Major Topic

Scaling/Root Planing/
Gingival Curettage
Periodontal Ligament/
Gingiva

PERIODONTICS

FiGlS

Which statement regarding an eutogenous free gingival graft is not true?

. It

can be placed to prevent further recessron

. It can be used to effectively widen the attached gingiva

. lt retains its orvn blood supply

and is not dependent on the bed of recipient blood

lessels

. The greatest amount olshrinkage occurs within the first 6 weeks

. It

is also useful for covering non-pathologic dehiscences and fenestrations

Copyrighr O

20ll

20ll

Denral Decks

***

This is false; it retains none ofits own blood supply and is totally dependent on the bed ofrecipient blood vessels.
In some instances. it can be used to cover a root surface with a narrow denudation. The procedure yields
a high degree ofsuccessful results when used for increasing the width ofthe aftached gingiva. The free
gingival gmft may be used theraputic.lly to widen the gingiva after recession has occurred. It may be
used prophylactically to prevent recession where the band ofgingiva is nanow and ofa thin, delicate
consistency.
The liee gingival graft is an autogenous graft ofgingiva that is placed on a viable connective tissue bed
cases, the donor site ftom which the graft
is laken is an edentulous region or the palatal area. The gmft ePithelium undergos degenemtion after
ir is placed. Then it sloughs, the epithelium is reconstructed in about a week by the adjacent epithelium
and proliferation ofsurviving donor basal cells. In two weeks'time, the tissue appears to have rcformed,
but matumtion is not completed until l0 to 16 weeks. The tim required is proportional to the thickness
ofrhe graft. Note: The free gingival graft receives its nutrients liom the viable connective tissue bed'

*here initially buccal or labial rnucosa was present. In most

The procedure mry or may not yield a successful result when used to obtain root coverage; the result
is nor highly predictable in such cases. The graft may be used to correct localized narrow recessions or
clefu but nol deep, wide recessions, In these instarces, the later.lly repositioned flap /a pedicle graft)
or a subepithelial connective tissue graft has a greater predictability. The free gingival graft is rarely
used on the facial or lingual surfaces of mandibular third molars f"speciallyfacial).

Ililler classification

system for recession:

. Class I: marginal tissue recssion does rrot extend to the mucogingival junction. There is no bone loss

or soft tissue in the interdental arca. It can be narrow or wide.

. Class II: maryinal tissue recession extends to or beyond the mucogingival junction. Therc is no loss
ofbone or soft tissue in the interdental areas. It can be wide or narow.
. Class III: marginal tissue recession ertends to or beyond the mucogingivaljunction. There is bone
and soft tissue loss interdentally or malpositioning ofthe tooth.
Therc is severe
"Cless Iv: marginal tissuerecession extends to orbeyond the mucogingivaljunction.
bone and soft tissue loss interdentally or severe tooth malposition.
In general, th prognosis for classes I and II is good to excellent; whereas class III, only partial coverage can be expected. CIass IV has a very poor prognosis.

. Mandibular first and second premolars

. Maxillary first and second molars
. Maxillary canines
. Mandibular molars with buccal and lingual class II or III furcation involvements

2
Coplright O 201 I -20 l2 - Denral Decks

. To cure periodontal disease

To eliminate the existing microflora

. To eliminate periodonlal pockets

. To change the existing microflora

Coplright O 20: I -2012 - Dntal Decks

Hemisection refers to the vertical sectioning ofthe tooth through both crown and root. Most
often, the technique is utilized in a mandibular molar region where the crown is divided
through the bifurcation region. One-half ofthe tooth is extracted if one specific root has excessive loss in osseous support and the remaining half of the molar tooth now is treated as a
premolar. Note: This process has been called bicuspidization or separation because it
changes the molar into two sepamte roots.
Root amputation refers to the separution ofan individual root from the crown structure ofthe
tooth. Burs and diamond stones are utilized to sever the crown and root prior to
extraction by root tip forceps. At the completion of the root amputation, the remaining
apical area of the crown and furcation region are recontoured similar to the shape of a
pontic so that maximal access is provided for oral hygiene methods. Most root amputations involve the maxillary first and second molars (tlrcse teeth are commonly involved periodon-

tal sites).
Root amputations or hemisections almost always result in irreversible pulpal damage that
Demands endodontic therapy. Ideally the endo is done first which ensures patient comfort.
Sometimes the decision to do a root resection cannot be made until flaps have been reflected
and the periodontal status has been carcfully assessed. The RCT must be delayed until after
the resection. Regardless ofthe sequence, consultation with both endodontist and periodonrist is required to ensure both aspects ofthe treatment can be performed.

\ote: As \\.ith

root resection, molars with advanced bone loss in the interproximal and interradicular zones are not good candidates for hemisection.

Important: Pontic design for crown and bridge: The sanitary and ovate pontics have convex
undersurfaces, which makes them easiest to clean. The ridge-lap and modified ridge-lap designs have concave surl'aces, which are more diffrcult to access with dental floss. The sanitary
pontic is mrely used because ofits unesthetic form. The ovate pontic is the ideal pontic form.
The alveolar bone must be a minimum of2 mm from the most apical portion ofthe pontic.

