perio 300

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  1. peri-implant mucositis
    • implant gingivitis
    • inflammation confined to the soft tissues
    • bleeding on probing
    • • Suppuration
    • • usually associated with probing depths ≥4 mm*
    • • no evidence of radiographic loss of bone beyond bone
  2. peri-implantitis
    • implant periodontitis
    • both bone/soft tissue
    • If no baseline, a vertical distance of 2 mm from the expected marginal bone level following remodeling
    • post-implant placement is recommended as the threshold for diagnosing peri-implantitis
  3. implant microbio
    • G+ facultative cocci, rods
    • G- anaerobes in small numbers(increase in disease)
    • Red: P.ging, Treponema denticola and Tannerella forsythia
    • Orange: Fusobacterium, Prevotella intermedia
    • peri-implantitis: S. Aureus, Candida, enteric rods
  4. Peri-implantitis/periodontitis pathophys
    • B-lymph, plasma cells
    • cytokines IL-1B, 6,8,12, TNFa
  5. Implant bone susceptible because absence of ___
    inserting collagen fibers
  6. peri-implantitis risk factors
    • plaque, hygeine
    • smoking
    • residual cement
    • diabetes
    • occlusal overload
    • increased loading time possibly one
  7. clinical consequences peri-implantitis, mucositis
    • mucositis successful w/o surgery if early
    • surgery for peri-implantitis unpredictable
  8. Phase I Therapy
    • Oral Hygiene Instructions
    • Subgingival Scaling & Root Planing
    • Re-evaluation and Reassessing the Periodontal Status
  9. ____ margin of mand posterior always generate plaque
    lingual, gingival
  10. target hygiene
    concave area, bass method
  11. OHI changes
    • bleeding/tenderness for 2 weeks
    • shrink in papilla
  12. Pocket sequelae
    • as the pocket progresses apically
    • localized areas of root resorption
    • localized areas of hypomineralization
    • cementum becomes soft
    • toxic material gets incorporated into cementum (becoming “diseased cementum”)
  13. _____ has the shortest root trunk  most likely tooth to have a furcation involvement
    mandibular 1st molar
  14. maxillary molars and maxillary first bicuspids presents root trunk concavities and furcation openings facing the ____ which makes plaque removal difficult.
    interdental areas
  15. Palatal concavity on
    max lateral incisor
  16. Most Common Areas of Recurrent Pockets
    • 1. maxillary first premolar (mesial aspect)
    • 2. maxillary first molar (mesial aspect)
  17. Mandibular First Molar internal concavity
    • mesial 0.7mm 100%
    • distal 0.5mm 99%
  18. Maxillary First Molar internal concavities
    • MB root presents a 0.3mm concavity in 94% of the extracted teeth studied.
    • DB root presented insignificant amount of concavity in 31% of the extracted teeth studied.
    • P presented insignificant amount of concavity in 17% of the extracted teeth studied.
  19. 58% of these cases studied, both in the maxillary first molar (buccal) and the mandibular first molar (buccal), the standard Gracey curette blade does not fit into the furcation opening.
  20. Cervical Enamel Projections:
    • An apical extension of the cemento-enamel junction in the area above the furcation opening
    • These projections shortens the root trunk, therefore leading to an earlier furcation opening and predisposes the area to furcation lesions
  21. Intermediate Bifurcation Ridge:
    • A narrow, uneven ridge of enamel which extends from the mesial to the distal root at the furcation opening. Found in 30% of cases studied.
    • Conclusion: plaque and calculus can accumulate onto this ridge.
  22. Apical Fused Roots:
    • The apical portion of the roots fuses creating a cul-de-sac like opening between the two roots. Found most often in the maxillary and mandibular second molars.
    • Conclusion: plaque and calculus accumulates inside this opening, which is impossible to clean or instrument
  23. Accessory Canals in the Furcation Area:
    • In numerous cases, caries involvement of the pulp can lead to bone loss in the furcation area via the accessory canal. If this bone loss communicates with the oral environment, a periodontal furcation defect can result.
    • Conclusion: plaque and calculus can contaminate the root surfaces of the furcation area due to bone loss from the pulpal lesion.
