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McCall’s Festooning
- A ring-shaped enlargement of the gingival margin on the vestibular surface (buccal or labial) of canines and premolars. It may be associated with occlusal trauma.
- "Lifesaver"
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Stillman’s Cleft
Small fissures extending apically from the midline of the gingival margin in teeth subjected to trauma.
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What does PSR stand for?
Periodontal Screening and Recording
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Who probe
- Color-coded band at 3.5-5.5 mm
- Ball tip
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Performing PSR
- Divide mouth into 6 sextants
- Probed all surfaces of all teeth
- Record only the highest code for each sextant.
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PSR Code 0
- Color band is completely visible in deepest sulcus of the sextant
- No calculus or defective margins
- No BOP
- No further documentation is needed
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PSR Code 1
- Color band is completely visible in deepest sulcus of the sextant
- No calculus or defective margins
- BOP is present
- (Gingivitis-no further documentation is needed, but Dr. Baker recommends documenting pt. ed.)
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PSR Code 2
- Color band is completely visible in deepest sulcus of the sextant
- Calculus or defective margins are present
- (Gingivitis-no further documentation is needed, but Dr. Baker recommends documenting pt. ed.)
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PSR Code 3
- Color band is only partially visible in deepest sulcus of the sextant
- This means probing depth is at least 3.5 and less than 5.5
- (If only in one sextant a comprehensive eval on that sextant; if more than one sextant a comp eval on entire mouth.)
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PSR Code 4
- Color band is NOT visible in deepest sulcus of the sextant
- This means probing depth is greater than 5.5
- (In any sextant a comprehensive eval of entire mouth)
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PSR Code *
- Added to any other code to note:
- Furcation
- Mobility
- Recession beyond the color band
- Mucogingival defects
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Mobility Class I
- Slightly mobile
- < 1 mm, horizontal
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Mobility Class II
> 1 mm, horizontal
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Mobility Class III
- >1mm, horizontal,
- Vertical (compressible)
- Rotates with finger pressure
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Furcation Class I
- Concavity can be felt
- Bone in furcation is intact
- Not detectable on radiographs
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BOP
- Bleeding on probing is sometimes delayed
- Lack of BOP is NOT always a sign of health, but BOP is ALWAYS a sign of disease.
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Furcation Class II
- Probe enters furcation but can't pass through
- Slightly widened PDL in furcation on radiograph
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Furcation Class III
- Probe passes all the way through to the other side
- Radiolucency in furcation on radiograph
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Furcation Class IV
Same as Class III only visible.
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Calculating Width of Attached Gingiva
- Measure from gingival margin to mucogingival junction
- Then subtract probing depth
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Calculating Clinical Attachment Level (CAL)
- If recession is present: Recession + probing depth
- If margin is swollen apical to CEJ: probing depth - distance from CEJ to margin
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5 Perio Assessment Tests
- Gingival crevicular fluid assessments (GCF)
- Salivary Testing
- Microbial Tests
- Immunologic Test
- Genetic Testing
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GCF Assessments
- GCF volume increases with inflammation
- GCF content changes with inflammation:
- Increased # of immune cells
- Chemical mediators of inflammation
- Host enzymes (especially collagenase
- Prostaglandins
- Testing is simple and cheap; similar to litmus paper testing that diabetics use
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Microbial Tests
- Cultures can look for specific periodontal pathogens
- Cultures take time to grow and are fairly costly
- Microbial DNA test can be used for refractory or aggressive disease
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Immunologic Tests
- Can test for the host response antibody to a specific organism.
- Expensive
- Currently not applicable to office use; only in research studies
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Genetic Testing
- Few patients are genetically programmed to produce too much Interleukin-1
- Saliva can be tested for this genotype
- These patients can be monitored closely
- (Interleukin-1 is one of the cytokines produced by the inflammatory cells in response to bacteria)
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Radiographic Signs of Bone Loss
- Widening of PDL
- Presence of calculus
- Loss of Lamina Dura in interproximal alveolar crest
- Radiolucent projections radiating from the PDL
- Reduction of interproximal bone height
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Horizontal Bone Loss
- Most common type of bone loss
- Suprabony pockets
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Vertical Bone Loss
- Uneven resorption of alveolar bone
- Forms trenches or craters in the bone
- Infrabony pockets
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Cone Beam CT
- State of the art when assessing bone quality and quantity
- Especially good prior to implant placement
- Cone beam is smaller machine than medical CT's
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Acute Gingivitis
- Bright red
- Papillae enlarged
- Rolled margins
- Soft, flabby, delicate consistency
- Appears "tight"
- Bleeding and/or exudate
- Tissue returns quickly to normal after treatment
- May progress to periodontitis
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Chronic Gingivitis
- Deeper red, bluish, or paler b/c more keratin
- More fibrotic
- Margins and papillae are still enlarged, but more blunted
- Less bleeding and exudate
- Tissue changes take longer to resolve than acute
- May be present for years without progressing, but could progress at any time
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Plaque-Induced Gingivitis
- Most commonly occurring type
- Plaque control will return tissues to health
- No attachment loss
- If existing attachment loss: plaque control can further prevent more loss, but tissues are more susceptible to additional break-down
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Peri-Implant Gingivitis
Factors that contribute to gingival or periodontal disease also contribute to gingivitis and loss of attachment around an implant.
