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Gingival collagen fiber system
- Gingivodental – attached gingiva to bone and cementum
- Circular – like a turtleneck
- Transseptal – cementum to cementum
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Epithelium
- Masticatory Mucosa – keratnized
- Alveolar mucosa – non-kerratinized
- Sulcular epithelium - non-keratinized
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Connective Tissue
- Masticatory Mucosa – Collagen fibers
- Alveloar Mucosa - Elastic fibers
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Periosteum
Inner most layer of the connective tissue - Bound Down (2 layers)
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Attachment Apparatus
- Cementum
- Periodontal ligament - .25mm; if thicker than .25mm, might be trauma from occlusion.
- Alveolar bone
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PERIODONTAL LIGAMENT
- .25 mm wide
- Functions: supportive, sensory, nutritive & remolding
- 70% water composition
- Consists of fibroblasts, epithelial cells, mesenchymal cells, bone and cementum cells
- Consists of collagen fibers and are called principal fibers
- Proprioceptors – for touch, pain & pressure
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________ is the most common cause of tooth loss.
Chronic periodontitis
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Localized periodontitis: < __% of sites involved.
30
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AGGRESSIVE PERIODONTITIS
- Localized – 1st molars & incisors
- Generalized – >=3 teeth + 1st molars & incisors
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Chronic Periodontitis is not linear, nor does it occur at the same rate in all areas of the mouth. It is a slow progressing disease with active and quiet periods of activity.
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Red complex
- P. gingivalis
- T. forsythia
- T. denticola
- Associated w/ bleeding on probing, CLINICAL PARAMETER OF DESTRUCTIVE PERIODONTAL DISEASES
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Green complex
- E. corrodens
- A. actino.
- C. gingivalis
- C. sputigena
- C. ochracea
- C. concisus
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Yellow complex
- S. mitis
- S. oralis
- S. sanguis
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GINGIVITIS AND PREGNANCY GINGIVITIS - _______;
ANUG - _____________;
CHRONIC PERIODONTITIS - _____________;
AGGRESSIVE PERIODONTITIS - _____________.
- P. INTERMEDIA
- P. INTERMEDIA, SPIROCHETES
- P. GINGIVALIS
- Aa, CAPNOCYTOPHAGA
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Histopathology of Gingival Disease (Page & Schroeder, 1977)
- Stage 1 – Initial Lesion
- Stage 2 – Early Lesion
- Stage 3 – Established Lesion
- Stage 4 – Advanced Lesion
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Initial Lesion (2-4 days)
- Histologic picture of clinically healthy tissue
- Microorganisms in the sulcus activate resident leukocytes
- Vascular changes:
- - Dilation of capillaries
- - Increased blood flow
- - Stimulation of endothelial cells
- - Increased vascular permeability allows PMN and monocytes to migrate through CT to bacteria
- Migration of leukocytes into sulcus via chemotaxis
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Early Lesion (4-7 days)
- Lymphocyte predominate inflammatory cell
- Bleeding upon probing
- First clinical signs of erythema, edema
- Epithelium proliferates into collagen depleted areas of connective tissue forming rete pegs
- Less collagen formation near the inflammatory infiltrate
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Established Lesion (14-21 Days)
- Plasma cell is the predominant immune cell present
- NO attachment loss
- Changes in early lesion worsen
- Continued breakdown of collagen, vascular proliferation, formation of rete pegs
- Moderately to severely inflamed gingiva
- Changes in color, size, texture, consistency, contour of gingiva
- Gingival lesion is reversible
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Advanced Lesion
- Extension of the lesion into alveolar bone
- Apical migration of junctional epithelium
- Bone loss
- Loss of attachment
- Clinical signs of acute and/or chronic inflammation may be present
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PROGNOSIS w/ periodontal treatment and maintenance (Caton & Kwok, 2007)
- Favorable -> likely periodontal stability
- Questionable; local and/or systemic factors controlled or not -> maybe periodontal stability
- Unfavorable; local and/or systemic factors can't be controlled -> unlikely periodontal stability
- Hopeless -> extraction needed
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Probe with force up to ___, because the tip of the probe does not penetrate the junctional epithelium. Forces up to ___ are used to reach the bone level and do bone sounding or mapping.