  24. Furcation therapy
    • Early Lesions
    • Specific biofilm removal (rubber tip, proximal, dry toothbrush)
    • Scaling and root planing
    • Moderate Lesions
    • Soft tissue surgery
    • Osseous recontouring
    • Crown / Restoration recontouring
    • Advanced Lesions
    • Root resection
    • Regenerative surgery
    • Extraction and Implant placement
  25. demarco curettes
    spoon looking for furca
  26. CAL (clinical attachment loss) and Radio correlation
    • health = 0
    • slight = 1-2mm
    • moderate = 3-4mm
    • severe >5mm
    • Radio distance from crest to CEJ (mm)
    • health 0-2
    • slight 3-4
    • moderate 5-6
    • severe >7mm
  27. localized
  28. Goal of Perio therapy:
    • plaque and calculus-free environment around the dentogingival area
    • Instrumentation in furcation area is difficult, unpredictable and sometimes impossible
    • Furcation Area: pocket bounded by root surfaces
    • Removal of this pocket by resection or regeneration is very unpredictable
    • 90% of perio abcesses associated with furcations
  29. Problems related to Furcation Lesions
    • Plaque retention
    • Calculus formation
    • Inaccessibility for plaque/calculus removal
    • Splinted restoration prove exceptionally challenging
    • Caries in furcation area
    • Routin home care usually not successful
    • Furcation involvement: can lead to diagnosis of advanced periodontal disease and less favorable prognosis for the affected tooth/teeth
    • i) Presents diagnostic and therapeutic dilemmas
    • 3) Furcation Involvement
    • a) ID the problem
    • b) Anatomical Factors
    • i) Description of root anatomy
  30. Root trunk length
    • (a) Distance from CEJ to separation of the roots
    • (b) Proportional to the time it takes for a lesion to reach the furcation opening
    • (c) Buccal aspect of Mn M1 has shortest root trunk length
    • (d) Crown margins extending past CEJ will shorten the root trunk length
  31. External Concavities
    • (a) Location of concavities determines cleansibility
    • (b) Interdental concavities are the most problematic
    • (i) Maxillary molars (mesial) and maxillary 1st premolars (mesial) most commonly with recurrent pockets
    • 1. Large lingual embrasure between canine and Mx PM1, between Mx PM 2 and Mx M1
  32. Internal Concavities
    • (a) Maxillary 1st Molar
    • (i) MB root: 0.3 mm in 94% of teeth
    • (ii) DB root: Insignificant concavity in 31%
    • (iii) P root: Insignificant concavity in 17%
    • (b) Mandibular 1st Molar
    • (i) M root: 0.7 mm in 100% of teeth
    • (ii) D root: 0.5 mm in 99% of teeth
    • (iii) Can only attempt to clean with a proxy brush
    • (c) Dimension of Furcation Entrance
    • (i) 81% are 1 mm or less
    • (ii) 58% are 0.75 mm or less
    • (iii) 58% of all teeth the standard Gracey curet does not fit
  33. Local Developmental Anomalies
    • (a) Cervical Enamel Projections
    • (i) Apical extension of CEJ in the area above furcation opening
    • (ii) Shortens the root trunk and predisposes to perio disease
    • (iii) Found in ~50% of teeth, leads to faster furcation involvement
    • (iv) Can be “man-made” with apical crown margin
  34. Intermediate Bifurcation Ridge
    • (i) Narrow, uneven ridge of enamel which extends from the mesial to distal root at the furcation opening
    • (ii) 30% of Mn M1, allows for plaque accumulation
  35. Apical Fused Roots
    • (i) Often found on 2nd molars
    • (ii) Apical portion fuses creating a cul-de-sac opening
    • (iii) If plaque accumulates here, it is impossible to clean. Tooth is usually hopeless
  36. Furcational Etiologic Factors
    • i) Primary factor is the accumulation of bacteria and the long-term consequences of resulting inflammation
    • ii) Local factors affect rate of plaque accumulation
    • (1) Oral hygiene and perio recall
    • iii) Increase furcation involvement with age
    • iv) Dental Caries and Pulpal Involvement may also affect furcations
    • (1) Accessory canals in the furcation area with pulpal infection can lead to bone loss and furcation involvement
    • (2) If endo lesion: RCT should resolve pathology. Will only get healing if the lesion is endo-related
    • (3) If needs endo and perio therapy, always do ENDO first
    • v) Extent of attachment loss required to produce furcation involvement is variable, depending on:
    • (1) Root trunk length
    • (2) Root morphology
    • (3) Local developmental anomalies (cervical enamel projections)
  37. Horizontal Classification (Classic, Glickmane)
    • i) Grade I: Incipient or early lesion
    • (1) Pocket is suprabony: slight bone loss and soft tissue involvemtn
    • (2) Little to no radiographic bone loss
    • ii) Grade II
    • (1) Bone destroyed on one or more aspects of furcation, partial penetration into furca
    • (a) Cul-de-sac lesion
    • (b) Radiograph may or may not reveal much change
    • iii) Grade III
    • (1) Bone completed destroyed between roots, forming a tunnel
    • (2) Orifice is occluded by soft tissue, so opening cannot be seen clinically
    • (3) Radiograph shows through and through RL opening
    • iv) Grade IV
    • (1) Same as grade III except gingival has receded enough to expose the orifice of the furcation and it can be seen clinically
  38. Horizontal Classification: Lindhe and Nyman
    • i) Grade 1
    • (1) Loss of bone into furcation but portion of alveolar bone and PDL is intact.
    • (2) Measures less than 3 mm
    • ii) Grade II
    • (1) Grade I but measures greater than 3 mm
    • iii) Grade III
    • (1) Through and through lesion
  39. Vertical Classification: determined by mm from roof of furca to probeable depth
    • i) Subclass A: 0-3 mm
    • ii) Subclass B: 4-6
    • iii) Subclass C: 7 mm or greater
  40. Furcation Therapy
    • a) Factors to consider
    • i) Classification
    • ii) Age
    • iii) Tooth associated with lesion and furcation characteristics
    • (1) Mn M1 or M2: B/L
    • (2) Mx M1 or M2: B/M/D
    • iv) Mobility
    • v) Soft tissue
    • vi) Bone environment
    • vii) Vestibular depth
    • viii) Endodontic factors
    • ix) Restorative factors
    • b) Early Lesions
    • i) S/RP and plaque removal
    • ii) Recontour restorations/soft tissue
    • c) Moderate lesions
    • i) Soft tissue surgery
    • (1) Removal of gingival tissue apically to uncover furcation opening for instrumentation
    • ii) Osseus recontouring
    • iii) Crown/restoration recontouring
    • iv) Resective root therapy
    • (1) Most obvious choice is the DB root or Mx M1
    • (2) Remaining root(s) must be viable and stable
    • v) Regenerative therapy
    • d) Advanced
    • i) Root resections
    • ii) Regenerative Surgery
    • iii) Extractions
  41. Masticatory Mucosa
    • i) Keratinized, attached
    • ii) On palate, near the teeth
  42. Lining mucosa
    i) Non-Keratinized, unattached
Card Set
perio 300
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