ - Autoimmune disease states (M, SLE)

. Macrophages

.

Scattered all over (microglia, Kryffer cells, sinus histioq,tes, alveolat macrophages, etc.) 48 hrs and transform as monoc)'tcs and reach site of injury within . Become activated by T cell-derived cytokines, endotoxins, and other products of inflammation

. Circulate

24

.TandBlymphocytes
. Antigcn-activated fyia macrcphages and dendritic cells) . Rclease macrophage-activating cytokines fln lurn, mac,ophages release lymphoqte-activdling
c|tokines until inflammalory stimulus is removed)

. Plasma

cells

. Terminally differentiated B cells . Produce antibodies . Eosinophils
. Found especially at sites ofparasitic infection, or at allergic

flgt-

ediated) sites

\{ast 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 extemal environment.

\last cells become activated when surface receptor-bound antigen-specific immunoglob',iin E (lgE) encounters an antigen that the IgE recognizes. This triggers mast-cell degranulation, Ieading to the rapid release of inflammatory mediators, such as histamine, proteoglycans, and cytokines. Mast-cell activation also stimulates the arrival of other ina critical step in local inflammation. flammatory cells
are not only necessary for allergic reactions, but recent findings indicate that ihe) are also involved in a variety ofneuroinflarnmatory diseases, especially those worsened by stress. In these cases, mast cells appear to be activated through their Fc receptors bl rmmunoglobulins other than IgE, as well as by anaphylatoxins, neuropeptides and cy-

\last cells

-

tokires to secrete mediators selectively without overt degranulation.

. \ote{ 'aa.*;

I . The mast cell content in human gingiva is high. The mast cell content ofinflamed 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.

. Stop persistent bleeding
. Maintain the sutured position ofthe flaps

. Improve patient comfort
. Prevent mechanical injury to healing tissues

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PERIODONTICS

Wbich one of the following will reduce the abrasive action ofa polishing agent?

. Using an agent with nice large particles . Using an agent containing particles that are dull and round

. Using a thick, viscous mixture ofpolishing

paste

. Applying the polishing agent with firm pressure and increasing to a heavy constant
pressure

. Polishing at a high speed with healy pressure

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Purposes of the periodontal dressing /periodontal packt): . Provide mechanical protcction for the surgical wound and therefore facilitate healing . Helps prevent post operative bleeding by keeping the initial clot in place . Supports mobile teeth during healing . Mechanically maintains post-surgical position ofthc flaps . Helps in shaping or molding thc ncwly formcd tissue . Provide patient comfort by isolating area from extemai irritations or injuries

Characteristics of acceptable dressing materiall . Nontoxic or nonirritating to the tissue

. Conveniently prepared, placed and removed with minimal discomfort to patient . Should maintain adhesion to itselfand to the teeth, kept in place mcchanically by interlocking in interdental spaces
T) p€s ofDrcssings (pdcfs): usually contain zinc oxide and may be either eugenol- or non-eugenol con-

talnlng.

. \on-etgenol

(soft pack) - 2 tubcs: . one tube contains: Zinc oxide, an oil (fot plasticir*), a gnm(for cohesiveness). and lorot-

hidol (a fungicide)

. one tube contains liquid coconut fatty acids thickened with colophony resin (or rosixJ
- Brand narnes: Coe-pak
and chlorothymol i/rl racteriostatic agenl) *** most widely used in the United Stales.

. Zinc oride.Eugenol Packs: are supplied as a liquid (eugenol) and a powder (zi1c oxide). l. Periodontal dressings have no well-defined effect on the processes ofwound healing or on \oaes surgical outcomes (i.e., gains ofpeiodontal attachmenl or the reduclion in probing depths).

2. For first week postoperatively, patient should rinse with 0.12% chlorhexidine gluconate nvice daily. 3. As a general rule, the pack is kept on for I week after surgery. .1. Bcfore removing, make sure sutures are not cmbcddcd in the dressing and that the dressing is not locked interproxjmally.

Using a thin, watery mixture of polishing paste or polishing at a low speed with light pressure will also reduce the abrasive action ofa polishing agent. The use of abrasive polishing agents and/or a rotary polishing instrument may be contraindicated in the following cases: . Patient with a communicable disease: the production of aerosols is likely to

*"*

occur.

lhich

may disseminate the disease

. Patient with respiratory problems . Patient with "green stain": usually the tooth surface under the stain is demineralized

. Patient \yith newly erupted teeth: have not mineralized completely yet ..{ny patient who is at increased risk for dental caries: those with xerostomia,
amelogenesis imperfecta, ran.rpant caries, or receiving radiation therapy to the head

*** ***

The use of a porte-polisher (manual polisher) may be helpful in some of the cases Iisted abor.e.

Dental tape and finishing strips may be used to polish interproximal tooth surfaces. polishing agent to remove generalized staining, consider the following: tooth sensitivity, type of stain present, type of restorations present and the condition of the tooth surface. *** Not all surfaces should be polI.

When selecting

a

Not€r.

ished. 2. Flexing the polishing cup into proximal areas increases its effectiveness.

.

. ...

Gingival fibers conslst of:

. Type I collagen

. Type II collagen . Type III collagen

. Type IV collagen

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'\

. Gram-positive aerobic cocci . Gram-negative aerobic rods
. Gram-negative anaerobic rods

. Cram-positive anaerobic cocci

89 Coplright O 20ll-2012 - Dental Decks

tissue of the marginal gingiva is densely collagenous, containing a prominent system ofcollagen fiber bundles called the gingival fibers. 2. The gingival fibers are arranged in three groups: gingivodental, circular, and transseptal. 3. The fype I collagen of gingiva, however, is not th€ same biochemically as found in other parts ofthe body, including the skin. 4. The collagen tumover 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 n.rajor components ofthe gingival connective tissue are collagen fibers (about 600% by volume), fibroblasts (5o%), vessels, newes, and matrrx (about 35%). 6. The three t)?es of connective tissue fibers are collagen, reticular, and elas-

l. The corurective

tic.
7. Collagen type I lorms the bulk ofthe lamina propria and provides the tensile strength to the gingival tissues. 8. Tlpe IV collagen (argyophilic reticuhm.fiber) branches between the collagen type I bundles and is continuous with fibers ofthe basement membrane and blood vessel walls. 9. The elastic fiber system is composed ofoxytalan, elaunin, and elastin fibers

distributed among collagen fibers.

Remember: Vitamin C is needed for hydroxylation of proline and lysine essential for
collagen formation.

Principal diffcrences between the periodontal abscess and the gingival abscess are location and history Abscesses confined to the marginal gingiva, causedby injury forcing oJJb,"ign material) to Ihe outer surface of rhe gjngiva. and not involving the supporting structrues are called gingival abscesses. A periodontll abscess is an infection located contiguous to the pcriodontal pocket and may result in the destruction ofthe PDL and al\ eolar bone. Note: The pericoronal abscess is associated with the crown ofa panially erupted tooth.

Periodontsl abscesses can be cla\sified as: . Acute: The most prevalent symptom that the patient will report with an acute periodontal abscess is one of acurc pain. The nature ofthe pain is a constant, severe, dull throbbing. Thermal changes do not seem to elicit or modiry the discomfon. The onset ofthis discomfort is rapid and becomes progressively more inrense. Exudate may be expressed with gende pressure. The patient may also notice an increase in mobiliq of an rndividual tooth. The patient probably will say that it is diflcult to close his,4rer teeth together \!irhour sriking the involved toolh first fille€h elevdte.l in lhe sockel.), causing incteased pain. There may be ststemic involv€ment characterized by an elevated temperatur€ and lymphrdenopathy' . Chronic: is usually characterized by no or a dull pain, slight tooth elevation, intermittent exudation, a fisrulous tract oftcn associated with a deep pocket, and without systemic involvement. Tiearmenl for an acute periodontal abscess is determined initially by whether there is localization ofthe abicesi. Iflhere is. then the lreatment is to provide dt^i'ngige (either thmugh the periodontal pocket or through d-rrerrdl ir.i-ilo/r, insrruct the patient to rinse with warm salt water and place chlorhexidine gluconatc on the alTecred area \\ ith a cotlon{ippcd applicator Ifthere is systemic involvement the paticnt should be prescribed arlibiotics ,,€itl,e,",.,mo-r:icillin or ifallergic then Clindan))cin or Azithrom)cirll. lfthere is severe swelling and inflafifiation lnot localr"edl, rhe paiient should be puton antibiotics and seen oDce the infection has localized. \ote: Bacreia associatedwith abscesscs ofthe periodontium include F. nuclcatum, P intermedia, P gingivalis. P micros. and T fors]1hia. As \\'ith a periodontal pocket, the chronic abscess is usually trealed with scaling and root planing or surgical
rherapy. Tlre radiographic findings associated with this abscess are not specific. There may be no change radiographically in the early acute lesion- Often, ho{ever in a chronic abscess therc will be a localized discrete mdiolucency lateral to the root or in a lircation, Note: It can cause rapid alveolarbone destruction. Note: Microscopically, an abscess is a localized accumulation ofPMNS within the periodontal pocket wall. Tle PMNS tiberate enztrnes that digcst the cells and other tissue structures, forming the liquid product known as pvs (exudate)

. TMJ symptoms

. Muscle

soreness

. Periodontal pocket formation . Cracked teeth or fillings . Wear facets on teeth . Widened PDL spaces on radiographs

90 Cop)'right C 20ll-2012 - Deotal Deck!

. When pulp chambers are small . In the presence oftooth sensitivity
. When major occlusal discrepancies may require orthodontics or full mouth reconsfiucuon

. In patients who are poor candidates for full mouth reconstruction because of
psychologic factors

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Bruxism is defined as diumal or noctumal parafunctional activity that includes clenching, bracing, gnashing, and grinding ofthe teeth. Although no causative association exists between bruxism and gingival inflammation or periodontitis, bruxism can cause tooth mobility, tooth wear and fracture, and periodontal and muscle pain and may contribute to masticatory system
disorders.

Important: A maxillary or a mandibular interocclusal appliance (occlusal splint/night guard)
is generally considered the most effective means ofmanaging bruxism. They are used to redistribute occlusal forces and to minimize excessive force on individual teeth. . To stabilize the dentition . To modifo the nature ofthe habit (bnrxrsrn) . To act as a splint after pedodontal surgery . To assist in conholling recurrence ofdrug-induced gingival enlargement

Note: Night guards are usually wom at night, but they may also be wom during the
day.

The primary purpose of a night guard in periodontal trauma is to modify and contlol bruxism or to redirect forces into a non-traumatic pattem.

***

\ight

guards should have the following characteristics:

. They should be made of hard acrylic . There should be no sharp edges needs to be comfortable . They should fit well and cover the occlusal surfaces ofthe maxillary
cover the palate

teeth

-

should not

. They should occlude evenly with mandibular teeth and permit the patient to move the mandible freely in all excursions

General objectives in selective grinding in the natural dentition: . To achieve a more favorable direction and distribution offorces . To coordinate the median occlusal position with the terminal hinge position of the mandible . To eliminate prematurities in excursive movements to either gain a group function or canine protected occlusion . To direct occlusal forces centrally along the long axis ofth€ tooth . To improve or maintain masticatory performance . To accomplish the occlusal adjustment without reducing vertical dimension and by retaining an acceptable interocclusal distance . To reduce or eliminate fremitus The usual steps ofocclusal adjustment:

. Eliminate prematurities in centric relation . Eliminate prematurities in protrusive movem€nts . Eliminate prematurities in lateral excursive movements . Re-establishment of physiologic occlusal anatomy and careful polishing of all
ground surfaces

l{ote: For lhe periodontal patient, occlusal adjustment (coronoplasty) should be not be done until inflammation is resolved.

Which of the foltowing is not correctly matched wlth regards to a periodontal treatment pl.n?

. Preliminary Phase : Plaque Control . Phase I : Mouth Preparation . Phase II : Periodontal surgery . Phase III : Restorative . Phase IV : Maintenance

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PERIODONTICS

Which of the following statements regarding the rssessment of tooth nobilitv is false?

. Teeth normally have

a very slight physiologic

mobility

. Mobility can result from multiple causes . Mobility is unacceptable and should be treated

. Periodontal

disease can result in tooth

mobility

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is a part ofPhase I or initial therapy. The preliminary phase includes trcatment ofemergencies only whether they bc pulpal, periodontal or any other. Phese

*** Plaque control

I (initial

therapy) ofperiodontal heatment planning includes:

. Caries control, extraction of hopeless teeth . Mouth preparatiotr - lnjtial scalirg (full mouth)
- Definitive root planing
. Oral hygiene instructions: This is the most important aspect ofinitial therapy. The dental hygienist or dentist teaches, motivates, and guides the patient in the performance ofmeasures for diseasc control. During a Fophy appointment, the hygienist or dentist can establish a rapport with the patient and individualize instruction for the particular patient. Show the proper brushing and flossing techniques and have them repeat these techniques to see ifthey understand what you are showing them.

. Occlusal adjustment . Night guards (if bnLtism

eYjsts)

.

tng (stabilizing loose teeth) . Re-examination (c,lrarting with probings) Remember: Iforal hygiene is poor, swgery is contraindicated! !!
,u Phase
Phese

Spli

II (Periodont.l surgery)
|

I

.-----1,- Reevatuation

--+-

Yn^r"

w 1-uint"nrn""ly'/

\l

'

Phase

lll

{restorative)

Correct sequence of periodont.l treatment

\4obility should be heated if it is progressive (increasing), acting to contribute to progression ofperiodontal disease, or if it is associated with patient pain. Mobility in the absence of inflammation is not harmful. Not all mobility can be eliminated. Also, some mobility is only transient. \{obility beyond the physiologic rarge is termed abnormal or pathologic. It is pathologic in that it exceeds the limits of normal mobility values; the periodontium may not necessarily be diseased at the time ofexamination.
lncreased tooth mobility may be caused by a variety offactors, including pregnancy, diseases (local and systemic), trarma (including orthodontic movement), and hypofunction or hyperfunction. The two factors most often seen would be plaque induced inflammatory disease and excessive occlusal forces (brttxism).

\ote: As a general rule, mobility

is graded clinically with a simple method. The tooth is held firmly between the handles of two metallic instruments or with one metallic instrument and one finger, and an effort is made to move it in all directions; abnormal mobil-

ity most often occurs faciolingually. Mobility is graded according to the of tooth movement, as follows: . Normal mobility . Grade I: slightly more than normal

ease and extent

. Grade lI: moderately more than normal . Grade III: severe mobility faciolingually and mesiodistally, combined with vertical
disolacement.

. They mature in the bone marow and migrate to lymphoid organs . They are found in the germinal centers ofthe spleen and lymph nodes . They are progenitors of plasma cells . They are involved in humoral (antibody-mediated) and cell-mediated immunity

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. Cementum that

is resorbing

. Newly formed cementum

. That pan ofthe cementum that

is adjacent to the enamel

. Cemenfum that contains cementoc)tes

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***

This is false; B cells are not involved with cell-mediated immunity.

