Perio Test 2

• 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"

Small fissures extending apically from the midline of the gingival margin in teeth subjected to trauma.

Periodontal Screening and Recording

• Color-coded band at 3.5-5.5 mm 
• Ball tip

• Divide mouth into 6 sextants 
• Probed all surfaces of all teeth
• Record only the highest code for each sextant.

• Color band is completely visible in deepest sulcus of the sextant 
• No calculus or defective margins 
• No BOP
• No further documentation is needed

• 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.)

• 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.)

• 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.)

• 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)

• Added to any other code to note:
• Furcation 
• Mobility 
• Recession beyond the color band 
• Mucogingival defects

• Slightly mobile 
• < 1 mm, horizontal

> 1 mm, horizontal

• >1mm, horizontal, 
• Vertical (compressible) 
• Rotates with finger pressure

• Concavity can be felt 
• Bone in furcation is intact 
• Not detectable on radiographs

• Bleeding on probing is sometimes delayed
• Lack of BOP is NOT always a sign of health, but BOP is ALWAYS a sign of disease.

• Probe enters furcation but can't pass through
• Slightly widened PDL in furcation on radiograph

• Probe passes all the way through to the other side
• Radiolucency in furcation on radiograph

Same as Class III only visible.

• Measure from gingival margin to mucogingival junction
• Then subtract probing depth

• If recession is present: Recession + probing depth
• If margin is swollen apical to CEJ: probing depth - distance from CEJ to margin

• Gingival crevicular fluid assessments (GCF)
• Salivary Testing
• Microbial Tests
• Immunologic Test
• Genetic Testing

• 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

• 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

• Can test for the host response antibody to a specific organism.
• Expensive
• Currently not applicable to office use; only in research studies

• 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)

• 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

• Most common type of bone loss
• Suprabony pockets

• Uneven resorption of alveolar bone
• Forms trenches or craters in the bone
• Infrabony pockets

• 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

• 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

• 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

• 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

Factors that contribute to gingival or periodontal disease also contribute to gingivitis and loss of attachment around an implant.

• Treatment is different
• Skin disease: Lichen planus, Pemphigus
• Infections: primary herpes, candidiasis
• Allergic reactions

Periodontitis

• Red, swollen tissues or Gray, fibrotic tissues
• Bleeding during brushing
• Bad taste, bad breath
• Loose teeth
• Purulence (pus)
• No pain in most cases

• Chronic (most common form)
• Aggressive
• Manifestation of systemic disease
• Necrotizing diseases
• Periodontal abscesses
• Associated with endodontic lesions
• Associated with developmental or acquired conditions

• 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

Less than 30% of mouth

More than 30% of the mouth

• Depends on: 
• Rate of progression and 
• Amount of clinical attachment loss

Less than 30% of the supporting structures for a given tooth have been lost

• more than 30% of support lost 
• 5mm or more of attachment lost 
• Class III furcations

• To separate patient into 2 groups:
• Periodontal health or gingivitis
• Periodontitis

• Reduce plaque biofilm to a level that is not a challenge to the host 
• Eliminate risk factors 
• Stop disease progression 
• Prevent recurrence

• Relapse after successful therapy 
• Patient has reverted to old habits 
• Short maintenance interval may prevent this

• 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.

• 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

• 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

• 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

• 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!!!!

• Most patients are smokers. 
• NUG:
• Most cases resolve with treatment 
• No permanent attachment loss 
• A few cases progress to…

• Necrosis extends to PDL and bone 
• Very rapid destruction 
• Very painful 
• Usually associated with impaired immune system (especially HIV/AIDS)

• Irrigation and debridement 
• Self-care instructions 
• Rest and good nutrition 
• Soft, bland foods at first 
• May need liquid supplement

• 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

• 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