It does not cure periodontal discase. The technique is performed in combination with apically positioncd flaps,
and rhe procedure eliminates periodontal pocket depth and improves tissue contour to provide a more easily
mainrainable environment. Before employing osseous resection or recontouring to treat an infrabony dcfect,
rhe rherapist should consider the following altemative trealments:
. )laintenance with pcriodic root
Note: Osseous resection surgery should not lte don until the
. Bone grafts
etiologic tlctors that resulted in the formation ofthe osseous
procedures
Reettachment-fill
defects are arrested. Clinically detectable inflammation must
'
. Hemisection or root amputation
be eliminated by scaling and root planing and by thc patien!'s
exercise of optimal plaque conlrol.

planing

Important: The most critical tactor in determirling whcther a tooth should be extraoed or have surgery per_
furmed on it is thc amount ofattachment loss (nhich is the apical nigration ofthe epithelia[ altachment).
\umerous therapeutic hard-tissue grafting materials for restoring periodontal osseous defects have been uscd.
\faierial ro be grafted can be obtained from the same individual /drlog dr.s), from a dil]'erent individual ofthe
*me species /d/1oglafsl, or from a different spectes (xenogralis).

(abilil! to induce thelormation oJ

graft), osteoindrrctive (abilit, ofmolecules conlained in the gruJi lo con-

Bone Srafting materials are genetally evaluated based on their osteogeni.

tl\ bo e br cellt containe.l in

the

\en neiEhboring cells inlo osteoblasts), or osteoconductiv (drilit! o/the grc-ft materitll
that tarors outside cells lo penetrate the graft
. Aulognous bone grafts:

andfom

netN

to sen'e as a

scalfold

bone) polenti^1.

- Osseous coagulum: mixture ofbone dust from co(ical bone and blood.
- Bone Blend: uses an autoclaved plastic capsule and pestle. Bone is rcmoved f.om a predetermined site,
riurated in the capsul to a workable, plastic-like mass, and packed into bony defects.
- Cancellous bone marrow transplants: bone obtained ftom the maxillary tuberosity oredcntulous ridges.
- Cancellous bon from extraoral sites: fresh orpreserved iliac cancellous marrow bone.
. Aflograft material: undecalcified freeze-dried bone allograft (FDBI [osteoconductive materialJ), decalcifiedFDBA, lDFDBA [osteoinductive mateial]). Note: DFDBA has a higher osteogenic potential fdae to
the pretenee olbone morphogenetic prcteins IBMP9 than FDBA and is therefore preferred.
. Xenografts: Bio-Oss has been used as a glaft material covered with a resorbable membmne lBro_Gude/
. Nonbone graft materitls: bioactive glass fPelioclas, Biocrun) and coal-derived materials.

. Full thickness periodontal flaps involve reflecting all of the soft tissue, including the
periosteum to expose the underlying bone

. The partial

thickness periodontal flap includes only the epithelium and a layer of the
underlying connective tissue

. Both full thickness

and partial thickness periodontal flaps can be displaced

.Flaps flom the palate are considered easier to be displaced than any other region
. Flaps should be uniformly thin and pliable

4
Coplrigbt O 2011,2012, Dental Decks

. Gingivectomy
. Apically positioned flap

. Distal

rvedge

. Laterally positioned flap

Coplriglt

O 201l-2012 - Denbl Decks

***

This is false; palatal flaps cannot be displaced (ouing to the absence ol unattached
gingiva).

A periodontal flap is a segment ofmarginal periodontal

tissue that has been surgically separated coronally from its underlying support and blood supply and attached apically by a

pedicle of supponing vascular connective tissue. Flap procedures are the most commonly used ofall periodontal surgical techniques. The most commonly used flaps are
full thickness mucoperiosteal flaps. These flaps include the surface mucosa (defned as epitheliunt, basement membrane, and connective tissue lamina propria) and the contiguous
periosteum ofthe underlying alveolar bone. A partial thickness flap includes only the epithelium and part of the connective tissue, which is separated from the periosteum by
sharp dissection. The periosteum remains in place on the bone. Alveolar bone is not
exposed. These flaps are used in the preparation ofrecipient sites for free gingival grafts
or when a dehiscence or fenestration is present on a prominent root.

ofthe flap must be uniformly thin, usually about 2 mm

thick. One determinant ofhow the flap will be raised, that is either as full thickness or
as a panial thickness flap, is the thickness (amount) of the attached gingiva prior to
surgerl'. Generally, a full thickness flap will be used where the attached gingiva is thin
) ntm or less in width), and a partral thickness flap may be used when the attached ginThe surgically created edge

ei

a ts thick (2 mm or more).

Distal wedge procedures (sometimes called proximal wedge procedures) are

frequently performed after wisdom teeth are extracted because the bone fill is usually
poor, leaving a periodontal defect. This region is occupied by glandular and adipose
tissue covered by unattached non-keratinized mucosa. Only ifsufficient space exists distal to the last molar, a band of attached gingiva may be present. In such a case a distal

s edge operation can be performed.

These procedures are also performed in the following areas

. The maxillary tuberosity region

. The mandibular retromolar triangle

ofthe mouth:

area

. Distal to the last tooth in an arch, or mesial to a tooth which approxirnates

an edent-

ulous area

\{any- designs have been presented for this flap procedure. However, the basic principle is one of making at least two incisions distal or mesial to the tooth and carrying these
incisions parallel to the outer gingival wall, thus forming a wedge; the base of which is
the periosteum overlying the bone and the apex of which is the coronal gingival surface.
Detachment ofthe wedge from the periosteal base and elimination ofthe tissues involved
in the distal pocket region also reduces tissue bulk and allows for access to the underlvins bone.