Lymphocytes: the three main tlpes oflymphocles are distinguished on the basis oftheir receptors for antigens: T lymphocytes, B lymphocytes, and natural killer (NK) cells. . T cells: recognize diverse antigens using a low-afiinity transmembranous complex, the T cell antigen receptor (TCR). T cells are subdivided based on whether they possess the co-receptors CD4 or CD8. Note: They are important in cell-mediated immunity Type 4 hypersensitivity reactions (contact dermatitis), and in the modulation of antibody-mediated immunity. . B cells: help control extracellular antigens such as bacteria, fungal, yeast, and virions. B cells recognize diverse antigens using the B cell antigen receptor (BCR). After antigen exposure, some B cells differentiate to foIm plasma cells which secrete IgM. Others differentiate into memory B cells. Note: They are important in antibody-m€diated

immunity. . Natural killer (NK) cells: recognize and kill certain tumor and virally infected cells.

\ote:

Patients with periodontitis often have T lymphocytes sensitized to plaque bacter-

ial antisens.

Cementum is the calcified, avascular mesenchynal tissue that forms the outer covering ofthe anatomic root. The two main types of cementum are acellular (primary-) and cellular (secondaD) cementum, Both consist ofa calcified interfibrillar matrix and collagen fibers.

The two main sources of collagen fibers in cementum are (1) Sharpey's frbers (extrinsic), *hich are the embedded portion ofthe principal hbers ofthe periodontal ligament and are formed by the fibroblasts, and (2) fibers that belong to the cemer'ttrmmatrix (intrinsry' and are
produced by the cementoblasts.
The major proportion of the organic matrix of cementum is composed of tlpe I (90n and We III tdboft so/a) collagens. Sharpey's fibers, which constitr.rte a considerable proportion ofthe bulk ofcementum, are composed of mainly collagen t,?e L Type III collagen appears to coat

tbe qpe I collagen of Sharpey's fibers. . Acellular cementum: is the fiISt cementum formed, covers approximately the cervical rhird or half of the root, and does not contain cells. Sharpey's fibers make up most of the srucrure ofacellular cementum, which has a principal role in supporting the tooth. . Cellular cementum: is formed after the tooth reaches the occlusal plane, is more irregular and contains cells (cementoclrtes).It is less calcified than acellular cementum. Sharpey's fibers occupy a smaller portion ofcellular cementum. cementum is resorbed or nicked in surgical procedures, the defect is repaired by the deposition of new cementum. Repair carmot occur where pockets are present or where the gingiva has receded and the cementum is exposed. Cementum that has become exposed, forming pan ofthe clinical crown, is often removed in the course ofscaling, root planing, or brushing.

If\ital

Note: Cementum deposition is a continuous process that proceeds at varying rates throughout Iife. Cementum formation is most rapid in the apical regions, where it compensates for tooth eruption, which itself compensates for attntion.

. It

is produced by cells

ofthe periodontal ligament

. The main function is to compensate for tootl wear

.The deposition ofnew cemenhrm continues periodically throughout life whereby root
frach.res may be repaired

. The cementum is indistinguishable on radiographs

. It is lighter in color than dentin, contains 45 to 50yo inorganic substance, alld its permeability diminishes with age

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When trauma from occlusion results from reduced ability of the tissues lo resisa tlle occlusal forces, it is known asi

. Primary occlusal trauma

.

Secondary occlusal trauma

. Tertiary occlusal trauma

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***

This is false; the main function is the attachment ofprincipal fibers ofthe PDL.

Other functions include:

L Compensates for the loss oftooth surface due to occlusal wear by apical deposition of cementum throughout life. 2. Protects the root surface from resorption during vertical eruption and tooth movement.

reparative function, allows reattachment ofconnective tissue following periodontal treatment. Note: Cementum repair requires the presence ofviable connective tissue. If epithelium proliferates into an area ofresorption, repair will not take place. Cementum repair can occur in devitalized as well as vital teeth.
3. Has a

The inorganic content of cementum (hydrotyapatite) is 45% to 50%, which is less than that of bone (65%o), enamel (97o/o), or dentin (70%o).
The cementnn at and immediately subjacent to the cementoenamel junction (CEJ) ts of particular clinical importance in root-scaling procedures. Three types ofrelationships inr.olving the cementum may exist at the CEJ. In about 60olo to 65% of cases, cementum overlaps the enamel; in about 30o% an edge-to-edge buttjoint exists; and in 5% to l0% the cementum and enamel fail to meet.

\ote: Unlike bone, which is continuously remodeled, the cementum grows slowly in thickness, throughout life, by apposition of new cemenfum at the surface. While cementum can be resorbed, it is not continuously remodeled like bone.

\\'hen occlusal forces exceed the adaptive capacity ofthe tissues, tissue injury results. The resultant injury is te.med trauma from occlusion. Trauma from occlusion refers to tissue injury, not occlusal tbrce. An occlusion that produces such injury is called a traumatic occlusion.
Trauma from occlusion may be: . -{cute: results from an abrupt occlusal impact, such as that produced by biting on a hard object. Restorations or appliances that interfere with or alter the direction ofocclusal forces on the teeth rray also induce acute trauma. It results in tooth pain, sensitivity to percussion, and incrcased tooth nobility. . Chronic: is more common than the acute form and is ofgrcater clinical significance. It most oiien develops from gradual changes in occlusion produced by tooth wear, drifting movement,

and extrusion of teeth, combincd with parafunctional habits such as bruxism and clenching, rather than as a sequela ofacute periodontal trauma.

\\'hen trauma l'rom occlusion is the result of alterations in occlusal forces, it is called "primary trauma from occlusion." It occurs if trauma from occlusion is considered the primary etiologic l'actor in periodontal dcsauction and if the only local altention to which the tooth is subjccted is tiom occlusion. Important: Changcs produced by primary fauma do not alter the level of connectr\e tissue attachment and do not initiate pocket fonnation. This is probably because the supracrestal gingival fibers are not affected and therefore prevent apical migration of the junctional epithelium. Secondary trauma from occlusion occurs when the adaptive capacity ofthe tissues to withstand occlusal forces is impaired by bone loss resulting from marginal inflammation. This reduces the pe.iodontal attachment area and altcrs the levemge on the remaining tissues. The periodontium becomes more lr:lncrable to injury, and previously well-tolerated occlusal lorces become traumatic.
Tissue response to traumatic occlusion occurs in three stages; injury, repaiq and adaptive remod-

eling of the periodontium.

. The periodontic component first . The endodontic component first . Both components at the same time . Them any way you want to

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.Improve patient comfort ard to provide better control ofthe occlusion ifthe anterior
teeth are mobile

. Improve oral hygiene

.

Prevent a natural unopposed tooth from migrating

. Prevent maxillary central incisors from separating after closure of diastema

coplright Cr20ll-2012 - Dental ltecks

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). The pain from the loss of pulpal vitality is the most common presenting complaint ofpatients with combined lesions. The symptoms reported are those most often found with pulpal disease. Thermal pulp testing provides information relative to the status ofthe pulp, and dental radiographs can confirm the presence of apical changes and the extent ofbone loss. Careful probing confirms the presence and morphology ofany periodontal pocket and permits location of the conmunication 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 heated. The periodontal therapeutic objeclives vary with the extent and conhguration ofthe residual periodontal lesion. Important: The long-term prognosis lor a tooth with a combined lesion is closely related to the extent and configuration ofthe periodontal attachment loss. With advanced horizontal bone loss, even an optimal endodontic result may not be sufiicient to retain the rooth. Ifthe periodontal lesion is an advanced, multiwalled vertical defect, the success of rherapy likely depends on the ability to fill or regenerate attachment to obliterate the defect.

Splinting therapy may be applied with bonded extemal appliances, intracoronal appliances, or indirect cast restorations to connect multiple teeth, with the goal ofimproving tooth stability. Unstable teeth may be caused by a lack of periodontal support from bone loss, a lack ofsupport from tooth loss. or the need to splint abuhnent teeth to support pontics.
There is no reason for splinting non-mobile teeth as a preventive measure. Splinting is only one measure used in the tr€atnlent ofperiodontal disease. Splinting should be used with other necessarl neasures such as root planing, oral hygicne insauctions, pocket elimination, and occlusal adiuslmenl. Loose teeth splinted to adjacent teeth may become stabilized. When many teeth are loose. adjacent sextants should be included io the splint. Teeth tend to loosen buccolingually yet may remain firm mesiodistally. Even whcn tecth do not tighten, the splint serves as an orthopedic brace thal pc.mits useful function of loose teeth. A variety ofmeans may bc utilized to achieve temporar_r 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.

.l.lndicationsforsplintingare(1)mobilityofteeththatisincreasingorthatimpairspa-

.' , .,tr' necessary

-\0:e3:

tient comfon, (2) migration ofteeth, or (3) prcsthetics where multiple abutments are

2. Before considering splinting, the clinician must identify the etiology of the instability. Any inflammation ofthe periodontal supporting apparatus must be controlled before making a decision on splinting, because inflammation can produce mobility in the presence ofnomral occlusal forocs 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 spacc must cxist between the connector and the papilla for access with dental floss anteriorly and with an interproximal brush on posterior teeth.

Extrinsic dental stains include:

. Green to brown slains caused by erythroblastosis fetalis . Brown, black, green, or orange stains caused by chromogenic bacteria in plaque . Red to brown stain caused by congenital porphyria . Gray or brownish stains caused by tetracycline

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Cop).righr C 201 l'2012 - Dental Decks

Trauma from occlusion can produce radiographically detectatlle cbanges in all ofthe followin g EXCEPT one. Which one is the,EXCEPIION?

. Lamina dura
. Periodontal pockets . width of the PDL
space

. Morphology ofthe alveolar crest
. Density ofthe surrounding cancellous bone

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Stains can be identified by location: . Intrinsic - stains that occur within the tooth substance . Extrinsic - stains that occur on the extemal surface ofthe tooth Stains can be identified by sources ofthe discoloration: . Endogenous - stain that originates from within the tooth. Endogenous stains are always intrinsic and frequently are discolorations of the dentin reflected through the enamel. Examples ofsourcesz drngs (tetacycline, systanic.fluoride), changes in pulp tissue of pulpless teeth, imperfect tooth development (amelogenes is impet'fecta) . Exogenous - stain that originates ftom an extemal source.

Brown, black, green and orange stains are generally seen on the labial surface ofanterior teeth and are usually caused by poor oral hygiene. Some theories attribute the change in color to by-products of some bacteria. Black stain is generally seen in the cervical portion of molar teeth in children. Green and orange stains are supposedly associated rvith an increased amount ofcaries and actually they represent pigmentation of dental plaque. Black line, tobacco, orange and green stains are all exogenous extrinsic stains, initially at least. After a period of time, both green and tobacco stains may become incorporated with the tooth. At this point, their classification changes. They become exogenous intrinsic stains.
Silver amalgam and topical fluoride are also examples ofexogenous intrinsic stains. An e\ogenous intrinsic stain is one that originates from a source outside the tooth and subsequently becomes incorporated within the tooth structure.

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 ofocclusal trauma is tooth mobility. Other clinical signs

***

of occlusal trauma include migration ofteeth and the tendemess of teeth to percussion. Traumatic lesions manifest more clearly in the faciolingual aspects, because mesiodistallv the tooth has the added stability provided by the contact areas with adjacent teeth. Radiographic signs of trauma from occlusion: . \\'idening ofthe periodontal ligament space . Thickening ofthe lamina dura . -\ngular bone loss and infrabony pocket formation . Root resorption
H)percementosis \ote: Trauma from occlusion is reversible, that is, the body can repair the damage the excessive occlusal forces are eliminated.

'

if

Other findings associated with excessive occlusal forces: . ,A.ltemating areas ofresorption and repair ofthe alveolar bone . Fibrosis olthe 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 ofbone . Narrowing ofthe periodontal ligament space

. Eliminate plaque . Clean nonadherent bacteria and debris fiom the oral cavity more effectively than
toothbrushes and mouth rinses.

. Disinfect pockets for up to . Prevent calculus formation

12 hours

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al

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. Compose 5% to

l0o%

ofdentifrices

. Compose l0% to 20% ofdentifrices . Compose
. Compose
207o to 40% 507o to 65%

ofdentifrices ofdentifrices

103 Cop]'right O 20ll-2012 - Dental Decks

Oral irrigators for daily home use by patients work by directing a high-pressure, steady or pulsating stream ofwater 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 ofplaque 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 inigation 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 physcician should be consulted.

Remember: The pathology associated with gingivitis is completely reversible with the removal ofolaoue and the resolution ofthe inflammation.

Dentifrices aid in cleaning and polishing tooth surfaces. They are used mostly in the form of pastes, although tooth powders and gels are also available. Dentifrices are made up ofabrasives (e.g., silicon oxides, aluminum oxides, granular polyvinyl chlorides), water, humectants, soap or detergent, flavoring and sweetening agents, therapeutic agents k.g.../luorides, pl,rophosphates), coloring agents, and preservatives. -\brasives (conrpo se 20oZ to 40oZ ofdentifrices) arc insoluble inorganic salts that enhance the abrasive action of toothbrushing as much as 40 times. Tooth powders are much more abrasive than pastes and contain about 95% abrasive materials. The abrasive quality of dentifrices affects enamel only slightly and is a much greater concem for patients with exposed roots. Dentin is abraded 25 times faster and cementum 35 times faster than enamel, so root surfaces are easily wom away, leading to notching and root sensitivity.

\ote: Typically,
than on the right

more wear occurs on maxillary than mandibular teeth and on the left half halfofthe dental arch.

Important: In dentifrices, fluoride ion must be available in the amount pans per million (ppm) to achieve caries reduction effects.

of

1000

to 1100

"Calculus control toothpastes," also referred to as "tartar control toothpastes", contain p).rophosphates and have been shown to reduce the deposition ofnew calculus on teeth. These ingedients interfere with crystal formation in calculus but do not affect the fluoride ion in the paste. Dentifrice with pyrophosphates has been shown to reduce the formation of new supragingival calculus by 30o/o or more. Pyrophosphate-containing toothpastes do not affect subgingival calculus formation or gingival inflammation. The inhibitory effect reduces the deposition ofnew supragingival calculus but will not affect
existing calculus deposits.

