Perio Midterm
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| Normal: Retrocuspid Papilla Gingival fibrous Nodules at MGJ | slightly raised sessile nodule lingual to the Mand. cuspid
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| PDL or "Double Periosteum" (creates/resorbs both cementum & bone) | soft CT between bone & tooth
.4- 1.5mm space (4) Functions:
SUPPORTIVE- suspends & maintains tooth in socket SENSORY- Pressure & Pain NUTRITIVE- nutrients to Cementum & Bone RESORPTIVE- 'remodel' the alveolar bone in response to pressure (Ortho)
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| Periodontium: | Gingiva, PDL, Cementum, Alveolar Bone
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| Gingiva: | Covers alveolar processes of jaw, cervical portions of teeth (4)Anatomical Areas: Free G., Gingival Sulcus, Interdental G., Attached G.
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| Interdental G. | 1 facial/1 lingual papilla- prevents food from getting stuck
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| Gingival Sulcus | Healthy: 1-3mm
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| Cementum (16-60microns) OMG Overlap 60%, Meet Margin 30%,Gap 10% 45-50% Organic + h20, 45-50% Inorganic | mesechimal CT 45-50% Inorganic
*more resistant to resorption than bone(good for Ortho, root remains)
Anchors PDL fibers to tooth (Sharpey's) Protects Dentin (seals Tubules), Compensates for occlusal attrition (forms at apical area of root
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| Alveolar Bone or Process | upper & lower jaw. surrounds & supports roots of teeth. Forms the Alveoli (sockets) NO teeth NO Alveolar Process
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| Cortical Bone: | Compact, outside wall, max. &mand. Thicker in molar regions, NOT seen radiographically
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| Alveolar Crest | Healthy: 1-2mm below CEJ, follow contours of CEJ
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| Cancellous Bone (Spongy) | Interior, between cribiform plate(alv. bone proper) and the Cortical bone
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| Alveolar Bone Proper OR Cribiform Plate OR Lamina Dura | thin, lines the socket
aka Lamina Dura (radiographically)
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| Gingiva Innervation | MAX: Superior Alvolar, Infraorbital, greater Palantine, Nasopalantine Nerves MAND: Mental, Buccal, Subligual Nerves
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| PDL & Teeth Innervation | MAX: Superior Alveolar Nerves (Anterior, Middle, Posterior) MAND: Inferior Alveolar Nerve
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| Periodontium Vascular Supply (gingiva,PDL, Alveolar Bone) | MAX: Anterior & Posterior Alveolar Arteries, Infraorbital, Greater Palantine Artery MAND:Inferior Alveolar Artery- buccal,facial,mental,sublingual Arteries
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| Teeth & Periodontal Tissues Blood Supply | MAX: Superior Alveolar arteries
MAND: Inferior Alveolar artery
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| Submandibular Lymph Nodes | drains MOST of the periodontal tissues
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| Deep Cervical Lymph nodes | Drains Palatal Gingiva of Maxilla
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| Submental Lymph Nodes | Drains gingiva in Mand. Incisors
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| Jugodigastric node | Drains gingiva in 3rd Molar area
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| Basal Lamina | separates epithelium sheets from underlying CT (thin, tough sheet)
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| Keratinized Epi cells | No Nuclei, tough
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| Non-keratinized Epi cells | Nuclei, soft/flexible cushion,
*Epi. tissues receive blood supply from CT
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| Desmosomes | specialized cell junction-connects neighboring epi cells
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| Hemidesmosomes | cell junction connecting epi cells to basal lamina
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| Periapical Cemental Dysplasia (NOT true Cementoma) PULP test for vitality to avoid unecessary RCT | 1. Osteolitic-bone loss, replaced by ,appears as PA lesion 2. Cementoblastic-excessive cementoblastic activity, specule deposits(like matrix) 3. Mature- Excessive irregular cementum deposited Xray- well defined radiopacity w/ radiolucent border
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| Bundle bone | Alveolar bone proper w/ Sharpey's fibers inserted
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| Interdental Septum | indicator of bone health
Perio Health: distance between CEJ & Interdental Septum (radiographically)
.96mm->1.22mm (avg of 1.5mm)
*Mand. Anterior 1.88->2.81mm
Center is 'spongy' Trabeculae
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| Gingival Pocket (Pseudopocket) | deepening of sulcus-solely from gingival enlargement(tissue swelling or increased collagen fibers in CT). JE remains coronal to CEJ, No PDL destruction
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| Periodontal Pocket | Pathologic deepening of sulcus
Suprabony-Horizontal bone loss
Infrabony- Vertical bone loss (uneven)
PDL & bone destroyed
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| Fenestrations | 'window' bone denuded over root NOT including the marginal bone
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| Dehiscence | bone denuded over root INCLUDING the marginal bone
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| Wolf's Law | bone will adapt to load placed
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| Mobility | Grade 1: up to 1mm
Grade 2: more than 1mm
grade 3: F,L,M,D
horizontal & vertical displacement
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| Inactive/ Active Lesion or Periodontitis | Inactive: little or no bleeding, minimal fluid and bacterial flora
Active: More bleeding, Large amounts of fluids/exudates and bacteria
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| Biofilm Marginal: Facultative | (4)Phases
1.adheres to glycoprotein pellicle
2. Initial colonization within 2dys w/ gram+
3. Secondary Colonization- slime layer produced, bacteria multiply
4. Mature biofilm-Pedunculated,gram -,anaerobes
*Must mature to cause perio damange
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| Epithelium attached biofilm | *most detrimental, bacteria invades g.,CT,bone surface