. The need for bone surgery or examination ofthe bone shape and morphology

. Situations in which the bottom ofthe pocket is apical to the mucogingival junction
. Esthetic considerations, particularly in the anterior marilla
. Elimination of gingival enlargements

Copltighr C 20ll'2012 - Dental Decks

The primary objective and advrnhge of surgical flap procedures

in the treatment of periodontal disease is:

Reduce or eliminate periodontal pockets

. To provide access to root surfaces for debridement

. Regrowth ofalveolar bone

. Maintenance ofbiological width
. Establishment ofadequate soft tissue contours

7
CoplriSht O 201 1,2012, Denial Decks

Gingivectomy means cxcision of thc gingiva. By rcmoving thc pockct wall. gingivectomy provides visibility and accessibility lor complete calculr,rs removal and tho.ough smoothing of the
roots, creating a favorable environment for gingival healing and restoration ofa physiologic gingival contour Abeveled incision is made apical to the pocket depth, the tissue is removcd, the area
is debrided, and a surgical pack is placed. Note: The gingivectomy tcchniquc was widcly perfonned in thc past. Improved understanding ofhealing mechanisms and the development ofmorc
sophisticated flap methods have relgated the gingivectomy to a lesser role in the current repertoire
of available techniques.

indication

The gingivectomy technique may be performed for the following indications:

. Elimination of suprabony pockets, regardless of their depth, if the pocket wall is fibrous and

fimr

. Elimination of gingival enlargements

. Elimination of suprabony periodontal abscesses
Importanti An adequatc amount of attached gingiva must be present beforc
done; otherw,isc the rcsult will be an area rvith minimal or no attached gingiva.

gingivcctomy is

Thc following factors should be considered when electing to perform a gingivcctomy rather than
a periodontal flap: contraindications
. Pocket depth fy'base of pocket is loc.tted at the mucogitlgiv.tljunction 01, apical to the alveolar crest, do not perfbt'm gingivectom)-)

r\-eed for access to bone (if osseou.s recontouritg is needed do not do gingiveclony)
. r\rrrount ofexisting attached gingiva fy'lnadequate do not do gingivectotny)
.\ gingivoplasty is directed towards reshaping the gingiva and papilla ofa tooth for corrcction
of deformities and to provide the gingiva with normal and functional form. The overall objective
is not to eliminate pcriodontal pockets, but rather to provide a more physiological tissue contour.
\\'hile it is true that portions ofthc gingiva arc excised dudng thc gingivoplasty procedure, it is thc
reshaping, not thc cxcision, of gingiva that defines gingivoplasty. Note: This procedure is conmonlv used to correct th tissue contours that result from ANUG.

provide
Th. rcchniqucs vary with $c goal that is sought- However, thc common goal ofall flapltocedurcs is to
cess

for insir' rnentation. It glvcs

the

clinician thc opporlunity

1.,

ac_

visualizc thc rools so lhat calcul,s may bc rcmovcd

\\':rhout dircct visualizalion providcd by a 0ap, it is rarc that a clinician can cffectivcly root planc beyond 5mm of
from thc rcgion of
:r!.bing dcpth or into furcalions of Lcsscr dcpth. It also makcs rcmoval ofgranulomatous tissue
and the potenepithelium
fact
it
contains
duc
to
thc
rcmovc
this'
to
:h: plriodontal dcfcct difficult. It is important
tirl presncc of bacterial infiltration.
patient f'ails to dcnonstratc adcquate oral hygiclc durinS initial thcrapy 6'dliirg a'd tuot plannry)'

Important: If a
surgen is contrainrlicated bccause aftcr surgcry thc incidencc ofdiscasc rccuncnce will bc greater iforal hygicne
.".l3,ns noo. thc bcst.ourse ofaclion is to conlinuc to strcss oral hygiene and maintain sreas with scaling and rool
al.:nrn-r

is basic to most pcriodontal tlap proccdurcs. ll is thc incision from ll'hich a flap is reucctcd
(l) it
e\Folc rhc undcrlying bonc anal root The intcmal bevel incision accomplishcs thrcc imponant objcctivcsl
gingiva
which'
ifapically
surfacc
ofthc
oute'
uninvolved
(2)
the
rclativcly
il
conscrvcs
,c,,,or ls rlc p<*t cr iining:
to thc bonc{ooth
r.r:rroncrj. becomcs atta;hcd gingiva; and (3) il produccs a sharp, lbin flap margin for adaptation

Tlr internal bclel incision

ro

P.riot1onlolog,. I tl" .1.

A. Diagm oflfie inrem.lbevel incision /rxi ir.irtorl to reflecl l) full thjckness

thu.opctiosteal) ttap. \ote that the itrcision ends on rfie bonc lo allow fo' dre re
flection ofrhe entire flap. B Diagrm ofrhe inlemal bevel iicision to reflect a par
tial-rhickness flap. Note thal rhe incision ends on dre mot surface to preser!e the
periosteun ofthe bone.

.In

addition to improving accessibility for instrumentation, removes the pocket wall,

thereby reducing or eliminating the pocket

. Facilitates inslrumentation but does not attempt to reduce pocket depth

. Improves accessibility

and eliminates the pocket, but does the latter by apically positioning the soft tissue wall ofthe pocket

. None ofthe above

8
Copfighr O 20ll-2012'Dmlal Decls

A soft tissue graft that is rotated or othrwise repositioned to correct

an adjacent defect is called a:

. Free gingival graft

. Pedicle graft
. Connective tissue graft
. Frenectomy

9
coplrighr O 201l-2012 'Dental Decks

The modified Widman flap (MWF) facilitates instrumentation but does not attempt to reduce
pocket depth. The reduction or elimination ofpocket depth is the main purpose of two flap
techniques: the undisplacd flap and tbe apically displaced flap. The decision of which to
perform depends on two important anatomic landmarks:

Pocket depth

. Location ofthe mucogingival junction

***

These landmarks establish the presence and width ofthe attached gingiva, which is the
basis for the decision.