. Stiffened end . Spongy floss
. Regular floss

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. The amount and location ofplaque . The caries experience

. The toothbrushing frequency . The condition ofthe toothbrush

105 Cop)right O 20ll-2012 - Denial Decks

Super Flosso 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
. Regular floss removes interproximal subgingival plaque

spaces

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 ImDlants

Over the years, many different toothbrushing methods have been described and promoted as being efficient and effective. These methods can be categorized primarily according to the paftem of motion when brushing and are primarily ofhistorical interest. as follows: . Roll: Roll method or modified Stillman technique . f ibratory: Stillman, Charters, and Bass techniques . Circular: Fones technique . \'ertical: Leonard technique . Horizontal: Scrub technique Srudies evaluating the effectiveness of the most common techniques have demonstrated no clear superiority for any method. The scrub technique is probably the simplest and most common method ofbrushing. Patients with periodontal disease are most frequently taught a sulcular brushing technique using a vibratory motion to improve access in the gingival areas. The method most often recommended is the Bass technique because it emphasizes sulcular placement ofbristles. Bass method: . Place tooth brush so that the bristles are angled approximately 45 degre€s from the tooth surfaces. This allows the b stles to extend into the gingival sulcus when pressure is applied to the brush in a horizontal direction. . Start at the most distal tooth in the arch, and use a vibratory. back-and-forth motion to brush Other methods dfbrushing, such as the modified Stillman and Charters, are variations ofthe Bass technique also designed to achieve thorough plaque removal at the gingival margins. They emphasize stimulation ofthe gingival circulation, which has not been demonstrated lo achieve healing results beyond those achieved by good plaque removal.

lmportant: No matter what toothbrushing method is chosen, the manual toothbrush should have soft nylon bristles and a small head. They should be replaced about every 3 months.

. Prescription solutions ofchlorhexidine digluconate oral rinse

. Prescription solutions oftehacycline oral rinse . Nonprescription essential oil rinse
. Nonprescription solutions ofpenicillin oral rinse

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106 l-2012 - Dentai Decks

Which of the following oral hygiene aids is appropriate for cleaning a Class If furcation?

. Stim-U-Dento . Interproximal
brushes

. Interdental stimulator
. Perio
Aid@

. Oral irrigator

107
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The agent that has shown the most positive antibacterial results to date is chlorhexidine, a diguanidohexane wilh pronounced antiseptic properties. Thc 0.12y. chlorhexidine digluconate preparation available in the United States for reducing plaque and gingivitis has been shown to bc equally effective as the higher-concentratton prodlct (0.21% aEteous solution). Localized, reversible side elfects ofchlorhexidine use may occur, primarily brown staining ofthe teeth, tongue, and silicate and resin restorations and transicnt impairmcnt of tastc perception. Chlorhexidine has very low systenic toxic activity in humans, has not produced any appreciable resistance oforal microorganisms, and has not been associated with teratogenic alterations. Note: 0.12% chlorhexidine contains l2% alcohol.
Chorhexidines effectiyeness may be explained by the f'act that it leaves the grcatest residual conccntration in the moulh after its use. It is approved by theADA as an antimicrobial and antigingivitis agent. Examples include: Peridex and PerioGard, Important: Substantivity is the ability of drugs to adsorb onto and bind to soft and hard tissues. The substantivity ofChlorhexidine was first described in the 1970s. Due to this property, Chlorhexidine can maintain effective concentration for prolonged pcriods of time.

fssential oil mouth rinses contain thymol, eucalyptol, methanol, and methyl salicylatc. These
products also contain alcohol (up to

24

dependtugon the preparallanl. An example is Listerine.

A product containing triclosan has shown some effectiveness in reducing plaque and gingivitis. It rs a|ailable in toothpaste form, and the activc ingredient is more effective in combination with zinc

citratc or a copolymer ofmethoxyethylene.
Other oral rinsc products on the market have shown some evidencc ofplaque rcduction, although long-term improvement in gingival health has not been substantiated. These include stannous fluoride. cetylpyridinurn chloide (quaternary afimo ia compounds), and sanguinarine.

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-Dento (balsa wood wedges): these are of primary importance in gingival massage. They are also good for patients with interdental recession. These picks /rriangular in cross seclion) are small enough to fit into most interdental spaces. As a supplement to brushing, they are useful for dislodging interproximal debris often missed bl meticulous brushing and for massaging the underlying interproximal gingiva. . Interproximal b rushes (proxabrusft): 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 ofa toothbrush. Its action massages rnd stimulates circulation of the interdental gingiva and may increase the tone ol the tissue. It is not
recorlmended for areas in which the papillae are normal and fill the interproximal spaces. It may cause injury to the gingival tissue.

Remember:
replaces brushing and flossing for removal ofor disruption ofplaque. 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 interproxinrally and works its way arotnd the tooth).

l. Nothing

.

10o%

Doxycycline gel

. 2% Minocycline microspheres .
25olo

Metronidazole gel

. Chlorhexidine (2.5 mg) in gelatin matrix

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. Periodontal ligament . Cementum
. Alveolar bone . Gingiva

109 Coplright O 201 I -20 12 - D€nhl Decks

The limitations ofmouth rinsing and irrigation have prompted research for lhe development ofaltemative delivery systems. Recently, advances in dclivery technology have resulted in the controllcd relcase ofdrugs. . Subgingival Doxycycline: The FDA approved l0% doxycline in a gel system usirg a syrin ge (Atridox.). It is the only local delivery system accepted by the ADA. . Subgingival Minocyclin€: The FDArcccntly approved a neq locally delivcrcd. sustained-releasc form ofminocycline micrcspheres f,1/erl,r,, for subgingival placement as an adjunct to scaling and root planing. The 2% minocycline is encapsulated into bioresorbable microspheres in a gel carrier . Subgingival Metronidazole: A topical medication containing an oil-based metronidazole 25o dental gel (glycerol mono-oleate and sesame oil) has been tested in a number of studies. This product is not available in the U.S. . Chlorhexidine in a gel.tin matrit: A resorbable delivery system has been tested lor the subgingival placement ofchlorhexidine gluconate with positive clinical results. PerioChip is a small chlp (1.0 x 5.0 r 0.JJ ,in) composed ofa biodegadable hydrolyzed gelatin matrix, cross-linked with glutaraldehyde and also containing glyccrin and water, into which 2.5 mg ofchlorhexidine gluconatc has been incorporatcd per chipSt"stemic administration of antibioticsl . Tetracycfincs: used to treat LAP f/oca lly aggressiw periodorlitrt, have the ability to concentrate in the periodontal tissues and inhibjt the growlh ofActinobacillus actinotherapeulics AdJ. Notei Subanlimicrobial-dose doxycycline fSDDl is a 20-mg dose ofdoxycycline (Perioslat) lhal is apprcved and indicated as an adjunct lo scaling and root planing in the trealment ofchronic periodontitis. It is taken twicc dajl-'.' for 3 months, up to a maximum of9 months continuous dosing. . |\Ietronidazole: is effective against Aa when used in combination with other agents. It is effective against anaerobes such as Porphlromonas gingivalis and Prevotella intermedia. . P€nicilfins lamoxicill{n and anoxicillin-cla|uldnate potassiun fAugnentin|), may be useful in the manacement ofaggressive periodontitis t'rotft localized and generali:ed Jbrms). . Ccphalosporins: not often used to treat dental-related infections. . Clindamycin: used when patients are allergic to penicillin. . Ciprofloxacin: is the only antibiotic in periodontal therapy to which all strains ofAa are susceptible. . Uacrolides /e,:'-/rmmycin, spiramycin, and azilhrom!-cin): only azithromycin is used and appears to conccntrate in gingival tissues.

The periodontiurr consists ofthe investing and supporting tissues ofthe tooth: gingiva, periodontal ligament, cementum, and alveolar bone. It has been divided into two parts:

l. Gingiva:
2.

the main function

ofwhich is protecting the underlying rissues

Attachment apparatus: composed ofthe: . Periodontal ligament . Cementum . Alveolar bone

The cementum is considered a part ofthe periodontium because, with the bone, it serves as the support for the fibers ofthe periodontal ligament. The gingival fluid (sulcular.fluid) contains components ofconnective tissue, epithelium, inflammatory cells, serum, and microbial flora inhabiting the gingival margin or the sulcus lpocket).In the healthy sulcus the amount ofgingival fluid is very small. During inflammation, however, the gingival fluid flow increases, and its composition start to resemble that of an inflan'matory exudate.
The main route ofthe gingival fluid diffusion is through the basement membrane, through the relatively wide intracellular spaces of the jrurctional epithelium, and then into the sulcus.

The gingival fluid is believed to: . Cleanse material from the sulcus . Contain plasma proteins that may improve adhesion ofthe epithelium to the tooth . Possess antimicrobial properties . Exert antibody activity to defend the gingiva

. From the gingival maxgin to the interdental groove

. From the free gingival groove to the gingival margin
. From the mucogingival junction to the iree gingival groove

. From the epithelial attachment to the cementoenamel junction

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The gingival fibers ar€ erranged in three groups. Which of the following is not one ofthose groups?

\

. Circular group
. Gingivodental group
. Apical group

. Transseptal group

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ln an adult, normal gingiva covers the alveolar bone and tooth root to a leveljust coronal to the CEJ. The gingiva is divided anatomically into marginal, attached, and interdental arcas.

. Marginal or unattached gingiva:

is the terminal edge or bordcr ofthe gingiva sunounding thc teeth in collar-like fashion. In about 5002 ofcases, it is denarcated from tho adjacent attached gingiva by a shallow linear depressior, the free gingival groove. Usually about 1 mm wide, the marginal gingiva forms the soft tissue wall ofthe gingival sulcus. . Attached gingiva: is continuous with the marginal gingiva. It is firm, resilient, and tightly bound to the underlying periosteum ofalveolar bonc. Thc facial aspect ofthe attached gingiva extends to the relatively loose and movable alveolarmucosa and is demarcated by thc mucogingival junction.

*** The width of the attached gingiva is an important clinical parameter. It is the distance betwcen thc mucogingival junction and the projection on thc extcmal surface ofthe bottom ofthe gingival sulcus or the periodontal pocket. [t should not be confused with lhe width ofthe keratinizcd gingiva because the latter also includes the marginal gingiva. *** The width ofthc attached gingiva on the facial aspect diffcrs in different areas ofthc mouth. It is generally grcatest in the incisor region and narrowcr in the posterior segmcnts. "** Because the mucogingival junction remains stationary throughout adult life, changes in the \\'idih ofthe attached gingiva are caused by modifications in the position ofits coronal portion. The width ofthe attached gingiva increases with age and in supraerupted teeth.
the gingival embrasurc, which is the interproximal space beneath the area oftooth contact. The interdental gingiva can be pyramidal or can have a "col" shape. Thc :hape ofthe gingiva in a given interdental space depends on the contact point between the two adjoining teeth and the presence or absence ofsomc degree ofrecession.

. Ilterdental gingiva: occupies

\ote: "Stippling" of the attached gingiva refers to the irregular surfacc texture of the attached gingiva, similar to the surlace of an orange peel. Stippling occurs at the intersection of epithelial ridges that causes the depression and the interspersing ofconnective tissue papillae between these intersections giving rise to the small bumps.

Thc conncctive tissue ofthe marginal gingiva is densely collagenous, containing a prominent systern ofcollagen fiber bundles called the gingival fibers. They consist oftype I collagen. The ginsival fibers have the following functions: 1 To brace the marginal gingiva firmly against the tooth. L To provide the rigidity necessary to withstand the forces of mastication without being deflected away from the tooth surface. I To unitc the free marginal gingiva with the cementum ofthe root and thc adjacent attached gingi\ a.
The gingilal fibers arc arranged in three groups: . Gingirodental group: thcsc fibers are those on the lacial, lingual, and interproximal surfaces. They'are embedded in the ccmentum just beneath the epithelium at the base ofthe gingival sulcus.

. Circular group:

these fibers course through the connective tissue of the marginal and interdcntal gingivae and encirclc thc tooth in ringlike fashion. They resist rotational forces. . Transseptal group: these fibers arc located interproximally and fonn horizontal bundles that extend betrveen the cemenhrm of approximating teeth into which they are embedded. They lie in the area between thc cpithelium at the base ofthe gingival sulcus and the crest of the interdental bone. They are sometimes classified with the principal fibcrs ofthe PDL.

. 1. The attachment apparatus is a term used to descibe lhese gingival fibers and the \otetl epithelial attachment. gingival fiber groups: (1) a group of .:...,-.:.a; ''*-'' 2. Some studies have also described two more 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 lbr generating tension in the collagen. This keeps the t€eth tishtlv bound to each other and to the alveolar bonc.

\
Beeause ofthe high turnover rate, the connective tissue

ofthe gingiva has a

remarkably good healing and regenerative capacify.
The reparative capacity ofthe gingival connective tissues is not as great as that ofthe periodontal ligament or th€ epithelial tissue.

. The first statement is true; the second statement is false

. The

second statement is true; the fust statement is false statements are true

. Both

. Both statements are false

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The principal libers ofthe periodontal ligament are arranged in four groups.

The molecular configuration ofcollagen fibers in the periodontal ligament proyides them with a tensile strength greater than that of ste€I,

. The first statement is true; the second statement is false

. The

second statement is true; the first statement is false

. Both statements are true . Both statements are false

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The dominant cellular element in the gingival connective tissue is the fibroblast. Numerous fibroblasts are found between the fiber bundles. Fibroblasts are of mesenchymal origin and play a major role in the development, maintenance, and repair ofgingival connective tissue.

Mast cells are numerous in the connective tissue ofthe oral mucosa and the gingiva. Fixed macrophages and histiocytes are present in the gingival connective tissue as components of
the mononuclear phagoclte system and are derived from blood monocytes. Adipose cells and

eosinophils, although scarce, also are present in the lamina propria.

In clinically normal gingiva, small foci of plasma cells and lymphocytes are found in the corurective tissue near the base ofthe sulcus. These inflammatory cells usually are present in
smallamounts in clinically normal gingiva.
Three sources ofblood supply to the gingiva are as follows; l Supraperiosteal arterioles: along the facial and lingual surfaces ofthe alveolar from which capillaries extend along the sulcular epithelium and between the rete pegs ertemal gingival surface. 2. Vessels ofthe PDL: which extend into the gingiva and anastomose with capillaries sulcus areai. Arterioles: which emerge fiom the cr€st ofthe interdental speta and extend parallel crest ofthe bone to anastomose with vessels ofthe PDL. bone,

ofthe
in the
to the

The l1'mphatic drainage olthe gingiva brings in the lymphatics ofthe connective tissue papi! lae. lt progresses into the collecting network extemal to the periosteum ofthe alyeolar process, then ro the regional lymph nodes, particularly the submaxillary group.

\\'ithin the gingival connective tissues, most nerve fibers are myelinated and are closely associated with the blood vessels. Gingival innervation is derived from fibers arising fiom nerves in the PDL and from the labial, buccal, and palatal nerves.

The most important elements ofthe periodontal ligament arc the principal fibers, which arc collagenous and ananged in bundles and follow a wavy course whcn viewed in longitudinal section. The terminal portions ofthe principal fibers that are inserted into cementum and bone ar€ termed Sharpe3-'s fibers.

fhc principal fibers ofthe pcriodontal ligament are arranged in six groups that develop sequentially in the dcveloping root: . Transseptal fibers: extend interproximally over thc alveolar bone crest and are embedded in the cementum ofadjacent teeth. These fibers keep all the teeth aligned (they maintain the integrity ol rhe dental arches). Note: These fibers may be considered as belonging to the gingiva because rhe)' do not have osseous attachment. . Alreolar crest fibers: extend obliquely from the ccnentum just beneath the junctional epirhelium to the alveolar crest. These fibers prevent the extrusion of the tooth and resist latelal tooth movements. . Horizontal fibers: extend at right angles to the long axis of the tooth from the cementum to
the ah eolar bone.