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Non-Plaque Induced Gingivitis
- Treatment is different
- Skin disease: Lichen planus, Pemphigus
- Infections: primary herpes, candidiasis
- Allergic reactions
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What is the most common cause of tooth loss in Adults?
Periodontitis
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Clinical Signs of Periodontitis
- Red, swollen tissues or Gray, fibrotic tissues
- Bleeding during brushing
- Bad taste, bad breath
- Loose teeth
- Purulence (pus)
- No pain in most cases
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Types of Periodontitis
- Chronic (most common form)
- Aggressive
- Manifestation of systemic disease
- Necrotizing diseases
- Periodontal abscesses
- Associated with endodontic lesions
- Associated with developmental or acquired conditions
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Chronic Periodontitis
- Onset may occur at any age
- Usually takes until 35 to cause significant attachment loss
- Initiated by bacterial plaque biofilms
- Host response to plaque is responsible for destruction
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Localized
Less than 30% of mouth
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Generalized
More than 30% of the mouth
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Severity of Periodontitis
- Depends on:
- Rate of progression and
- Amount of clinical attachment loss
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Slight to Moderate Severity of Attachment Loss
Less than 30% of the supporting structures for a given tooth have been lost
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Advanced Severity of Attachment Loss
- more than 30% of support lost
- 5mm or more of attachment lost
- Class III furcations
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What is the purpose of the PSR?
- To separate patient into 2 groups:
- Periodontal health or gingivitis
- Periodontitis
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Treatment of Chronic Periodontal Disease
- Reduce plaque biofilm to a level that is not a challenge to the host
- Eliminate risk factors
- Stop disease progression
- Prevent recurrence
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Recurrent Periodontitis
- Relapse after successful therapy
- Patient has reverted to old habits
- Short maintenance interval may prevent this
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Refractory Periodontitis
- ANY periodontitis that DOES NOT RESPOND to treatment.
- Attachment loss continues despite excellent treatment and self-care.
- Smokers more likely to have this.
- Refractory is no longer a separate diagnostic category, but the term is still useful for both chronic and aggressive diseases.
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Aggressive Periodontitis
- May be genetic predisposition
- Possible neutrophil defect
- Very rapid attachment/bone loss
- Poor response to therapy
- Usually some teeth will be lost
- Severity of disease seems excessive for amount of plaque
- Tissue does not appear inflamed
- No contributing systemic disease
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Localized Aggressive Periodontitis
- Formerly known as Localized Juvenile Periodontitis (LJP)
- Becomes evident early in life (teens)
- More females than males
- More people of African descent
- 1st molars and incisors most often affected
- Strong association with A.a. Actinomyces actinomycetomicans
- Abnormal neutrophil function
- Vertical bone loss is common
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Generalized Aggressive Periodontitis
- Formerly known as Rapidly Progressing Periodontitis (RPP)
- Usually evident before age 30
- Rapid destruction of supporting tissues throughout the mouth
- Higher levels of A.a and Porphyromonas gingivalis
- Abnormal neutrophils
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Treatment of Aggressive Periodontitis
- Localized variety MAY subside in adulthood
- In severe cases, goal is to slow progression of disease
- Maintain as many teeth for as long as possible
- Evaluate family members for genetic risk
- Short recall intervals!!!!
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Necrotizing Periodontal Diseases
- Most patients are smokers.
- NUG:
- Most cases resolve with treatment
- No permanent attachment loss
- A few cases progress to…
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Necrotizing Ulcerative Periodontitis (NUP)
- Necrosis extends to PDL and bone
- Very rapid destruction
- Very painful
- Usually associated with impaired immune system (especially HIV/AIDS)
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Treatment of Necrotizing Diseases
- Irrigation and debridement
- Self-care instructions
- Rest and good nutrition
- Soft, bland foods at first
- May need liquid supplement
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Periodontitis Associated with Endodontic Lesions
- Perio/Endo:
- Periodontal attachment loss is severe enough to extend to accessory pulp canals
- Pulp becomes infected
- Endo/Perio:
- Tooth has a non-vital pulp
- Endodontic abscess extends into PDL and drains into the sulcus
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Abnormal Development or Acquired Periodontal Conditions
- Local tooth related defects: Enamel pearls
- Muco-gingival defects
- Trauma from occlusion
- Remember - - for occlusal forces to CAUSE damage to the periodontium, there must be existing attachment loss
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