The modified widman flap has been described for exposing the root sufaces for meticulous
instrumentation and for removal ofthe pocket lining. This flap uses the three horizontal incisions but is not reflected beyond the mucogingival line. Note: It is not intended to eliminate
or reduce pocket depth, except for the rcduction that occurs in healing by tissue shrinkage.
The undisplaced ftnrepositioned) flap, in addition to improving accessibility for instrumentation. removes the pocket wall, thereby reducing or eliminating the pocket. This is essentially
an excisional procedure ofthe gingiva. Note: Curently, the undisplaced flap may be the most
frequently performed type ofperiodontal surgery. It differs from the modified Widman flap in
that the soft tissue pocket wall is removed with the initial incision; thus it may be considered
an "intemal bevel gingivectomy." The undisplaced flap and the gingivectomy are the two techniques that surgically remove the pocket wall.
The apicallt- displaced flap also improves accessibility and eliminates the pocket, but it does
the latrer by apically positioning the soft tissue wall ofthe pocket. Therefore, it preserves or
increases the width of the attached gingiva by transforming the previously unattached keratinized pocket wall into attached tissue.

The pedicle graft was the first periodontal plastic surgery procedure to be used for root
coverage. lt provides a superior result from an esthetic standpoint, but is less versatile
than the connective tissue graft. Important: The base of the graft remains attached to
the donor site to maintain the blood supply.

\\'ith pedicle grafts, there is less concem about nutrient flow from graft bed to graft. The
properly performed pedicle graft never loses its blood supply during the surgical procedure.

The major advantages ofpedicle grafting include:

. Predictable correction ofgingival recession

is possible, because the graft has an uninterrupted blood supply

. Postoperative discomfort is usually minor
. Since the color ofthe graft matches the adjacent gingiva, the procedure provides good

esthetics

Indications include:

. To u'iden an inadequate zone ofattached gingiva

. To repair an isolated area ofgingival recession
Contraindications include:
. The prospective donor site lacks sufficient attached gingiva
. The donor site has a fenestration or dehiscence of its supporting bone

\ote:

Pedicle grafts are not well-suited for repairing generalized recession defects. They
rvere designed for repair of isolated recession. Many recession defects don't have a suitable adjacent donor site.

. A soft tissue graft used to correct mucogingival junction involvement

. Placement of nonresorbable barriers or resorbable membranes and barriers over

bony defect
. A free gingival graft used to increase the amount ofattached gingiva

. Placement of an autograft to treat a bony defect

10
Coptrighr

201 |

,2012 - Dntal Decks

. Infection
. Edema
. Disruption ofthe vascular supply before engraftment
. The formation of scar tissue

11

Cop).righr O 201 I -2012 - Deital Decks

The method for the prevention of epithelial migration along the cemental wall ofthe pocket that has
gainedwide attention is guided tissue regeneration fcfRr. This method is based on thc assumption that
only the periodontal ligament cells have the potential for regeneration ofthe attachment appa.atus of
the tooth. GTR consists ofplacing baniers ofdifferent types to covcr thc bone and periodontal ligamcnt.
thus temporarily separating them from the gingival epithelium. Excluding the epithelium and the gingival connective tissue from the root surface during thc postsurgical healing phase not only prevents epithelial migration into the wound, but also favors repopulation ofthe area by cells from the periodontal
ligament and the bone.
The initial membranes developed were nonresorbable (pobitetrulluotoethv"le e IPTFE]) and therefore required a second, although frequently simple, procedure to remove it. This second procedure was donc
after thc initial stages ofhealing. usually 3 to 6 weeks after the first intervention. The second procedure
was a significant obstacle in the utilization ofthis GTR tcchnique, and therefore resorbable membranes
$ ere developed.

Resorbable membranes marketed in the United States include OsseoQuest aco,"e/, a combination of
poly-glycolic acid, polylactic acid, and t methylene carbonate that resorbs at 6 to 14 months; Biocuide
tOsteoHealth), abilayer porcine-derived collagen; Ahisorb fr1oc,( Dnlg), a polyactic
gel; and Bio^cid
\lend /Calcitech), abovine Achilles tendon collagen that resorbs in 4 to l8 weeks. Ofthese,
Biocuide
is easier to use and generally preferred.

Currenth. regenerative procedures are applicable and predictable under a certain set of circumstances:
(l) The parient exhibits exemplary plaque control both before and after regenerative therapy, (2) The
parient does not smoke, (3) There is occlusal stability ofthe teeth at the regenerative site, (4) Osseous
detects are vcrtical in nature, with the mor walls ofbone remaining increasing thc likelihood ofrcgenetali\ e success.

\o&q'
.. -'
'-o--''

L A fienum becomes a problem ifthe attachment is too close to the marginal gingiva. Tension on the frenum may pull the gingival margin away from the tooth.
2. A frnectomy is complete removal ofthe frenum.
3. A frenotomy is incision ofthe frenum, this proccdure usually is suffice for most periodontal DurDoses.

***

The second most common reason is infection.

Tcchniques used to increase the width ofattached gingiva include the fiee gingival autogmft, fiee connecti|e tissue autograft, and the apically positioned flap. These techniqucs are used for widening the atrached gingiva apicat to the area ofrecession. Techniques used for gingival augmentation coronal to the
recession (root coverage) include the free gingival and connective tissue autograft, as well as pedicle
autografts (laterally and coronalll' positioned llaps), lhe srbeplthelial connective tissue graft (Langer)
and guidcd lissue regeneration.
Free gingival autografts jnvolve taking a section ofattached gingiva from another area of the mouth
rusualh-the Inrd palate or an edentulous regionJ and suturing it to the recipient site. The success depends
upon lhe graft being immobilized at the recipient site. Free gingival grafts arc used to create a widened
zone of anached gingiva with the possibility ofgaining root coverage as well. The diflculty in getting
complele root coveragc lies in the fact that an avascular graft is placed over a root surface also devoid

tria blood supply. Note: The ideal thickness for this graft is I to

1.5 mm.