. Oblique Iibers: the largest group in the periodontal ligament, they extend from the cementum in a coronal direction obliquely to the bone. They bear the brunt ofvertical masticatory stresses
and transform them into tension on the alveolar bone. . Apical tibers: radiate in a rather ircgular manner from the cementum to the bone at the apical region ofthe socket. They do not occur on incompletely formed rcots. . Interradicular fibers: fan out from th€ cementum to the tooth in the furcation areas of multirooted tceth.

\ote: Small collagen fibers associated with the larger principal collagen fibers have been found. These fiben run in all directions, fonning a plexus called the indifferent fiber plexus.
Important: The molecular configuration of collagen fibers provides them with a tensile strength greater than that of steel. Consequently, collagen imparts a unique combination of flexibility and strength to the rissues

. The first statement . The

is true; the second statement is false

second statement is true; the first statement is false

. Both statements are true . Both statements are false

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Csrvicrl line contours are clos€Iy related to the att|chment
of the gingiva

rt the neck of th€ tooth. The greatest contour ofthe cervical lines and gingival attachments occur on:

. The distal surface ofanterior teeth
. The distal surface ofposterior teeth

. The mesial surface olanterior teeth . The mesial surface ofposterior teeth

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The junctional epithelium consists ol a collar-like band of stratifred squamous nonkeratinizing epithelium. It is thee to four layers thick in early life, but the number of layers increases with age to l0 or even 20layers. Also, thejunctional epithelium tapers from its coronal end, which may be l0 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 stata; th€ basal layer facing the connective tissue and the suprabasal layer extending to the tooth surface. Not€: The length of the junctional epithelium ranges from 0.25 to 1.35 mm (ayerage is 0.97 mm).

Thejunctional epithelium is formed by the confluence ofthe oral epithelium and the reduced enamel epilhelium during tooth eruption. However, the reduced enamel epithelium is not essential for its fonnation; in fact, the junctional epithelium is completely restored after pocket instrumentation or surgery and it forms around an implant.

Thejunctional epithelium is attached to the tooth sudace (epithelial attachment) by means of an internal basal lamina. It is attached to the gingival connective tissue by an €xternal basal lamina. The intemal basal lamina consists ofa lamina densa (qdjqcent to the enamel) anda lamina lucida to which hemidesmosomes are attached. Hemidesmosomes have a decisive roie in the firm attachment ofthe cells to the intemal basal lamina on the tooth surface.
In order for a new attachment to folm after periodontal treatment the following must occur: 1. Compl€te removal of calculus, altered cementum, diseased junctional epithelium, and

pocket epithelium
is referred to as a longjunctional epitheliunt) is different from the junctional epithelium in health. In disease, migration of the junctional epithelium occun, along with degeneration in the connective tissue under the attachment; as the junctional epithelium prolilerates along the root surface /gers longer) the

2. Need undifferentiated mesenchymal cells lmportant: The junctional epithelium in disease (which

coronal portion detaches. Barrier membranes, which are often used to treat bony defects, help to pre\ enl this long junctional epithelium lrom forming.

***

The mesial surface ofthe maxillary central has the greatest curvature.

All te€th generally have a greater proximal cervical line (CEJ) curvature on the mesial rhan the distal. Also, the proximal cervical line (CEJ) cuwanres are gr€ater on the incisors and tend to get smaller when moving toward the last molar, where there may be no cun ature at all.
The cemento-enamel junction ofall teeth curves in two directions: . Tolvards the apex on the facial and lingual surfaces . Arra!'from the apex on the mesial and distal sufaces

ln the absence of periodontal disease, the configuration of the crest of the interdental alr eolar seota is determined bv the oosition ofthe CEJ on adiacent teeth.
The rvidth ofthe interdental alveolar bone is determined by the tooth form present. RelatiYely 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.

.

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
canines

of

. On

the facial surfaces of the mandibular canine and

lirst premolar

and the lingual

surfaces adjacent to the

mandibular incisors and canines

. None ofthe above

'fi6
Cop) rieht O 201 l -201 2 - D€ntal

Deks

. Buccal mucosa . Vermillion border of the lips

. Hard palate . Gingiva

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may occur also at the mesiobuccal root of maxillary first molars, associated with prominent roots and sometimes with bony dehiscences ard at the mandibular third molars.
The width ofthe attached gingiva is determined by subtracting the sulcus or pocket depth

*** Narrow gingival zones

from the total width ofthe gingiva (gingival margin to mucogingival lize). 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 insufncient when stretching ofthe lip or cheek induces movement ofthe free gingival margin. The width of the attached gingiva 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 segmeats (1.9 mm in maxillary and 1.8 mm in m an dib u I ar.fi rs t premo lars ).

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.

,. L The "attached" gingiva is structured . foteq tication and brushing.
,

to withstand frictional stresses ofmas-

!*;

2. The alveolar mucosa appears to be well-adapted to permit movement but is

not able to withstand frictional stresses.

Ttre three functional types of oral mucosa are lining, masticatory and specialized mucosa. These renns provide functional descriptions ofthe oral mucosa in specific locations.

. \Iasticatory mucosa: covers the gingiva and hard palate. - Epithelium: it has a keratinized or parakcratinized stratified squamous epithelium.
Lamina propriar has two layers: a thick papillary layer ofloose connective tissue and reticular layer ofdense connective tissue.
a

deep

. Lining mucosa: coven all of soft tissue ofthe oral cavity except
donal surface ofthe tongue.

the gingiva, hard palate, and

- Epithelium: genefallt the epithelium of the lining
million border ofthe lip, however, it is keratinized.

mucosa is nonkeratinized. On the versubjcct to unusual frictional strcss, thc epithelium may become parakeratinized or keratinized. Other cells found in the cpithelium of rhe lining mucosa are Langerhans cells, melanocytes, and Merkel cells. - Lamina propria: under the epithelium ofthe lining mucosa, a loose connectivc tissue with thin collagen fibers forms a papillary larnina propria that caries blood vessels, lymphatic ves-

lf

sels. and nerves.

- Submucosa: a distinct submucosa underlies the lining mucosa, except on the inferior ofthe tongue. The submucosa contains large bands ofcollagen and elastic fibers that bind the mucosa to the undcrlying muscle. The submucosa also contains the larger nerves, blood vessels, and lymphatic vessels that supply the neurovascular networks ofthe lamina propria throughout the oral cavity. In the lips, tongue, and cheeks, the submucosa contains many minor salivary glands. - Specialized mucosa: is restricted to the dorsal surface ofthe tongue, and is characterized by the presence of surlace papillae of several types and by tastc buds in the epithelium. Thc cpithelium is keratinized.
mucosa, whether keratinized, nonkeratinized or parakeratinized, is ofthe stratified squamous type ofepithelium and the underlying central core ofconnective tissue. Although the epithelium is predominantly cellular in nature, the connective tissue is less cellular and composed primarily ofcollagen fibers and ground substance.

Important: All oral

Bone consists of:

. Two-thirds organic matter and one-third inorganic matrix . One-third organic matter and two-thirds inorganic matrix . One-halforganic matter and one-half inorganic mahix

. Two-thirds inorganic matter and one-third organic matrix

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. Cementoblasts . Osteoblasts

. Fibroblasts
. Macrophages

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The alveolar process is the portion ofthe maxilla and mandible that forms and supports the tooth sockets (alveoli).lt forms when the tooth erupts to provide the oss€ous attachment to the forming PDL; it disappears gradually after the tooth is lost. The alveolar process consists ofthc lbllowing:

. An external plate ofcortical bone formed by haversian bone and compacted bone lamellae. the alveolar bone proper, which is secn as the lamina dura in radiographs. Histologically, it contains a series ofopenings f.'ribriform plute) through which neurovascular bundles link the PDL with the central component ofthe alveolar

. The inner socket wall ofthin, compact bonc callcd

bone, the cancellous bone. . Cancellous trabeculae, betwecn these two compact layers, which act as supporting alveolar bone. The interdental septum consists of cancellous supporting bone enclosed within a compact border. In addition, thc bones ofthejaw includc the basal bone, which is the portion ofthc jaw located apically, but unrelated to the teeth.

Most ofthe facial and lingual portions ofthe sockets are formed by compact bone alone; cancellous bone surrounds the lamina dura in apical, apicolingual, and interradicular arcas. Osteoblasts, the cells that prcduce the organic matrix ofbone, are differentiated from pluripotent follicfe cells. Alveolar bone is formed during fetal growth by irrrd membranous ossification and consists ofa calcified matrix with osteocytes enclosed within spaces called lacunae.
Bone consists oftwothirds inorganic matter and one{hird organic matrix. The inorganic matrix is composcd principally ofthe minerals calcium and phosphatc, along with hydroxyl, carbonate, citrate. and trace amounts ofother ions, such as sodium, magnesium, and fluoride. The mineral salts are in the form of hydroxyapatite crystals and constitute approximately two thirds of the bone structure. The organic matrix consists mainly of collagen type | (90%), with small amounts ofnoncollagenous proteins such as ostcocalcin, osteoncctin, bonc morphogcnetic protcin, phosphoproteins, and

proleoglycans.

Types ofcells identified in the periodontal ligament; . Connective tissue cells: fibroblasts, cementoblasts. and osteoblasts. Fibroblasts are the most comnlon cells, they synthesize collagen and possess the capacity to phagocytoze "old" collagen fibers. Note: Cementoclasts and osteoclasts are also se€n in the cemental and osseous surlaces

ol-thc PDL.
the epithelial rests of Malassez form a latticework in the periodontal ligament and are considered remnants of Hertwig's root sheath, which disintegrat€s during root der elopment. They are distributed close to the cementum throughout the PDL ofmost teeth and are most numerous in the apical and cervical arcas. . Defense cells: include neutrophils, lymphocl4es, macrophages, mast cells, and eosinophils. These cells. as well as those associated with neurovascular elements. are similar to the cells in other connective tissues.

. Epithelial rest cells:

Tbe lunctions ofthe periodontal ligament are categorized into: Ph!sical: attachment ofthe tooth to the bone via principal fibers and the absorytion ofocclusal tbrces. Formatiye: fonnation ofconnective tissue components by activities ofconnective tissue cells r cent erttoblas ts, f brob lasts and osteoblasts). Remodeling: by activities ofconnective tissue cells that are able to form as well as resorb cementum lcementoblasts or cementoclasts), the periodontal ligament (fibroblasts oljibrocldsts), and the alveolar bone (osteoblasts or osteoclasts). \utritive: through blood vessels that maintain the vitality ofits various cells.

Sensory: carried by the trigeminal nerve, proprioceptive and tactile sensitivity is impaded th.ough PDL f.ler.ralion ofcontact behl,een leeth). Note: The periodontal ligament 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 and proteoglycans, and glycoproteins, such as fibronectin and laminin.
Tbe PDL rnay also contain calcified masses called cementicles, which are adherent to or detached from the root surfaces. These develop from calcified epithelial rests.

. The first statement is true; the second statement is false

. The

second statement is true; the first statement is false

. Both statements are true . Both statements are false

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Although the average width ofthe periodontd ligrment space is documentad to be about considerable variation exists.

_,

. 0.002 mm . 0.2 mm . 2.0 mm

.20 mm

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Collagen is synthesized by fibroblasts, chondroblasts, osteoblasts, odontoblasts, and other cells. The several tlpes ofcollagen are all distinguishable by their chemical composition, distribution, function, and morphology. The principal fibers ofthe periodontal ligament are composed mainly ofcollagen type I, whereas reticular fibers are composed ofcollagen type III. Collagen type lV is found in the basal lamina.

Collagen is a protein composed ofdifferent amino acids, the most important ofwhich are glycine, proline, hydroxylysine, and hydroxyproline. The amount of collagen in a tissue can be determined by its hydroxyproline content. Collagen is responsible for maintenance ofthe framework and tone oftissue.
1. Less regularly arranged collagen fibers are found in the interstitial connec-

lqo1"3; tive tissue between the principal fiber groups; this tissue contains the blood

-

vessels. lymphatics. and nerves.

2. Although lhe periodontal ligament 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 ofthe root. They are thought to regulate vascular flow. 3. The principal fibers are remodeled by the periodontal ligament cells to adapt to physiologic needs and in response to different stimuli.

The periodontal space is diminished around teeth that are not in function and in unerupted teeth, but it is increased in teeth subjected to h,?erfunction.

***

ofa complex vascular and highly cellular connectile tissue that surrounds the tooth root and connects it to the irmer wall of the alveolar bone. It is continuous with the connective tissue ofthe gingiva and communicates with the marow spaces through vascular channels in the bone.
The periodontal ligament is composed

The periodontal ligament is abundantly supplied with sensory nerve fibers capable of rransmitring tactile, pressure, and pain sensations by the trigeminal pathways. Nerve bundles pass into the periodontal ligament flom the periapical area and through channels from the alveolar bone that follow the course ofthe blood vessels. The bundles divide into single myelinated fibers, which ultimately lose their myelin sheaths and end in one of four qpes 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's corpuscles, also mechanoreceptors, found mainly in the midroot
region.
,1.

Spindlelike pressure and vibration endings, which are surrounded by a fibrous

capsule and located mainly in the apex.

\ote:

Orthodontic treatment is possible because the PDL continuously responds and changes as a result ofthe functional requirements imposed upon it by extemally applied
forces.

. Thick, keratinized stratified squamous epithelium without rete pegs . Thick, nonkeratinized stratified squamous epithelium with rete pegs
. Thin, keratinized nonstratified squamous epithelium with rete pegs

. Thin, nonkeratinized stratified squamous epithelium without rete pegs

122 Copright O 20ll-2012 - D€nbl Decks

. Decrease in the pH . Increase in the pH

.

Decrease in the viscosity

. Increase in the viscosity

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The epithelial component ofthe gingiva shows regional morphologic variations that reflect tissue adaptation to the tooth and alveolar bone. These variations include:

. Oral (outer) epithelium:

covers the crest and outer surlace ofthe marginal gingiva and the sudace of the attached gingiva. On average, the oral epithelium is 0.2 to 0.3 mm in thickness. lt is keratinized or parakeratinized. The oral epithelium is composed offour layen: stratum basale, stratum spinosum, stratum granulosum, and stratum comeum. . Sulcular epithelium: lines the gingival sulcus, it is a thin, nonkeratinized stmtified squamous epithelium without rete pegs, and it extends from the coronal limit ofthe junctional epithelium to the crest ofthe gingival margin. . 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 oflayers increases with age to l0 or even 20 layers. Also, the junctional epithelium tapers liom its coronal end, which may be l0 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 f'acing the connective tissue and the suprabasal layer extending to the tooth surface. The length ofthejunctional epithelium ranges from 0.25 to 1.35 mm,

lmportant: The attachment ofthejunctional epithelium to the tooth is reinforced by the ginsival fibers. which brace the marginal gingiva against the tooth surface. For this reason, the junctional epithelium and the gingival fibers are considered a functional unit, refered to as the dentogingiYal unit.