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| Biofilm Levels Distance from bone:Never<.5mm or>2.7mm less than 3mm is bone destruction | Healthy: 100-1000, 75%-80% gram+, non-motile, mostly Cocci
Gingivitis: 1,000-100,000, Equal gram-& gram+
Periodontitis:100,000-100,000,000
more Gram- anaerobes,motile,asaccralytic
small % are perio pathogens
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| Endotoxins | harmful proteins
Gram - have Lipopolysaccharides (cell walls)
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| Etiology of Gingivitis & Periodontitis | Tooth Anatomy, Nutrition, Malocclusion, Medication i.e. Dilatin, Hormones/birthControl, xerostomia, Faulty dentistry, Disease i.e. diabetes, HIV
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| 1st changes/clinical signs of Gingivitis | 1st- increase in crevicular fluid
MOST DETECTABLE- Bleeding
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| PDL cells | CT cells, Fibroblasts(collagen), Osteoblasts, osteoclasts, Cementoblasts
-Epi Rest cells (Malassez)remnants of Hertwig's root sheath
-Defense cells
-Neurovascular Cells
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| 6 Principal fibers | *Apical:fully formed tooth resists vert.force*Interradicular:multirootvertical/lateral*Horizontal: 10-15% of coronal root *Oblique: 2/3 of fibers,80-85% of root *Transseptal:1st affected by disease/inflammation, under col*Alveolar Crest:counterbalance
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| Fremetus | Vibrations when occluding
+slight ++barely visible +++clearly visible
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| Periodontal Disease Bacteria | AA:parent->child,aggressive perio (25%chronic)
*Fusobacterium nucleatum: early stage gingivitis, subg plaque in perio w/ severe attach loss
*Porphyromonas g-grows in JE, perio, destroy bone
*Bacteroides forsythus-subg plaque,Deep pockets, aggressive pe
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| PMN (Neutrophils) | Acute, Anaerobic glycolysis=acidity
leaves axial stream->pavementing
Lysosomes- can kill/digest bacteria after phagocytosis
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| Hyperemia | 10X more blood
increased permeability
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| Edema fluid (Exudate BEFORE Cellular Phase) | Leukocytes & Plasma proteins leak from capillaries into tissue at injury/infection site, Activates Lymphatic system, Dilutes toxins
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| Macrophages (in tissue) Monocytes (in blood) | not as many but live longer, no memory
phagocytosis
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| B cells->plama cells->Antibodies | Antibodies:Neutralize bacteria, Coat bacteria for easier phagocytosis, Activate complement system
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| Cytokines (Produced by various cells) | powerful protein mediators: recruits cells, increase permeability, can cause tissue destruction in chronic cases
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| Prostaglandins (mainly PMNs and Macrophages produce) | powerful inflammatory mediators, trigger osteoclast activity-> Destroys Bone, Promotes overproduction of MMP
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| MMP (Matrix Metalloproteinases) produced by various cells | 12+ enzymes, collagen destruction
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| Complement System | proteins that facilitate phagocytosis, and puncture cell membranes
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| Gram + | Thick Single Cell Wall, Purple
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| Gram - | Double cell Wall, doesn't stain purple
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| Biofilm formation | 1. Initial Colonization, 2dys mainly Gram+ 2. Secondary Colonization: Slime layer (protects, adheres), bacteria multiplies 3. Mature- complex mushroom microcolonies, extremely resistant antibiotics/microbials- Mechanical Removal!
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| Exotoxins | harmful proteins i.e. leukotoxins (AA), hydrogen sulfide, ammonia
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| Furcation Class | I: curvature felt w/probe, penetrates<1mm II: penetrates, but not completely through, III: Completely through IV: same as III but visible because of recession
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| Oxytalin and Eulanin | immature elastin, parallel to root surface, regulates vascular flow
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| COL: | depression just apical to contact area- VERY susceptible to infection
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| Epi Cells | (rests of Malasssez) PDL latticework, diminish w/ age, close to cementum side of PDL,remneants of Hertwig's root sheath, cluster or interlacing strands, more in apical and cervical area
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| Primary, Acellular Cementum | more in coronal half of root, mostly calcified Sharpeys fibers
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| Secondary, Cellular Cementum | More apical root portion, Increases w/ age in apical and furcations
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| Physiologic Mesial Migration | age 40, 5mm loss in Q length from 3rd Molar to midline
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| Vascular Proliferation | capillaries from Endothelia cells (BV) feed/bring fibroblasts, fragile, Granulation tissue forming
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| Fibroblastic Proliferation | 'Star' shaped then elongates, creates collagen, Granulation tissue forms
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| Dark Field Microscopy | detects basic type and mobility-NOT specific or exact amount
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| Calculus | Ca, Phosphorus, carbonate, Sodium, Magnesium, Potassium...S
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| Saccrolytic Asaccrolytic | loves Carbs= caries
loves proteins (more dangerous by products)
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| Unattached Plaque | Gram -, free floating, susceptible to Phag.
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| Tooth attached plaque | gingival margin almost to JE, Gram+, Caries
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| Virulence | Colonize, Invade, Damage
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| Vasodilation | 2nd, Kinin System, caused by histamines from Mast cells (basophils)---fragile
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| ARESTIN |
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