Tte free connective tissue autograft technique is based on the fact that the connective tissue caries the
genetic message for the ovcrJying epithelium to become keratinized. Thereforc, only connective tissue
from a keratinized zone can be used as a graft. The advantage ofthis technique is that the donor tissue
ji obraincd from the undersurface ofthe palatal flap, which is sutured back in primary closure; therefore,
healing is by first intention.
The apicrlly displaced flapi this technique uses the apically positioned flap, either partial thickness or
full rhickness, to increase thc zone ofkeratinized gingiva.
Rememberi Pos ition ed f7^ps (i.e., lalerully positioned fap, cotonally positioned Jlap, and apical4' positione.l.flap) are procedures in which the coronal portion ofthe flap is elevated from an atea adjacent
to thc recipient sitc, and freed-up, but the base ofthe flap is still connccted to the underlying donor site
tissue. In these procedures, the vascular supply to the llap is maintained, as opposed to the free gingival graft.

Important: Thcro is no necrotic slough ofpositioned flaps bccausc thcsc flaps take their vascular supply with them. In a free gingival graft, the healing involves revascularization ofthe graft. The top layers of the graft are thc last to be revascularized; therefore the epithelium dics off (degeneralion),
producing the necrotic slough.

. A coronally positioned flap

. A modified Widman flap
. A double papilla flap

. A free gingival flap

12

cop)'ight C 20ll-2012 - Dental Dcks

. Sharp
. Rounded
. It doesn't matter whether the comers ofa periodontal flap are sharp or rounded

13
Coplright

e 20ll-2012

- Dental Decks

Laterafly (horizontally) displaced flap: this technique was the standard technique for
many years and is still indicated in some cases. The laterally positioned flap can be used
to cover isolated, denuded roots that have adequate donor tissue laterally and vestibular
depth.

Sliding partial-thickness grafts from neighboring edentulous areas (pedicle grafts) canbe
used to restore attached gingiva on teeth adjacent to edentulous spaces with denuded roots
and a small, vestibular fomix, often complicated by tension from a frenum. The "double-

papilla flap" attempts to cover roots denuded by isolated gingival defects with a flap
formed byjoining the contiguous halves ofthe adjacent interdental papillae. Results with
this technique are often poor because blood supply is impaired by suturing the two flaps
over the root surface.

Indications include:
. Traunra from incorrect toothbrushing (gingivql recessiotr)
. Covering the exposed root surface with gingiva also helps to reduce or eliminate the
problem of hypersensitivity

. l. Deep periodontal pockets are often treated by flap surgery. These cases
\otee will often result in reduced pocket depth by formation of a long junctional
epithefium (soft tissue reattachment), even ifthere is no change in the posil
ion ofthe gingival margins.
2. The best indicator of success of a periodontal flap procedure is postoperative maintenance and plaque control by the patient.
3. One month alter flap surgery a fully epithelialized gingival crevice with a
well-defined epithelial attachment is present. There is a beginning functional
arrangement of the supracrestal fibers.

priodontal flap is a scction ofgingiva and/or mucosa surgically separated from thc underlying tisiues to provide visibiliry ofand access to thc bonc and root surfacc. The flap allows the gingiva to be
displaced to a different location in patients with mucogingival involvement.
Periodontal flaps can be classilied based on the following:
. Bone exposure aftcr flap reflection:
- full-thickness fmrcoperiosteal) Ilaps. allthe soft tissue, including the periosteum, are reflected to
expose the underlying alveolar bone.
- partial-thickness (mucosal) tlaps only thc cpithclium and a layer ofthe underlying connective
!issue are reflected. Also called split-thickness flap.
. Based on flap placemcnt aficr surgcry:
- nondisplaced flaps: when the flap is retumed and sutured to its original position.
- displaced flaps: which are p)aced apically. coronally, or laterally to their original position.
. Based on fianagement ofthe papilla:
- conlenlional flapr thc interdental papilla is split beneath thc contact point ofthe two approximating teerh to allow reflection ofbuccal and lingual flaps.
- papilla preservation flap: incorporates the entire papilla in one ofthe flaps.
The Four Basic Rules For Flap Design:
L The base of the flap should be wider than the free margin in order to afford sufficient blood circulation ro the liee margin ofthe flap.
l. The lines of the incision must not be placed over any defect in the bone to prevent delayed heal-

ing.
3. lncisions that traverse a bony eminence fcdr?ire/ should be avoided. The mucosa covering bony
cminences is thin and healing is slow and may result in an ugly scar formation.
,1. All comers ofthe flap should be rounded. Sharp points will delay healing.

Important:
. Healing should take place without complication if basic surgical principles are followed.
.lncisions made in tissues that harbor uncontrolled infection may cause rapid spread ofthe infection. Do not do this. Most periodontal surgical procedures are perfomed only after anti-infective
therapy has been completed.