\ote: Histologicalll', the best way to distinguish the free gingiva from the epithelial attachment is the fact that the epithelium ofthe epithelial attachment does not contain rete pegs and the free gingiva does. Rete pegs are epithelial projections that extend into the gingival connectir e tissue. Connective tissue projections that extend into the overlying epithelium are called connective tissue papillae.

The theoretic mechanisms by which plaque becomes mineralized can be grouped into two
maln categofles:

L14ineral precipitation results from a local rise in the degree ofsaturation ofcalcium and phosphate ions, which may occur through the lollowing mechanisms: . An increase in the pH ofthe saliva causes precipitation of calcium phosphate salts by lot\ ering the precipitation constants. The pH lnay be elevated by the loss ofcarbon dioxide and the formation ofammonia by dental plaque bacteria. . Colloidal prot€ins 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 offree phosphate ions. 2. Seeding agents induce small foci ofcalcification that enlarge and coalesce to form a calcified mass. This concept is refered to as tbe epitactic concept, or more appropriately, heterogenous nucleation. lt is suspected that the intercellular matrix ofplaque 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.

\ote: Mineralization of plaque

starts extracellularly around both gram-positive and gramnegative organisms. Bacterionema and Veillonella species have the ability to form intracellular hydroxyapatite crystals.

Remember: Materia alba is a concentation ofmicroorganisms, desquamated epithelial cells, leukocytes. and a mixture ofsalivary proteins and lipids, with few or no food particles, and it lacks the regular intemal pattem observed in plaque.

. Desquamated epithelial cells

. Gingival crevicular fluid
. Phosphatases formed by bacterial plaque

. Saliva

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. Microorganisms
. Water . Minerals

. Tissue cells

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Calculus is dental plaque that has undergone mineralization. lt forms on the surfaces of natural teeth and dental prostheses. Saliva is the source of mineralization for supragingival calculus, whereas the serum bansudate called gingival crevicular fluid fumishes the minerals for subgingival calculus. . Supragingival calculus: is located coronal to the gingival margin. It is usually white or pale yellow in color and is hard with a claylike consistency. lt is easily removed by a professional cleaning. The two most comrnon locations for supragingival calculus to develop are the buccal surfaces of the maxillary molars and the lingual surfaces ofthe mandibular anterior teeth. Saliva from the parotid gland flows over the facial surfaces ofthe maxillary mola$ through Stensen's duct, whereas the odfices of Whadon's duct and Bartholin's duct empty onto the lingual surfaces ofthe mandibular incisors from the submandibular and sublingual glands, respectively. . Subgingival calculus: is located below the crest of the marginal gingiva. lt is typically hard and dense and frequently appears dark brown or greenishtiack (due to exposure to gingival crevicular JIuidJ while being firmly attached to the tooth surlace
Differences in the manner in which calculus is attached to the tooth surface affect the relative ease or dilfjculty encountered in its removal. lt has been shown that calculus can attach to tooth surfaces through four modes: l. Attachment by means ofan 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
,1.

Penetration ofcalculus bacteria into cementum
a gain in clinical

Important: A reduction in gingival inflammation and probing depths with

aftachment can be observed after removal ofsubgingival plaque and calculus.

Dental plaque is dcfined clinically as a structured, rcsilicnt, yellow-grayish substance that
fixed restorations. primarily composed of bacteria in a matrix of salivary glycoprotcins and exhacellular Plaquc is polysaccharides. The microorganisms exist within an intercellular matrix that also contains a few
adheres tenaciously to the intraoral hard surfaces, including removable and

host cells. such as epithclial cells, macrophages, and leukocltes.

Dental plaque is broadly classified as: . Supragingival plaque: is fould at or above the gingival rnargin; when in direct contact with the gingival rrargin, it is r€ferred to as marginal plaque. Gram-positivc cocci and short rods predominate at thc tooth surface, whereas gram-negative rods and filaments, as well as spirochctcs, predominale in (he outer surfacc ofth€ matue plaque mass. . Subgingival plaque: is found below the gingival margin, between the tooth and the gingival pocket epithcliurn. In general, the subgingival microbiota diffcrs in composition from the sr-rpragingival plaque, primarily because of the local availability ofblood products and the low oxrdation-reduction lredo.r) potential, which characterizes the anaerobic envircnment. Cervical plaque: - Tooth associated; gram-positive rods and cocci - Tissue associated: gram-negative rods and cocci, filaments. flagellated rods and spirochetcs

. Deeper parts ofthe pocket:
- Tooth associated: gram-negative rods - Tissue associated: gram-negative rods, flagellated rods and spirochetes. Filamentous organisms become fewer Ke! point:The composition ofthe subgingival plaque depends on the pocket depth. The apical part is dominated by spirochetes, cocci, and rods, whereas in the coronal part, more filaments are observed. Important: The overall pattem obscrved in dental plaque development shows a shift from the early aerobic environment characterized by gram-positive facultative speci€s to a highly oxygen-deprived environment in which $am-negative anaerobic microorganisms prcdominate.

. Adhesion

. Pleomorphism . Coaggregation

. Orgarization

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. Porphyromonas gingivalis

. Tannerella forsyhia
. Treponema denticola . Eikenella conodens

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The process ofplaque formation can be divided into three major phases:
1. The formation of the pellicle on the tooth surface: all surfac€s ofthe oral cavity are coated with a pellicle (the initial phase ofplaque deNelopment). Within nanoseconds atler vigorously polishing the tecth, a thin, saliva-derived layer, called the acquired pellicle, covers the tooth surface. This pellicle consists ofnumerous components, including glycoproteins fnrrcins), pro-

line-rich proteins, phosphoproteins fe.g., .rtatherin),histidine-nch proteins, enzymes (e.g., alphaamylase.), and other molecules that can function as adhesion sites for bacteia (receptors).

Note: The mechanisms involved in enamel pellicle formation include electrostatic, van der
Waals, and hydrophobic forces. 2. lnitial adhesion and attachment of bacteria:

- Phase l: Transport to the surfacei involves the initial tmnsport of the bacterium to the

tooth surface. - Phase 2: Initial adhesion: results in an initial, reversible adhesion ofthe bacterium, mediated through van der Waals and elecfostatic forces. - Phase 3: Attachment: aftcr initial adhesion, a firm anchorage between bacterium and surface will be establishcd.

- Phase 4: Colonization ofthe surface and biofilm formationr read #3 below

Colonization and plaque maturation: When the firmly attached microorganisms sart growing and the newly formcd bactcrial clustcrs remain attached, microcolonics or a biofilm can develop. From this stage forward, new mechanisms are involved because new intrabacterial connections may occur At least l8 genera from the oral cavity have shown some form ofcoaggregztion (cell-to cell recognition ofgenetically distinct partner cell types). Essentially all oral bacteria (but especidlly Fusobacterium wcleatur, possess surface molecules that foster some ty-pe ofcell-to-cell interaction. This process occurs primarily through the highly specific stereochemical interaction of protein and carbohydrate molecules located on the bacterial cell surl'aces. in addition to the less specific interactions resulting from hydrophobic, electrostatic,and van der Waals forces.
3.

enr complexes was based on the frequency with which djfferent clusters of microorganisms were recovered. The e^rly (primaD,) colonizers arc cithcr indepcndent of defined complexes (Actinomlces naeslLtndii, A. viscosus) or members ofthe yellow (Streptococcus spp.) or purple complex€s f,4clir?om|ces odontolvticus).
The microorganisms primariJy considered secondary (/ate) colonizers fell jnto the green, orange orred complexes. The green complex includes Eikenella corrodens, Actinobacillus actinotherapeutics serotlpe a. and Capnoc)'tophaga species. The orange complex includes Fusobacterium, Ptevotella, and Campylobacrer species. The green and orange complcxes include species recognized as pathogens in periodontal and nonpcriodontal infections. The red complex consists ofPorphytomonas gingivalis, Treponema denticola. and Tannerella fors)'thia. This complex is ofparticular interest because it is associated with bleeding on probing, which is an important clinical parameter ofdestructive periodontal diseases.

Recent studies ofplaque samples looking for 40 subgingival microorganisms using a DNA hybridizarion mcthodology, defined "complexes" ofperiodontal microorganisms. The composition ofthe diffcr-

Plaque as a biofilm: The dental plaque biofilm has a similar structure to all biofilms fcomposed oJ micro(olonies e closed in a polysacchaide mdf,r. It is heterogenous in structure, with clear evidence of open fluid-filled chsrrnels running through the plaque mass. These water channels pennit the passage ofnutrients and other agents throughout the biofilm, acting as a primitive "circulatory" system. The inrercellular matrix consists of organic and inorganic materials derived Aom saliva, gingival crevicular fluid, and bacteial products.

Important: In a biolilm, bacteia have the capacity to communicate with each othet (called quorum sezsing,). This involves the rcgulation ofexpression ofspecific genes thrcugh the accumulation ofsignaling compounds that mediate inter-cellular communication. When these sjgnaling compounds reach a rhrcshold levcl (cal/ed quorum cell density), gene expression can be activated.
Note: Tle high density ofbacterial cells in a biofilm also facilitates thc exchange ofgenetic information among cells ofthe same species and across species and even genera. Conjugation, transformation, plasmid transfer, and transposon transfer have all been shown to occur morc easily in a biofilm. Remember: Following a prophy, plaque is most likely to accumulate on the interproximal tooth surfaces first.

. Filaments . Cocci
. Rods
. Vibrios

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At l€asts two thirds ofthe inorganic component ofcalculus is cr;stalline in structure. Of the four main crystal forms, whlch one is more common in the mandibular anterlor region?

. Magnesium whitlockite

. Brushite . Octocalcium phosphate . Hydroxyapatite

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Bacterial plaque is the primary etiologic factor for the initiation ofperiodontal disease. Plaque formation begins immediately after a tooth surface is cleaned. The rate ofplaque formation is affected by diet, age, salivary flow, oml hygiene, tooth alignment, systemic disease and host factors. Changes in the q?es oforganisms occur

within plaque as the plaque matures. Days I to 2; young plaque consists primarily of cocci (i.e., Slreptococcus mutans and sanguis) . Days 2 to 4: cocci still dominate but there are increasing numbers offilamentous forms and slcndcr rcds. Gradually the filamentous forms replace many ofthe cocci. . Days 4 to 7: filanents increase in numbers, and a mo.e mixcd flora begins to appear with rcds, filamentous forms. and fusobacteria. . Days 7 to 14: vibrios and spirochctes appear, and the number ofwhitc blood cells increases. More gmmnegative and anaerobic organisms appear The signs ofinflammation are beginning to be observabl€ in the grngrva. . Dsys 14 to 2l: vibrios and spirochetes are prevalent in older plaque, along with filamentous forms. Gin-

givitis is evident clinically. As plaque ages: . Thc number ofcocci decreases and the number ofrods, fusiform, filaments, and spi.ochetes increases . The number ofaerobic bacteria decreases and the number of anaerobic bacteria increases . The number ofgram-positive organisms decr€ases and the number ofgram-negative orBani$ns increases Key point: As the biofilm (plaque.) matures, there is a shift from a predominance of facultative, gram-positive bacteria to gram-negative, anaerobic bacteriaThe transition from gram-positive to gnm-negative microorganisms obscrvcd in the structural devolvement ofdental plaque is paralled by a physiologic transition in the developing plaque. The early colo-

nize$ (e.g., St/eptococci, Actinomyces species) lse oxygen and lower the redox potential of the
environment, which then favors the growth ofanaerobic species. Gmm-positive species use sugars as an energy source and saliva as a carbon source. The bacteria that prcdominatc in mature plaque are anaerobic and asaccharolytic and use amino acids and small peptides as energy sources. l. The organic constituents ofplaque include polysaccharides fd€rtla n), proteirs (i.e., albunin), glycoprotetns (fron saliraJ, and lipid material. 2. The inorganic components ofplaque are predominantly calcium and phosphorus, with trace amounts ofother mincrals, including sodium, potassium, and fluoride. 3.The source ofinorganic constituents ofsupragingival plaque is primarily saliva.

Supragingival calculus consists of inorganrc (70%-90%) and organic components. The inorganic portion consists of 76%0 calcium phosphate, 3% calcium carbonate, and traces ofmagnesium phosphate, and other metals. The principal inorganic components are calcil]m (39%); phosphon:s (19%o); carbon dioxide (l .9%,'l magnesium (0.8%o) and trace amounts of sodium, zinc. strontium, bromine, copper, manganese, tungsten, gold, aluminum, silicon, iron, and fluorine. At least two thirds ofthe inorganic component is crystalline in structurc. The four main c4stai forms are as follows;

. H! droxyapatite f582,) . \Iagnesium whitlockile (2191,) . Octacalcium phosphate (12%) . Brushite (9?6) Hydroxyapatite and octacalcium phosphate are detected most frequently (in 97% to 100% oJ all
Genemll-v. two or more crystal forms are typically found in a sample of calculus.

supragingival calculus/ and constitute the bulk ofcalculus- Brushite is more common in the mandibular anterior region and rnagnesium whitlockite in the posteior 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 supragingival calculus. The ratio of calcium to phosphorus is higher subgingivally, and the sodium content increases with the depth ofperiodontal pockets. Salivary proteins present in supmgingival calculus are not found sub-

gingivally.
Not€: Calculus (bor, supragingival and subgingival) located on interproximal surfaces can be seen on bite-wing radiographs as interproximal spurs.

. The number of osseous walls that were deshoyed by periodontal disease
. The number ofosseous walls left surroundins the tooth

. The number ofosseous walls that will remain after surgery . Periodontal probe readings

't

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. Periodontal probing . Radiographs . Exploratory surgery
. Testing for mobility

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disease. The bone is reduced in height, but the bone margin remains approximatcly pc.pcndicular to thc tooth surface. The interdental septa and facial and lingual plates are affected, but not necessarily to an equal degree around the same tooth. Vertical or angular defects are those that occur in an oblique direction, leaving a hollowed-out trough in thc bone alongside the root; the base ofthe defect is located apical to the surrounding bone. In most instances, angular defects have accompanying intrabony periodontal pockets; intrabony pockets, however, always have an undcrlying angular defcct. Angular defects are classified on the basis ofthe number of osseous walls. Angular defects may have one, two, or three walls. The number of walls in the apical portion ofthe defect may be grcater than that in its occlusal portion, in which case the telm combined osseous defect is used. Important: Surgical exposure is the only sure way to determine the presence and configuration ofvertical osseous dcfects.