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The radicular bone should be approximately _____ to the CEJ to make room for ________, which is the space for ______________.
- 2 mm apical
- the biologic width
- the junctional epithelium plus the collagen fibers of the attached gingiva that are in cementum
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Facial/lingual defects are classified as:
inconsistent margins, reverse architecture (radicular bone higher than interproximal bone), dehiscences, furcations, etc.
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Mucogingival defects
- No keratinized gingival tissue – alveolar margin
- No keratinized attached gingiva
- Aberrant frenum
- Shallow vestibule
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Necrotizing Ulcerative Gingivitis – NUG
Necrotizing Ulcerative Periodontitis – NUP
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ANUG
- Referred to as Trench Mouth
- Marginal gingiva is affected
- Punched out gingival margins
- Painful – odor
- Pseudomembrane
- Fusospirochetes predominant
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HIV - AIDS
- CD-4 Lymphocytes affected.
- Normal CD4 Th count = 500 cells/mm(3) to 1200
- CD-4 < 200 cells/mm(3) is HIV to AIDS
- Viral load – how much virus is present
- Present medication to control the viral load - ART, Antiretroviral Therapy
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ORAL MANIFESTATIONS OF HIV - AIDS
- Opportunistic infections
- Oral Candidiasis - can wipe off
- Kaposi’s Scarcoma - lesions on skin, palate, etc.
- HIV-G – Linear Gingival Erythema
- HIV-P - NUP
- Oral Hairy Leukoplakia - side of tongue
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HSV–1
Herpes Simplex Type 1- oral
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HSV–2
Herpes Simplex Type 2 – genital
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Epstein Barr Virus
Mono + Oral hairy leukoplakia; Herpes virus
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Varicella – Zoster
Chickenpox & Shingles; Herpes virus
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Cytomegalovirus
possible association with Karposi’s Sarcoma – common oral lesion on the palate in HIV infected individuals; Herpes virus
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Causes of gingival enlargement/hyperplasia
- Chronic Inflammation
- Puberty Gingivitis
- Pregnancy Gingivitis
- Drug Induced - Ca chan blocker (Nifedipine); Phenytoin (Anticonvulsant; Dialin); immuno-suppressing
- Hereditary – Gingival Fibromatosis
- Blood Dyscrasias
- Neoplasm
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Gingival manifestations of systemic conditions
- Mucocutaneous disorders
- 1. Erosive Lichen Planus
- 2. Pemphigoid
- 3. Pemphigus Vulgaris
- Allergic reactions
- 1. Dental restorative materials
- 2. Toothpastes - Mouthrinses
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Histology of desquamative diseases
- Nikolsky’s Sign – Lifting off of the epithelium; present in bullous diseases & autoimmune diseases
- Separation of epithelium at the basement membrane – Erosive Lichen Planus or BMMP
- Separation of epithelium at the spinous layer of the (within) epithelium – Pemphigus Vulgaris
- Immunofluoresence – Basement membrane
- a. Shaggy appearance & T - cell mediated – ELP
- b. Linear appearance & Humoral (B antibodies) - BMMP
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Biopsy types
- Excisional - whole lesion (small) + normal tissue
- Incisional - part of big lesion + normal tissue
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Abscesses of periodontium
- Gingival
- Periodontal
- Pericoronal
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ATTACHMENT APPARATUS POSSIBLE RELATIONSHIPS
- Normal relationship – Cementum + Periodontal Ligament + Bone
- Ankylosis – Cementum + Bone; No ligament; fused cementum and bone
- External Root Resorption – Normal relationship, but the cementum is resorbed and the tooth structure is destroyed. Etiology is unknown
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Socransky’s criteria for defining perio pathogens
- Associated With Disease, Increases At Diseased Sites
- Clinical Resolution With Elimination Or Decrease
- Elicit Host Response
- Capable Of Causing Disease In Animal Models
- Demonstrate Virulence Factors
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What is the innate immune response?
- Intact epithelial barrier (junctional and sulcular epithelium)
- Outflow of Gingival Crevicular Fluid (GCF) from the sulcus - dilution and flushing
- neutrophil & macrophage in the sulcus - phagocytosis
- Antibodies in the GCF
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What is calculus & how is it attached?
- Calcified Dental Plaque
- Covered With A Layer Of Uncalcified Plaque
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