. Coronally displaced (positioned) flap

. Laterally displaced (positioned) flap

. Double papilla flap

. Apically displaced (positioned) flap

14

Cop),riglitC 20ll-?012 - Deit.l Decks

A free mucosal autograft (subepithelial connective tissue graf) differs from

free gingival graft in that the transplant in a free mucosal grtft is:

. Connective

tissue with an epiftelial covering

. Connective tissue without

an epithelial covering

. Epithelial tissue with its own blood supply

. Epithelial tissue without its own blood supply

15
CoplriSht

20l

2012

Denral Decks

An apically displaced (positioned) flap (APF) is a full-thickness, mucoperiosteal flap. It has

a relatively high degree of predictability and is a "work-horse" ofperiodontal therapy. The
objective ofthis tlpe offlap is to surgically eliminate deep pockets by positioning the flap apically while retaining the keratinized gingiva. Additionally, surgical access is obtained for osseous surgery treafinent of infrabony firtabony) pockets, and root planing.
In the course of this flap surgery, after gaining access to the underlying osseous tissue and
performing the required therapy, the flap is suhlred to place at a more apical level, sometimes
exposing the alveolar bone margin. When this is done, additional attached gingiva grarulates
from the periodontal ligament and covers the barely exposed bone. This additional tissuejoins
the apically positioned attached gingiva to form a broader zone of gingiva. Note: On the
palatal surface of maxillary molars you need to trim the flap margin to the proper length during the procedure.
Indications for APF include:

. Moderate or deep pockets

. Furcation-involved teeth
. Crown lengthening
An APF is contraindicated if a patient is at risk for root caries. Excessive root surf-aces are
ol'ten exposed after perfbrming an apically positioned flap. APF's are also conffaindicated
\\ here tooth exposure would be unesthetic.

Remember: For all mucogingival procedures, blood supply is the most significant concem.
Biomodification ofthe root surface: the root surface ofthe pocket can be treated to improve
irs chances ofaccepting the new attachment ofgingival tissues. Several substances have been
proposed for this purpose, including citric acid, fibronectin, and tetracycline. Other agents
used inciude growth factors (/. e., PDGE IGE bFGE BME and TGF) and one enamel matrix
protein dedvative obtained from developing porcine teeth (trade name is Emdogain).

free mucosal autograft (suhepithelial connective lissue graft) differs from a free gingival graft
in that thc transplant in a frec mucosal graft is connective tissue without an epithelial covcring.
Epithelial differentiation is induced by the underlying conncctive tissue, so that l'ree grafts of
dense connective tissue taken from keratinized areas result in the formation of keratinized tissue
even when transplanted to non-keratinized zones. This procedure is somewhat more difficult than
fr.-e gingival grafling. This procedure is often used on canines where there is little keratinized
gillgir a to create a band ofgingivalike tissue.
Remember: During healing, the epithelium of free gingival grafts degenerates (necrotic slough),
and re-epithelialization occurs by proliferation of epithelial cells from adjacent tissue and surviring basal cells ofthe graft tissue.

-\

\ote: Free gingival grafts are often used in conjunction with a frenectomy to prevent reformation ofhigh lrenal attachments.
Healing after flap surgeryl

. Immediately after suturing

hoarr. a connection between the flap and the tooth or

bone surface is established by a blood clot.
. 1 to 3 days after surgery: the space between the flap and the tooth or bone is thinner, and epithclial cclls nrigrate over the border ofthe flap, usually contacting the tooth at this time.
. 1 week after surgery: an epithelial attachment to the root has been established by rneans of
hemidesmosomes and a basal lamina. The blood clot is replaced by granulation tissue derived
from the gingival connective tissuc, th bone manow, and the periodontal ligament.
. 2 weeks alter surgery: collagcn fibers begin to appear parallel to the tooth suface. Union ofthe
nap to the tooth is still weak because ofthe presence of immature collagen fibels.
. I month after surgery: a fully epithelialized gingival crevice with a well-defined epithelial attachment is present. There is a beginning functional arangement ofsupracrcstal fibers.
(up lo 24

Note: Full-thickress flaps, which denude the bone, result in a superficial bone necrosis at I to
resorption follows and raches a peak at 4 to 6 days, declining tberealler This
results in a loss ofbone ofabout I mm: bone loss is greater ifthe bone is thin.
3 days; osteoclastic

Free gingival autograft

. Double papilla flap

. Modified Widman flap

. Laterally displaced (positioned) flap

16
Cop)righr O 201l-2012 - Dental Decks

. Ostectomy
. Osteoplasty
. Positive architecture
. Negative architecture

Coplright Q 2011-2012 - Dnral Decks

(l) nondisplaced flaps, when the flap is retumed and sutured to its original position, or
(2) displaced flaps: which arc placed apically, cororally, or laterally to their original position.
Both full-thickness and partial-thickness flaps can be displaced, but to do so, the anached gingiva must bc totally separated from the underlying bone, thereby enabling the unattached po(ion ofthe gingiva to be movable. Howevcr, palatal flaps cannot be displaced because ofthe absence ofunattached gingiva.
l. Apically displaced flaps have the important advantage ofpreserving the outer portion of the
pocket wall and transforming it into artached gingiva. Therefore these flaps accomplish the double objectivc ofeliminating the pockct and increasing the width ofthe attached gingiva.
2. Laterally displaced flaps arc used to coffect or prevent recession by providing root coverage
and crcating a broader band ofgingiva. It may be used in the absence ofrecession to widen the
Flaps are classified as

zone ofgingiva.
3. Displacd flaps are allphysically attached at their apical base by a pedicle
an