Horizontal bone loss is the most common pattem ofbone loss in periodontal

l. Osseous craters arc concavities in the crest ofthe interdentalbone confined within the facial and lingual walls. Craters have been found to make up about one third (3 5.2o/o) of al], defects and about two thnds (62%o) of all mandibular defects. They are more common in posF te.ior segments than in anterior segments. They are best heated with osseous surgery f,.econtouring). 2-The relative degree ofsuccess ofperiodontal bone grafting is reported to vary directlywith the number of bony walls of the defect (vascularized, osseous sul.face arca) and invcrscly u jth the surface area ofthe root against which the graft is implanted. Thus a narrow, threewalled angular defect usually yields the greatest success, a two-walled defcct the next best, and a one-rvalled defect the least. 3. A dehiscence is a loss ofthe buccal or lingual bone overlaying the root portion ofa tooth, leaving the area covercd by soft tissue only. 4. The three-wall vertical defect was originally called an intrabony defect, Thc telm inbabony was later expanded to designate all vertical defects. 5. The one-wall vertical defect is also called a hemiseptum. 6. Suprabony pockets are associated with horizontal bone loss. They are not intraosseous.

***

This is because a dense buccal and/or lingual plate ofbone will tend to mask the defect, blocking it out on the radiographs. This information can only be determined by ex-

ploratory surgery. Important: Radiographs will not show: L The number of walls left surrounding the tooth 2. The exact configuration ofthe defect 3. The location ofthe epithelial attachment Remember: The two most critical parameters for the prognosis of a periodontally inr olved tooth are rnobility and attachmentloss (which is most critical). Angular defects are classified on the basis of the number of osseous walls. Angular defects may have one. t\r'o. or three walls. The number of walls in the apical portion ofthe defect may be greater than that in its occlusal portion, in which case the term combined osseous defect
is used.

Pock€t d€pth is the distance between the base ofthe pocket and the gingival margin. The lelel of attachm€nt on the other hand, is the distance between the base ofthe 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 ofattachment and thus provide a better indication ofthe degree of periodontal destruction. Pocket formation causes loss of attachment ofthe gingiva and denudation ofthe root sur-

ofthe attachment loss is generally, but not always, correlated with the depth of tlre pocket. This is because the degree of attachment loss depends on the location ofthe base ofthe pocket on the root surface, whereas the pocket depth is the distance between the base ofthe pocket and the crest ofthe gingival margin. Pockets ofthe 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.
face. The severity

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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The principal differences between intrabony and suprabony pockets are the relationship ofthe soft tissue wdl ofthe pocket to the alveolar bone, the pattern of bon€ destruction, and the direction of the transseptal fibers of the periodontal ligament.

In intrabony pockels, the base ofthe pocket is apical to the crest of the alveolar bone, and the pocket wall lies between the tooth and the bone.

. The first statement is true; the second statement is false . The second statement is truej the first statement is false . Both statements are true . Both statements are false
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Deepening ofthe gingival sulcus may occur by coronal movement ofthe gingival margin, apical displacement ofthe gingival attachment, or a combination ofthe two processes. Pockets can be classified as follows: . Gingival pocket (pseudopocket): this t)?e of pocket is formed by gingival enlargement without destruction ofthe underlying periodontal tissr.res. All gingival pockets are suprabony (the base ofthe pocket is coronal to the crest ofthe alveolar bone).T\e sulcus is deepened because ofthe increased bulk ofthe gingiva. . Periodontal pocket: this type of pocket occurs with destruction ofthe supporting periodontal tissues. Progressive pocket deepening leads to destruction ofthe supporting periodontal tissues and loosening and exfoliation ofthe teeth. Two types ofperiodontal pockets exist: . Intrabony (infrabony, subcrestal, or intraalveolar): in which the bottom of the pocket is apical to the level ofthe adjacent alveolar bone . Suprabony (supracrestal or supraalveolar): in which the bottom ofthe pocket is coronal to the underlying alveolar bone.
a bluish red, thickbned marginal gingiva; a bluish red, vertical zone from the gingival margin to the alveo-

Clinical signs that suggest the presence ofperiodontal pockets include

iar mucosa; gingival bleeding and suppuration; tooth mobility, diastema formation; and sl mptoms such as localized pain or "pain deep in the bone." The only reliable method of Iocating periodontal pockets and determining their extent is careful probing ofthe gingir al margin along each tooth surface.

1. Base ofpockct is apical to crest ofalveolar bone so that the bone is adjacent to soft tissue wall.

2. Pattem ofbone destruction is venical

largrldrl

i . Interproximally, transseptal fibets that are
renored dlrrirlg progressive periododal disease ale armnged horizontally in the space betweel the base of Docket and alv€olar bone. Oo facial and lin8ual surfaces, periodontal ligament fibers beneath pocket follow thei. normal horimnral-oblique cou6e betwe€n th€
-1.

3. Interproximally. transseptal fibers are oblique rather than horizontal. Thcy exlend from cementum beneath base of pockel along alveolar bone and over crest to cementum of adjacent tooth 4. On facial and lingual surfaces, periodontal ligament fibers follow ang!lar pattem ofadjacent bone. They extend liom cementum beneath base ofpockct along jlveolar bone and over cre\l ro join with ouler perio.leum.

rooth and bone.

i:.r(ured \nh pedrssion, Iio'!

Neq,man

Vc,

Iakei IIH, KloLkevold PR. C.ftanza l-A.

Cnah:n\ clinicol P.rio.lo"h|oAr701../. Eh.-

. The bone loss is vertical in nature .
The bone loss is horizontal in nature

. Transseptal fibers are horizontal

. Supracrestal fibers follow the normal bone contour

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. Incipient bone loss

. Partial bone loss (cul-de-sac)
. Total bone loss with through-and through opening ofthe furcation

. Similar to the above, but with gingival recession exposing the furcation to view

Cop),righr C 20ll'2012 - Dental Decks

P dio d on

t a l a s^,

I

lr " e,l.

Elsevier.2006.

Different t)?es ofperiodontal pockets. A, Gingival pocket. There is no destruction ofthe supporting periodontal tissues. B, Suprabony pocket. The base ofthe pocket is coronal to the level of the underlying bone, Bone loss is horizontal. C, Intrabony pocket. The base ofthe pocket is apical to the level ofthe adiacent bone. Bone loss is vertical.

The term furcation involvement refers to the invasion of the biflircation and trifurcation of multirooted teeth by periodontal disease. The denuded furcation may be visible clinically or cor ered b1, the wall of the pocket. The extent of involvement is determined by exploration \\ irh a blunt probe, along with a simultaneous blast ofwarm air to facilitate visualization. Furcation involvements have been classified as grades I, II. lll, and lV according to the amount oftissue destruction. . Grade l: is incipient bone loss . Grade ll: is partial bone loss (cul-de-sac) . Grade III: is total bone loss with through-and-through opening ofthe furcation . Grade I\': is similar to Grade IIl, but with gingival recession exposing tbe furcation to
r

ieu

Findings that complicate furcation involvement and account for some painful symptoms include caries ofthe cementum and dentin, tooth resorytion in the furcation, abscess formation in the f'urcation, and involvement ofthe pulp via lateral canals in the furcation. Definitive diagnosis of furcation involvement is made by careful clinical probing. X-rays are helpful but on11 as an adjunct to the clinical examination. The major principle oftreatment ofinvolved furca is to eliminate the involvement whenever possible. A variety ofmethods are available for treatment. Not all ofthem provide for elimination ofthe furcation; some provide only for increased accessibility for plaque removal. Bone grafts haye relatively little effectiveness in treating furcations. Howevel guided tissue regeneration is used to treat Grade II furcations with good success. Note: Furcation involvement of maxillary second molars have the poorest prognosis following therapJ.

Imponant: Microscopically, furcation involvement

presents no unique pathologic features. is simply a phase in the rootward extension ofthe periodontal pocket.

It

. The first statement is true; the second statement is false
. The second statement is true; the first statement is false

. Both . Both

statements are true statements are false

136 Copyighr C 20ll'2012 - Dental Decks

When using the periodontal probe to measure pocket depth, tbe measurement is taken from the:

. Base ofthe pocket to the CEJ . Free gingival margin to the CEJ . Junctional epithelium to the margin ofthe free gingiva . Base ofthe pocket to the mucogingival junction

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Gingival enlargement is a well-knowr consequence of the adninistntion of some anticonvulsants, immunosuppressants, and calcium channel blockers. Clinical and microscopic features the enlargements caused by the different drugs are similar.

of

The growth starts as a painless, beadlike enlargement ofthe interdental papilla and cxtends to the lacial and lingual gingival margins. As the condition progresses, th€ marginal and papillary enlarg€ments unite; they may develop into a massive tissue fold covering a considerable portion of the crowns, and may interfere with occlusion. When uncomplicated by inllammltion, the lesion is rnulberry shaped, firm, pale pink. and resilient, with a minutely lobulated surface and no tendency to bleed. The presence ofthe enlargement makes plaque control difficult, often resulting in a sccondary inflammatory process that complicates the gingival overgrowth caused by the drug. Secondary inflammatory changes not only add to the size of the lesion caused by the drug, but also produce a red or bluish red discoloration. oblitcrate thc lobulated surface demarcations, and incrcasc bleeding tendency.

Anticonyulsants; the first drug-induced gingival enlargements reported were those produced by phenytoin (Dilantin). Other hydrantoins known to induce gingival enlargement are cthotoin lPagatnne) arndmephenytoin (Mesanloin). Other anticonvulsants that have the same side effect are the succinimides (eliosuximide lZerontin], nethsuxinimide lCelontinl, and valp,"oic acid lDepakenel).

lmmunosuppressants: Cyclosporine is a potent immunosuppressive agent used to prevent organ rransplant rejection and to treat scveral diseases ofautoimmune origin. Cyclosporine-induced gingir al enlargement is more vascularized than phenytoin enlargement. Another immunosuppressive drug. tacrolimus, has been used effectively and results in much less gingival overgowth.

Calcium channel blockers are drugs devcloped for thc treatment of cardiovascular conditions.
These dnrgs are the dihydropyridine derivatives (amlodipine fLotrel,

Norvascl,y'lod?nre fPlendil], nicardiptue [Carden], nifedipine fAdalat, Procardia]): the benzothiazine derivatives (diltiazem ICardizem, Dilacor XR, Tlazac]); and the phenylalkylaminc dcrivatives (verupantil fcalan, Isoptin,

\ erelan. Covcra HSI).

Periodontal probes are used to measure the depth ofpockets and to determine their cont.igurations. The typical probe is a tapered, rodlike instrument calibrated in millimeters, * ith a blunt, rounded tip. Ideally, probes are thin, and the shank is angled to allow easy insertion into the pocket. The probe is inserted along the long axis of the tooth into the pocket lvith a firm, gentle pressure fapproximqtely l0 to 20 grdrrs) until resistance is met. The probe is walked around each surface of the tooth. This method is less painful and more eflicient, provides a complete and accurate assessment ofthe depth ofthe epithelial anachment and will detect bony defects better.
Periodontal probing provides the most accurate assessment ofperiodontal pocket depth. The true topography ofvertical osseous defects cannot be determined by radiographic examination alone. Bone levels may be high, yet pockets may be deep. Extensive bone loss ma-u- exist and yet be unaccompanied by pockets if the gingiva has receded. The most important r€ason for using the periodontal probe is that it determines the loss ofat-

tachment.

' ., l. Bleeding scores: bleeding is still the most reliable indicator ofthe \ore*.: ofgingival or periodontal inflarnrnation. ,' '&i

presence

z. Plaque score: with plaque disclosing solution, used to help visualize plaque for the patient and clinician. Also used at multiple visits to show patients improvement in their level of oral hygiene. 3. Recession is measured in millimeters from the CEJ to the marginal ginsiva ofeach tooth root.

. It should

be parallel to the long axis of the tooth at the point angle

. It should be parallel to the long axis ofthe tooth at the contact area

. It

should touch the contact area and the tip should angle slightly beneath and beyond contact area
be perpendicular to the long axis

tle

. It should

ofthe tooth in front of the contact area

'|

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How should the periodontal probe be inserted into th€ sulcus?

. Perpendicular to the long aris ofthe tooth . With . With
a

firm pushing motion

a short oblique stroke

. Parallel to the tooth surface

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The periodontal probe may be angled approximately l0"on each interproximal surface so that the tip ofthe probe is placed apical to the contact point of adjacent teeth and may detect any interdental crater but, in most instances, the direction ofthe probing is parallel to the long axis ofthe tooth.

***

Periodontal measurements are taken by inserting the probe under the marginal gingiva and gently moving it down to the junctional epithelium (bels soft, eldstic and resilient). In a healthy site, the tip ofthe probe stops within the junctional epithelium and in a diseased site it penetrates into the connective tissue. In severe disease, the probe tip may
Denetrate to the alveolar bone

.,nnd '&t

l. The clinical probing depth is always greater than the histologic sulcus or pocket depth. Probing accuracy is only within I mm. 2. The calibrated periodontal probe should have a tapered shaft approximately

t

0.5 mm in diameter at the tip. It is important to have uniform instruments throughout the practice in order to ensure as much standardization as possible. 3. Furcation areas can be best evaluated with the curved #2 Nabers probe. 4. The periodontal probe can also be useful in the detection ofsubgingival deDOSltS.

The tip ofthe probe should always be kept in contact with the tooth, thus preventing soft tissue injury. The probe is gently "walked" along the junctional epithelium in an up and

do.*'n motion (called circumferential probing) always remaining under the gingival
margin. It is imperative that the probe be walked along the entire gingival sulcus since the from depth of the epithelial attachment varies. Six measurements are recorded -three the buccal and three from the lingual: disto-buccal, buccal, mesio-buccal, distolingual, lingual and mesioJingual. These measurements are the distance in millimeters from the base ofthe pocket (junctional epitheliuz) to the margin ofthe free gingiva.

, ]i..oto{

l.The most importart 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 conect probe force (approximately l0 to 20 grazs) depresses the thumb pad approximately l-2 mm.

Ifyou should

meet resistance after inserting the periodontal probe into the sulcus, you should:

. Rernove the probe and reinsert it in a different spot

. Lift the probe away from the tooth . Force

and attempt to move it apically

the probe beyond the obstruction
a narrower diameter

. Remove the probe and select one with

. Record the measurement where

the probe stopped

IrO
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Which of the following is the most common error when performing periodontal probing?

. Using the wrong type or probe

. Incorrectly reading

the periodontal probe

.

Excessively angling the probe when inserting
axis ofthe tooth

it

interproximally beyond the long

. Forgetting to also probe the lingual ofevery tooth

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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 looth, 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.

L Recession is the measurement of the migration of the free gingival margin apical to the CEJ ofthe tooth. Recession is measured as a positive value. The recession measurement added to probe depth at a particular site indicates the amount ofperiodontal 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 ofattached gingiva: (l) Place the probe on the external surface ofthe gingiva and measure from the mucogingivaljunction to the gingival margin to detemine 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 ofthe attached gingiva.

*"*

This will give greater probe readings than are actually present,

Tilting the probe could affect the accuracy of the measurements. If the probe is angled too much, it will extend beyond the contact area and if it isn't angled enough, then it $ ill be at the line angle instead of under the contact area. Both mistakes will result in inaccurate readings. The tip should be flat against the tooth near the gingival margin u ith the probe approximately parallel with the long axis ofthe tooth for insertion.
l\,lote: In the presence of inflammation, the probe may extend apical to the most coronal extent ofthe junctional epithelium (bottom ofpocket) and give a slightly greater depth than
is actually present.

Important: Ifa patient is at risk for subacute bacterial endocarditis, he or
premedicated before performing periodontal probing.

she needs to be

Remember: Bacteremia can occur even with mastication or brushing. However, it does not last long. The important consideration is the presence or absence of periodontal inflammation. The presence of inflammation leads to a longer duration of bacteremia with resultant risks for natients at risk of acute bacterial endocarditis.

. Centrals

and laterals

. Canines and premolars . Second and third molars
. First and second molars

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. Bayer's theory . Chemiosomotic theory

. Hydrodynamic theory . Quanhrm th€ory

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*** Toothbrush tratma' (abrasion)
in the dental arch,

usually occurs on teeth that are the most prominent

The maintenance oforal health is enhanced by the use ofa soft-bristle toothbrush with a dentifrice of optimum abrasiveness and a dental floss. A hard-bristle toothbrush is capable of causing gingival recession and abrasion of enamel and / or cementum and should be avoided. The abrasive quality of dentifrices affects enamel, but abrasion is more ofa concem for patients with exposed dentin because dentin is abraded 25 times faster and cementr.rm 35 times faster than enamel. This can lead to root surface abrasion and root sensitivity. Hard tissue damage from oral hygiene procedures is mainly due to abrasive dentifrices, whereas gingival lesions can be produced by the toothbrush alone. Trauma ftom toothbrushing may result in the following: . Recession of the marginal gingiva . Lacerations of the soft tissues including the attached gingiva and the alveolar mucosa

. \Lshaped notches in the cervical areas of teeth . Gingival clefts: which are narrow grooves that extend from the crest of the gingiva
to the attached gingiva

lJote: The location of the above alterations is frequently inversely related to the rightor left-handedness ofthe patient.

Remember: ln gingival atrophy or recession, the tissue appears to be otherwise normal. The gingiva is thin, finely textured and pale pink in color with normal papillae. The gingival sulci is very shallow. Plaque is minirnal.

The Hydrodynamic theory postulates that the pain caused by dentinal

ofroot sensitivity results from indircct innervation
mcchanoreceptors in the pulp.

fluid movement in the tubules' which stimulates

lt may occur spontalvhen the root becomes exposed as a result ofgingival recession or pocket foimation, or it may neouslv appear after scaling and root planing and surgical procedures. The primary symptom is cold sensitiviq. Plaque and food debris, ifallowed to remain on exposed root surfaces, often lead to incrcased sensiriviq. Note: To reduce the sensitivity to thermal change after removal ofa periodontal dressing, it is bejt to keep the rcots free ofplaque.
Root h-'-persensitivity is a relatively common pioblem in periodontal practice
The mosl common agents used by the patient for oral hygiene are dentifrices. Although many dentifrice produfis contain fluoride, additional active ingredients for desensitization are strontium chlodde, potassium ninate. and sodinm cihate. The ADAhas approved the following dentifrices for desensitizing pur-

poses: Sensodyne and Thermodent, which contain strontium chloride, Crcst Scnsitivity Protection, Denquel. and Promise, which contain potassium nitrate; and Protect, which contains sodium cifiate

Important: Desensitizing agents act through the Fecipitation of crystalline salts on the dentin surface, \shich block dentinal tubules.
various oflce treatrnents for the desensitization ofhypersensitive dentin:

. Caviry vamishes
. Antiinfl ammatory agents . Treatments that partially obturate dentinal tubules
- Fluoride compounds ofdentin . Sodium fluoride - Silver nitrate - Zinc chioride-potassium ferrocyanide . Stannous fluoride - IontoDhoresis - Formalin - Strontium chlo de - Calcium compounds: . Calcium hydroxide - Potassium oxalate . Dibasic calcium phosphate - Restorative agents - Dentin bonding agents - Bumishing

. Prescription of home fluoride rinses . Minimal removal oftooth structure during root planing

. The application ofdesensitizing
. Thorough daily plaque control

agents that contain fluoride

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When extensive scding ond root planing must be performed, tle best approach would be:

. A series of appointments set up to scale and root plane a segment or quadrant of teeth
at a time (thoroughly and completely)

. Gross debridement (sub and supragingival) of the entire mouth, followed by appointments for fine scaling and polishing . Perform everything in a single appointment . None ofthe above

a series

of

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Sometimes these areas will become sensitive ifthe root is expos€d. Th€ 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 b), qllowing reminer-

slization ofthe 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, dentinal sensitivity, and most importantly, predisposition to root
canes. The acids and toxins produced by the plaque organisms are very irritating to the pulp by way ofthe odontoblastic processes. This irritation ofthe pulp heightens its sensitivity to other stimuli. No attempt to reduce hypersensitivity will be successful unless the roots are consistently kept free ofplaque.

Desensitizing agents can be applied by the patient at home or by the dentist or hygienist in the dental office. The most likely mechanism ofaction is the reduction in the diameter olthe dentinal tubules so as to limit the displacement offluid in them. This can be attained by: . formation ofa smear layer produced by bumishing the exposed surface . topical application ofagents that form insoluble precipitates within the tubules . impregnation oftubules with plastic resins . sealing of the tubules with plaslic 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 ofa hard toothbrush can lead to hard and soft tissue damage.

The most common cause ofgingival recession is tooth injury (abrasion). Thrs type ofrecession is common on the left canines ofright-handed persons (or right canines ofleft-handed per-to/ls,/,

L There is potential for abscess formation in a deep pocket when only a superficial scaling is periormed. 2. OHI may be more effective if a patient can see healing tissue in an area which 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 ofthe 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 ofthe soft tissue response to scaling and root planing, including probing, should not be conducted earlier than 2 weeks post operatively. Reepithelialization of the wounds created during instrumentation takes I to 2 weeks. Until then, gingival bleeding on probing can be expected even when calculus has been completely removed because the soft tissue wound is not epithelialized. 5. Ifany bleeding or swelling is noted in localized areas ofthe 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 frft e base ofthe pocket).

. Mesial surfaces of maxillary premolars

.

Proximal surfaces of mandibular incisors

. Trifurcations of maxillary molars . Distal surfaces ofmandibular molars

't46 Copright O 20ll-2012 - Dental Decks

Some degree of curettage is done unintentionally when sealing and root planing are performed; this is called inadvertent curettage-

\

Curettage accomplishes the removal of tbe chronically inflamed granulation tissue that forms in the lateral wall of the periodontd pockct.

. The first statement

is true; the second statement is false is true; the first statement is false

. The second statement

. Both statements are true . Both statements are false

147 Coplright O 201I-2012 - D€ntal Decks

Mesial surfaces of maxillary premolars and the proximal surfaces ofmandibular incisors are most likely to have flutings. Also, root proximity is a major problem when performing scaling and root planing on mandibular incisors. Trifurcations on maxillary first molars are the most difficult of all to root plane.

*** Key point:

anatomic features ofteeth frequently limit the effectiveness and efficiency

ofcalculus removal.
Remember: If while root planing you find only a thin ring ofcalculus in the bottom third ofa deep pocket, you can assume that the calculus previously extended the full length of the pocket but the top part was previously removed. Likewise, if after scaling and root planing, the patient retums in one week with hard, black deposits of calculus around the gingival margin, this indicates that a reduction in inflammation occurred after the procedure and old calculus is now exposed.

,\otes

1. The best crit€rion to evaluate the success ofscaling and root planing is no evidence ofbleeding upon probing. Remember: Bleeding upon probing indicates

.,,--;i.- inflammation in the tissue. The amount of inflanrnation present is used to determine the effectiveness ofperiodontal instrumentation and home care by the
patient. 2. Cementum, dentin, and calculus are removed during root planing. 3. Tactile sensitivity refers to the ability to distinguish degrees ol roughness and smoothness on the tooth surface.

The word curettage is used in periodontics to mean the scraping ofthe gingival wall ofa periodontal pocket to separate diseased soft tissue. Scaling refers to the removal ofdeposits from rhe root surface, whereas planing means smoothing the root to remove infected and necrotic tooth substance.

-\ differentiation has been made betwe€n gingiyal and subgingival curettage. . Gingival curettage: consists ofthe removal ofthe inflamed soft tissue lateral to the pocket
ir all

. Subgingival curettage:

refers to the procedure that is performed apical to the epithelial arrachment, severing the connective tissue attachment down to the osseous crest.

Indications for curettage are very limited. It can be used after scaling and root planing for the lbllo* ing purposes; ) . Curettage can be performed as part of new attachment attempts in moderately deep inrrabonv pockets located in accessible areas where a type of"closed" surgery is deemed adr isable. 2. Curettage can be done as a nondefinitive procedure to reduce inflammation before pocket elimination using other methods or when more aggressive surgical techniques (e.9., Jl"pl are contraindicated. 3. Curettage is also frequently perlormed on recall visits as a method ofmaintenance treatment for areas ofrecurrent inflammation and pocket depth.

Important; Curettage does not eliminate the

causes

of inflammatiorr (i.e., bacteriql plqque

ond deposits). Therefore, curettage should always be preceded by scaling and root planing.

Note: Gingival curettage always requires some tlpe of local anesthesia

for mesial sutfaces, Gracey

The aurette is selected so that the cutting edge will be against the tissue fe.g., Gracey#13-14 #11-12 for distal surfaces). Clrettage can also be performed with a 4R-4L Columbia Universal curette.

. To remove cfuonically inflamed tissues . To change the bacterial microflora . To remove etiologic agents from the root surface . To eliminate pockets

l,{8
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. Fibrotic

. Edematous
. Fibroedematous . Formed within an intrabony pocket

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The major objective of scaling and root planing is to renove etiologic ag€nts which promot€ gingival inflammation in the periodontal tissues. Removal of plaque, calculus and endotoxins rcsults in a subsequent shift liom disease-associated, gram-negative anaerobes to health-associated, gram-positive, facultative microorganisms. Important: By providing smooth root surfaces there willbe areduced potential forbacterial accumulation. which is done in an attemot to achieve soft-tissue reattachment.
Scaling and root planing are techniques ofinstrumentation applied to th€ root surface to divest it ofplaque, cal-

cified deposits and softered or roughen€d cementum. When thoroughly performed, lhese techniques produce a smooth, clean, hard polished root surface. Scaling and root planing is the primary treatment for pe.iodontal inflammation. In simple cases, this fieatment is useful in reducing shallow pockets and reducing the number ofbacteia within these shallow pockets and may be the only treatment necessary In severely advanced periodontal disease where surgery may not be possible, scaling and root planing are the only treatment f€asible. Since the removal ofplaque and deposits is th€ definitiv€ treatment for periodontal inflammation, rool planing and scaling are more frequently used than any other type of therapy. The most eff€ctive instrument for subgingival scaling and root planing is a sharp cur€tte. They are generally smaller than scalers and are designed to permit atraumatic entry to the subgingival spac€. The tactile sensiiiviry ofmost curettes is greater than scalers, and, as such, curcttes are well suitcd for subgingival calculus deteclion. calculus removal, and rootplarling. Each working end has acufting edge on both sides ofthe blade and a rounded toe. There are two basic qpes ofcurcttes: univefial and area spccifrc (Gracer- curetles).

Double ended Gracey curett€s are paired in the following manner: . GraceJ #l-2 and 3-4: anterior reeth . Gracey #5-6: anterior teeth and premolars . Gracey #7-8 and 9-10: posterior teeth: facial and lingual surfaces

. Gracey #11-12: posterior teeth: mesial surface . Gracey #13-14:posterior teeth: distal surface
Ext€nded-shank cur€ttes: have a longerterminal shank, a thinnedblad€, and a large-diameter terminal shank. Ther- are available in finishing (for light scaling) or igid (br remotalofhedr), or tenacious calcalus.) designs. Itinibfaded curettes: have shorter blades dra lf the length) whtcll allows easier insertion and adaptation.
GraceJ_

cureltes: are mini-bladed curettes with a morc curved blade. Langer and mini-Langer curetles: combine the shank design ofGracey curettes with dre universal blade design lg0-degrce angle oftlleface and lower slnnk).

Indications for curettage are very limited. It can be used after scaling and root planing for the tbllorving purposes: I . Curettage can be performed as part of new attachment attempts in moderately deep inirabony pockets located in accessible areas where a type of"closed" su4ery is deemed adr isable. 2. Curenage can be done as a nondefinitive procedurc to reduce inflammation before pocket

elimination using other methods or when more aggressive sugical techniq,res (e.9., Jlaps)
are contraindicated. 3. Curettage is also frequently performed on recall visits as a method ofmaintenance treatmenr for areas ofrecunent inflammation and pocket depth.

Contraindications ofgingival curettage

as a

definitive procedure include:

. Acute periodontal inflammation
. Firm. fibrotic tissue

. Intrabony pockets
. Nlucogingival involvements . \\'hen the lateral gingival wall is extremely thin

L Patients with edematous and granulomatous inflammation r€spond better to

\oten

curettage than do those with conditions offibrous hyperplasia. mesenchymal cells must be present, (2) Complete removal ofjunctional and pocket epithelium must be accomplished, as well as, (3) The complete removal of calcuIus and/or altered cementum.

Important: It is recommended that all students read The American Academy ofPeriodontology Statement Regarding Gingival Curettage. This can be found on the intemet at:
http ://www.perio.org/resources-products/pdf/38-curettag€.pdf

. Heavy touch ard light pressure, keeping the tip perpendiculal to the tooth surface and
constantly in motion

. Light touch and healy
lonary

pressure, keeping the tip parallel to the tooth surface and stat-

. Light touch and light pressure, keeping the tip parallel to the tooth surface and constantly in motion

. Heavy touch and healy pressure, keeping the tip perpendicular to the tooth surface and
stationary

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. Curette

. Sickle scaler
. Hoe . File

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Ultrasonic instruments have been widely used as a valuable adjunct to conventional hand instrumentation for nany years. The selection ofeither ultrasonic or hand instrumentation should be determined by the clinician's preference and experience and the needs of each patient. The success ofcither treatment mcthod is determined by the time devoted to the procedure and thc thoroughness ofroot debridement. ln practice, clinicians typically use a combination ofboth ultrasonic and hand instrumentation to achicve thorough debridement. Ultrasonic instrumentation is accomplished with a light touch and light pressure, keeping the tip parallel to the tooth surface and constantly in motion. Leaving thc tip in one place for too long or using the point ofthe tip against the tooth can produce gouging and roughening o{-thc root surt'ace or overheating ofthe tooth. The working end ofthe ultrasonic instrument must come in contact $'ith the calculus deposit to fracture and remove it. The working tip must contact all aspects of the root surf'ace to removc plaquc and toxins thoroughly. Although as much as 10 mm or morc of the length of the ultrasonic tip vibrates, only a small portion of it can be adpated to contact the cu^ed root suface at any one time or point. As with hand instruments, a series of focused, overlapping strokes must be activated to ensurc complete root coverage.