oflining mucosa and

int.ct blood supply,

Periodontal flaps use horizonlal and verticrl incisionsi

Horizontal incisions: are directed along the margin ofthe gingiva in a mesial or a distal direction.
.Intrnal bevel incision: starts from adesignated area on the gingiva and is directed to an area at or near
the crest ofthe bone. The starting point on the gingiva is determined by whether the flap is apically displ^ced 10.5- 1.0 nn fron the.free gingivol marg ,?/, not displaced r/rrl coronal to the base ofthe pocket),
or used in the modified Widrn n ll^p (no more than I to 2 mm apical to the gingival morgin). Also called
reverse
the first incision /lrecduseil is lhe itial incision in lhe releclion ofthe periodonlal llap)
^nd.the
bevel incision rhecalre its bevel is in relJerse directiofifrom that ofthe gingivectomv incision).
. crevicualr incision (also termed the second inci.rial,/: is made from the base ofthe pocket !o the crest
ofthe bone. Tle combination ofthe intemal bevel and crevicular incisions creates acollaroftissue around
the teeth and contains most ofthe inflamed and granulomatous areas that constitut the lateml wall of thc
pocker. as well as thjunctional epithelium and the connective tissu fibels.
. Interdental incision
incrsion): this incision separates the collar ofgingiva from the tooth.

tird

Tlese three incisions allow the removal ofthe gingiva around the tooth and visualization ofthe alvcolar bone.
vertical or oblique releasing incisions: can be used on one or both ends ofth horizontal incision, depending on the pupos ofthe flap. They are used ifthe flap is to be positioned apically or laterally and must
exte d beyond the mucogingival line, reaching the alveolar mucosa, to allow for thc rclease ofthc flap to
be displaced. Note: Ifno vertical incisions are made, the flap is called an envelope flap.

Procedures used to corect osseous defects have been classified in two groups:

. Osteoplasty: refers to reshaping the bonc without removing tooth-supporting bone

. Ostectotuy for orreoectotAi includes the removal oftooth-supporting bone

***

One or both ofthcse procedures may be necessary to produce the desircd results.
\lorphologicafly descriptire tefins (these lenns all relale to d preconceit'ed slandard ol ideQl osseous

. Positive and negative architecture refer to the relative position ofinterdental bone to radicular bone.
The architecrurc is said to be "positive" ifthe radicularbone is apical to the interdental bone. The bone
is said ro have "negative" architecture ifthe interdental bone is more apical than the mdicular bone
Flat architecture is the reduction ofthe interdcntal bone to the same height as the radicular bone
\ote: Osseous form is considered to be "ideal" when the bone is consistently more coronal on the inrerproximal surfaces than on the facial and lingual surfaccs. The ideal folm ofthe marginal bone has
simjlar interdental height, with gradual, curved slopes between interdental peaks.

Follol\ing ostectomy, peaks ofbone tJpically remain at the facial and lingual/palatal line angles ofthc
reerh /rido\ i peak). Ifthese are not removed, periodontal pockets can recur Ostectomy to a positive
architecture requires the removal ofthe line-angle inconsistencies (widow \ peak), as well as some of
the t-acial. lingual, and palatal and interproximal bone. The result is a loss ofsome attachment on the facial and lingual root surfaces but a topography that more closely resemblcs "ideal" bonc
Terms ihat relate to the thoroughness ofthe osseous reshaping techniques include:
. Definitive osscous reshaping: implics that further osseous reshaping would not improve the overall

result.

. Compromise

osseous reshaping: indicates a bone pattem that cannot be improved without signifiremoval
that would be detrimental to the overall result.
cant osseous
between
the depth and configuration ofthe bony lesionfs) to rootmorphology and
\ote: The relationship
the adjacentteeth determines the cxtent thatbone and attachment is removcd during resection. The technique ofostectomy is best applied to patients with early to moderate bone loss f2--t nrr) with moderate
length root runks that have bony defects with one or two walls. These shallow to moderate bony defects
can be effectively managed by ostcoplasty and ostectomy. In some surgical procedures, it is necessary
to leave interradicular bone exposed, This usually results in bone loss ofno clinical consequence.

. One-wall intrabony defects

. Two-wall intrabony defects (osseous craters)
. Three-wall intrabony defects

. Through-and-tbrough furcation defects

1E

Coprriglr O 20ll-2012 - Dental Decks

. Bacteroides melaninogenicus
. Wolinella intermedius
. Bacteroides gingivalis
. Bacteroides intermedius

t9
Cop''righr

201

l'2012 - Dental Deck

Horizontal bone loss is the most common pattcm ofbone loss in periodontal

disease. Thc bone is reduced in height, but the bone margin remains approximately perpendicular to the tooth surface. The interdental septa and facial and lingual plates are affected, but not necessadly to an equal dcgree around
the same tooth.

Vertical or angular defects are those that occur in an oblique direction, leaving

a hollowed-out trough
in the bone alongside the root; the base ofthe defect is located apical to the surrounding bone- In most
instances, angular defects have accompanying intrabony periodontal pockcts; intrabony pockets, however, always have an underlying angular defectAngular defects are classificd on the basis ofthe number ofosseous walls. Angular defects may have
one, two, or three walls. The number of walls in the apical portion of the defect may be greater than that
in its occlusal ponion, in which case the term combined osseous defect is used. Important: Surgical exposure is the only sule way to dctermine the presence and configumtion ofvertical osseous defects.
The relative degree ofsuccess ofperiodontal bone grafting is reported to vary directly with thc number
ofbony walls ofthe defect (rascularized, osseous surface area) and inversely with the surface area of
the root against which the gmft is implaDted. Thus a nanow, three-walled angular defect usually yields
the greatest success, a two-walled defect the next best, and a one-walled defect the least.
l. Osseous grafting techniques and materials include: osseous coagulum, autogcnous inhaoral bone, autogenous iliac crest bone, freeze-dried bone allograft (FDBA, which is undecalcijied), decalcified freeze-dried bone allogftft @FDBA), FDBA or DFDBA combined

with autogcnous bone.