Important: Subgingival root surface roughness does not seem to interlere with healing after scaling and.oot planing. Thus it does not appear useful to rcinstrument root surfaces with hand insrruments after a clinically detectable smooth surface has been crealed with sonic or ultrasonic
scaler

Contraindications to the use of ultrasonic and sonic scaling devices:

. Oldcr cardiac pacemakers . Known comnrunicable diseases that can be transmitted by aercsols . Patients at risk for respiratory disease, including patients who are immunosuppressed or have
chronic pulmonary disorders . Patients with titanium implants, porcelain or bonded restorations (unless you
use

plastic- tipped

,lserts)

ofa curette has a cutting edgc on both sides ofthe bladc and a rounded toe The curette is finer than the sickle scale$ and does not have any sharp points or comcrs other than the cutting edges of the blade. Thereforc, curettes can be adapted and provide good acccss to deep pockets, with minimal ioli rissue trauma. [n cross section the blade appears semicircular with a convex base. The lateaal bord.r ol thc convex base forms a cutting edge with the face of the semicircular blade Therc are cufting edges on both sidcs ofthe blade. Therc are two basic types ofcurettes:
Each rvorking end

. Lnilersal curettes: have cutting

edges that may be inserted in most areas ofthe dentition by altering and adapting the finger rest, fulcrum, and hand position of the operator. The bladc size and the anglc and lengrh ofthe shank may vary but the face ofthe blade of everyuniversal curefte is at a 90degree angle (perpendlcrrlar) to the lower shank when seen in cross section from the tip The blade olthe universal curctte is curved in onc direction from the head ofthe blade to the toe . Area-Specific cu rettes: Gracey curettes are represcntative ofthe area-specific curettes, a set ofseveral instruments designed and angledto adaptto specific anatomic areasofthe dentition The Gracey curenes also diffcr from the univcrsal 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 approxinlately 60 to 70 degrees from the lower shank.

.\.oler'

L Using curcttes with short, even working strokes followed by longcr ones is the most effcctive and efficient way ofperforming root planing. The correct cutting edge can be secn as a largcr. outer curve. 2. Final root planing strokes are longer and lighter than scaling strokes.1. Root planing strokes become lighter as the cementum becomcs smoother. 4. Exploratory scaling and root planing strokes differ in angulation, pressure, length, and dircction.

Remember: To establish the correct working angle once a curet is inserted subgingivally, the shank must be moved away liom the tooth in order to open the angle ofthc bladc to the tooth surface At proper working angulation f/ ess lhan 90o but more lhan 15"), the lowet shank of a Gracey curet is parallel to the tooth surface being scaled. The lowcr shank ofa universal cu ret would be tilted slightly towtrd the tooth.

. The first statement is true; the second statement is false

. The

second statement is true; the first statement is false

. Both statements are true . Both statements are false

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.

Proceeding to another tooth and then returning to the sensitive tooth later in the
apporntment

. Moving the instrument slower . Making necessary adjustments to the water spray

. Tuming up the power ofthe device
. Using less pressure

't

53
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CopriShi

O20ll

The two g?es ofultrasonic units are magnetostrictive and piezoelectric. In both t'?es, altemating electrical curent genemtes oscillations in materials in the handpiece that cause the scaler tip to vibrate. Depending on the manufacturet these ultrasonic vibrations at the tip of the instruments ofboth lypes range liom 20,000 to 45,000 cycles per second. In magn€tostrictive units the pattem ofvibration ofthe tip is elliptic, which means that all sides ofthe tip are active and will work when adapted to thc tooth. In piesoelectric units the pattem ofvibration ofthe tip is linear, or back and fonh, meaning that the two sides ofthe tip are the most active.

Sonic units consist ofa handpiece that attaches to a compressed-air line and uses a vadety ofspecially designed tips. Vibrations at the sonic tip range from 2000 to 6500 cps, which provides less power forcalculus removal than ultrasonic units. Ultrasonic and sonic tips are designed to operate in a wet field with a water spray directed at the end of the tip. Within the water droplets ofthis spray mist are tiny vacuum bubbles that quickly collapse, releasing energy in a process known as cavitation. The cavitating water spmy serves to flush calculus, plaque, and debris dislodged by the vibrating tip ftom the pocket. Magnetostdctive ultrasonic tips generate heat and require this water for cooling. Sonic and piezoelectric units do not generate this heat but still utilize water for cooling frictional heat and flushing away debris.

Dental Endoscope: this device consists of a reusable fiberoptic cndoscope over which is fitted a disposable steriie sheath. It fits onto periodontal probes and ultrasonic instruments that have been designed to accept it. This device allows clear visualization deeply into subgingival pockets and furcations. It permits operaton to detect the presence and location ofsubgingival deposits.

EJA system (enhanced isual assessment):this system

uses motor-dtiven diamond files to correct over-

hanging or overcontoured proximal alloy or resin restorations.

Prophy-Jet air-powder polishing device: was the first specially designed handpiece to deliver an airpor|ered slurry of warm water and sodium bicarbonate for polishing. lt is very effective for the removal oferrrinsic stains and soft deposits. Note: Polishing powdets containing aluminum trihydroxide orother substances mthcr than sodium bicarbonate are being used to offset the abmsive effect of sodium bicarbonate on restorations as well as dentin and cementum. Contraindications to the use ofair-powered polishing devices are those patients with rcspiratory illncsses, hemodialysis, hlpertension and infectious
dlseases.

***

The opposite ofthese is true!! All ofthe rest are appropriate actions to be considered in that situation.

If sensitivity is encountered during . Lighten the pressure

use:

. Adjust the water spray: increase water flow to cool the tip . \4ove to another tooth and then retum later to the sensitive tooth . Decrease the power
Power driven instruments work best with quick hand movement moYements.

-

rapid, controlled

Remember:
\\'aves.

*** The ultrasonic principle

is based on the use of high-frequ€ncy sound

. Supragingival calculus
. The CEJ

.

Smooth root surfaces

. Subgingival calculus . Inflammation

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. Hoe . Files

scalers

. Chisel scalers . Quetin furcation curettes

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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), 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 ofthe tip ofthe 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.

The five basic scaling instruments are as follows: . Curette: the curette is the instrument ofchoice for removing deep subgingival calculus, root planing altered cementum, and rcmoving the soft 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 frner than the sickle scalers and does not have any sharp points or comers other than the cutting edges ofthe blade. Therefore, curettes can be adapted and provide good access to deep pockets with minimal soft tissue damage. . Sickle scalers fJrpragingival scalers)i have a flat surface and two cutting edges that conr erse in a sharply pointed tip. The shape ofthe instrument makes the tip strong so that it will not break off during use. The sickle scaler is used primarily to remove supragingival calculus. . Files: have a series ofblades on a base. Their primary function is to fractwe or crush large deposits of tenacious calculus or bumished sheets of calculus. Files can easily gouge and roughen root surfaces when used improperly. Therefore, they are not suitable for fine scalind cn.l r^^f nl,nino . Chisel scalers: are designed for the proximal surfaces ofteeth too closely spaced to permit the use of other scalers, and are usually used in the anterior part ofthe mouth. They are double-ended instruments with a curved shant 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 a push motion

rvhile the side ofthe blade is held frrmly against the root. . Hoe scal€rs: are used for scaling ofledges or rings ofcalculus. The blade is bent at a 99degree angle; the cutting edge is formed by thejunction ofthe flattened terminal surface with the inner aspect ofthe blade. The cutting edge is beveled at 45 degrees. Note: McCall's #3, 4, 5, 6, 7, and 8 are a set ofsix hoe scalers designed to provide access to all tooth surfaces. Each instrument has a different ansle between the shank and handle.

. Use a push stroke to force the tip out ofthe sulcus

. Gently examine the gingival sulcus
. Take a periapical radiograph of the area

.

Place the patient in an upright position

156 CopltiSht O 20l l-2012 - Denlal Deck

It

is impossible to

carry out periodontal procedures efficiently with dull instruments.

. The first statement . The

is true; the second statement is false

second statement is true; the first statement is false

. Both statements are true . Both statements are false

157

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*** Never use a push stroke, this could force the tip further into the sulcus. Gently examine the sulcus using a curcl in a spoon-like stroke, attempting to pull the fragment out.
The procedure should be stopped immediately and the patient placed in an upright position. Before proceeding subgingival, check the floor ofthe mouth and the mucobuccal fold lbr the fragment. A periapical radiograph should then be taken bcfore going any further to locate thc fragment. Try not to alarm the patient. The last thing you want is for the patient to bccome frantic.

Thc best way to prevent curet breakage is to use proper sharpening techniqucs to maintain thc original instrumcnt dcsign and discard inshuments when the blade starts to thin out. Athinner blade
is weaker and will break more easily.

Remember: The Schwartz Pedotrievers arc highly magoctized instruments designcd for the retrieval ofbrokcn instrument tips from the periodontal pocket.

Set ofmany curettes, designed specific areas and surfaces

for

One curette designed for all arcas and surfaces

One cutting edge used; work outer edge only

with

Both cutting edges used; work with either outer

or inner edge

Curved in two planes; blade curves up and to the side Offset blade; facc ofblade beveled Blade not oflset; face ofblade beveled at 90 at 60 degrees to shank degrees to shank
R.:rrdu.ed urrh pemision, fronr NeMnrn MG, Tak€r IIII, Klokkevold PR. Camnz. FA. (-dfta4:ai Clini.al P.nodont.lop,I ll" al. Else-

To do its job at all, a dull instrument must be held more firmly and pressed hardcr than a sharp lnstrument. This reduces tactile sensitivilv and increases the possibilitv that th€ instrument will in-

advertently slip. Thc objective of sharpening is to restore the fine, thin, linear cutting edge ofthe instrument. This is done by gnnding the surfaccs ofthe blade until theirjunction is once again sharply angular rather rhan rounded. It is important to restore the cutting edge without distorting thc original angles ofthe instrument. When these angles have been altered, the instrument docs not function as it was de5r!:ned lo funclion. \rhich limits its clfcctircncss.

Principles of sharpening:

. Choosc sharpcning stone appropriate for instrument (/a1 cone, coarse, etc.) . L se a sterilizcd sharpening stone if the instrument to be sharpened will not be resterilized belbre it is used on a patient . Establish the proper angle between the stone and the surface ofthe instrument . \'lainlain a stable, firm grasp ofboth the instrument and the sharpcning stone
. .\r'oid excessive pressure

.\oid formation of a "wire edge" which is produced when the direction of the sharpening strokc is away from, rather than into or toward, the cutting edge. When back-and-forth or up-anddown sharpcning strokes are used, formation of a wire edge can be avoided by finishing with a do$n stroke toward the cutting edge. . Lub cate the stone during sharpening. Oil should be used for natural stones and water for s).nthetlc stones . Sharpen instrumcnts at first sign ofdullness

.

\otei The technique for sharpening a universal curette can be used to sharpen a Oracey curette, horvever, bear in mind that thc Gruccys cutting edge is offset and it also curves, unlike the universal's cutting edge. Remember: India and Arkansas oilstones are examples olnatural abrasive stones. Carborundum. ruby, and ceramic stones are synthetically produced.

. Only when using
. When using

a coarse

artificial stone only

a mounted ruby stone

. When no oil is used for lubrication ofthe stone

. When the last stroke ofthe stone

is drawn away from the cutting edge

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- Denial Decks

. Short, straight shank . Long, shaight shank . Short, angled shank
. Long, angled shank

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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-fbrth or upand-down sharpening strokes are used, fonnation ofa wire edge can be avoided by finishing with a down stroke toward the cutting edge.

The cutting edge of an instrument is formed by the angular junctiqn of two surfaces of its blade. The cutting edges of a curett€, for example, are formed where the face of the blade meets the lateral sufaces. When the instrument is sharp, thisjunction is a fine line running the length ofthe cutting edge. As the instrument is used, metal is wom 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 categodzed by their method ofuse; . Mount€d 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 genemlly 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 ofthe 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 drarvn across it, or the stone may be stabilized and held stationary while the instrument is

dra*n

across it. 1. The optimal internal angle between the face of the blade and the lateral surface ofa universal curette and a Gracey curette is 70" to 80o. 2. An instrument whose cutting edge is 90o or more will slip over calculns deposits and requires heavy lateral pressue to remove calculus deposits. 3. The best grasp to use when holding an instrument to be sharpened is the palm

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grasp.

How an instrument shank is designed influences the intended use ofthe instrument. It is recommended that an instrument with a rigid shank be used for removal ofheavy calculus deposits. *** Straight shanks are used in the anterior areas and contra-angled shanks are used in the posterior areas.

Rigid, thick shank:

. Stronger

. Less flexible . Provides less tactile sensitivity . Stronger instruments are needed for healy calculus removal
Less rigid, more flexible shank: . Pror ides more lactile sensirivit)

. Lsed for removing fine calculus and for root plal|ing

the universal curettes in that the blade is not at a go-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.

Important: The Gracey curettes ditler from

-{ngulation refers to the angle between the lace ofthe bladed instrument and the tooth surface. It may also 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 "bumishing" it. lfangulation is more than 90 degrees, the lateral surface ofthe blade. rather than the cutting edge, will be against the tooth, and the calculus will not be removed and may become bumished.

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.

. Vertical strokes . Oblique shokes . Horizontal stokes

. Circular strokes

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There are three basic atrokes used during instrumentation. Any ofthese 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. Hodzontal strokes are used selectively on line angles or d€ep 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 ofthe calculus or roughness. . Exploratory stroke: is a light, "feeling" stroke that is used with probes and explorc$ to evaluate the dimensions ofthe pocket and to detect calculus and inegularities ofthe tooth surface. The instrument is grasped lightly and adapted with light pressure against the tooth to achieve maximal tactile

sensitivity. . Scalilg strok€: is a short, powerful pull stroke that is used with bladed instruments for the removal ofboth supragingival and subgingival calculus. The scaling motion should be initiated in the forearm and hansmifted from the wrist to the hand with a slight flexing ofthe fingers. Tte scaling stroke is not initiated in the wrist or fingers nor is it carried out independently without the use ofthe forqarm. . Root planing stroke; is a moderate to light pull stroke that is used iio final smoothing and planing ofthe root surface. With a moderately firm grasp, the cuette is kept adapted to the tooth with even, lateral pressure. A continuous series oflong, overlapping shaving stok€s is activat€d. As the surface becomes smoother and resistance diminishes, lateral pressue is progressively reduced. l, "Pulling" strokes are safer than "pushing" shokes because the push stroke may force calculus into the supponing tissues. lts use, especially in an apical direction, is not recommend,. 11o3"4!|

,- ,---_

g ^ * .. 2. Probing stroke: upward and downward movement within a periodontal pocket.
3.

-

Tle modilied pen grasp

is the most useful grasp for periodontal instrumentation.

third ofthe 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 ofa bladed instrument such as a curctte, angulation should be as close to 0 degree as possible. During scaling and root planing, optimal angulation is be4. The lower

tween 45

rnd 90 degrees.

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