2. Root resorption is the most common side effect ofosseous grafting.

3. An alfograft is a graft taken fiom one

h[ma (donor) and placed in anothcr

human fre-

A dehiscence is a loss ofthe buccal or lingual bone overlaying thc root portion ofa tooth,
leaving the area covered by soft tissue only.
5. The three-wall vertical defect was originally called an intrabony dfect. Thc term intrabony was )ater expanded to designate ail vertical defects.
6. Thc onc-wall vertical defect is also called a hemiseptum.
7. Two-wall intrabony defects (osseous cralersl are best corected by rccontouring ofthe facial and linsual walls to restore normal intcrdental architecturc.
4.

The purpose ofthis card is to hopefully clear up any confusion on the recent reclassifications ofa number ofperiodontal pathogens. The bacteria have stayed the same, but the names have changed.
Rc.d Rcchisilic.tiod ofPetodoot
Clrld6edor

l Patbogen'

Pr.r'lo0s

Porphyromonas eingilalis
Baclereids

drlodo

Ba.lercidls

intrmaliu

alis

Ba1eo'd6 relsinogenicN

Purphtrumondq cndodonirlis

Prcvotclla nelaninogenica

. The first statement is true; the second statement is false

. The second statement is true; the first statement is false

. Both

statements are true

. Both statements are false

20
Cop)aighr O 20ll-2012 - Dental Decks

Mediators produced as a part ofthe host response that contribute to

tissue destruction include all of the following EXCEPT one.
Which one is the.EXCEPIION?

. Free radicals

Proteinases

. Prostaglandins
. Cytokines

21

Cop!'righr

e 201l'2012 ' De.tal

Decks

Most investigations that evaluated the cffcct ofsmoking on nonsurgical therapy have demonsfated less
reduction in probing depth and smaller gains in attachment levels in smokers compared with nonsmokels,

Depending on which clinical parameters are used to assess periodontal disease, smokers are 2.6 to 6
times more likely to develop periodontal disease than nonsmoken.
Important point: Smoking is onc ofthc most signiricart risk factors currently available to predict the
development and progressjon of periodontitis.
Smokers:

. Demonstrate more orangc and rcd microbial complexes

. Have an increase in Tannerella forsyhia levels

. Have

a depressed immunc system, smoking exefis a significant negative effect on the protective
clcments of thc immune system. Studies show that smoking not only dampens the response of host
defense cells such as neutrophils, but also leads to increascd release oftissue-destructivc enzl.mcs.

L Most systemic diseascs and conditions that may affect periodontal diseases generally alter
host barrier and host defcnse mechanisms. Although many conditions cause gingival inflammation and ulce6, rtot all peop]e develop periodontal disease. Certain factors put individuals at higher risk than others.
2. Osteoporosis f/o.t.t of bone densitl) has been associated with periodontal disease in postmenopausal women. There is some evidence that some tleatments for osteoporosis, such as
bisphosphonates, may reduce bone loss, including the bony structures that support the teeth.
3. Autoimmune conditions fe.g., Crohn's disease, rheutnatoid arthrilis, lupus er,-themalosus, CREST q,ndrone) have been associatcd with a higher incidence ofperiodontal discasc.
Smokeless tobacco use has been associated with oral lcukoplakia and carcinoma. However,
no generalized effects on periodontal disease prcgrcssion secm to occur, other than localized
attachment loss and rcession at the site oftobacco product placement.
5. Patients receiving radiation ther|py show periodontal aftachment loss and tooth loss to
be greater on the radiated side compared with the nonradiatcd side. Periodontal health should
be estabiished prior to beginning radiation therapy.1.

se (MMPs) are considered to be primary proteinases involved

in periodontal tissue destruction by degradation ofextracellular matrix molecules MMPs
are a family of proteolytic enzymes found in neutrophils, macrophages, fibroblasts, epithelial cells, osteoblasts, and osteoclasts that degrade extracellular matrix molecules, such
as collagen, gelatin, and elastin. MMP-8 and MMP-1 are both collagenases; MMP-8 is
released by infiltrating neutrophils, whereas MMP-1 is expressed by resident cells, including fibroblasts, monocltes/macrophages, and epithelial cells. Note: MMPs are also
produced by periodontal pathogens P gingivalis and A. actinotherapeutics.

llatrix metafloprotein

Cltokines are important signaling molecules released from cells. lnterleukin-l f1Z-1),
IL-8. and rumor necrosis factor alpha (TNFa), appear to have a central role in periodontal tissue destruction. The properties of these cytokines that relate to tissue destruction
inr olr e stimulation ofbone resorption and induction oftissue-degrading proteinases. IL1 is a potent stimulant ofosteoclast proliferation (bone resorption), differentiation, and acrivation. IL-8 is important in attracting inflammatory cells and TNFCI, has similar effects
as IL- I but is much less potent than IL-1. It is also imponant in activating macrophages.
\ote: \Ionocytes/macrophages are very important in regulating the irnmune response
tbrough the release of cytokines.
\{acrophages are recruited to the area ol inflammation and are activated (foi binding to
ZPt to produce prostaglandins (e.g., prostaglandin 82, PGE) Prostaglandins are biochemically synthesized from the fatty acid, arachidonic acid of cells membranes in response to cyclo-oxygenases (COX-l and COX-2). Cox-2 is upregulated by IL-1, TNF,
and bacterial LPS and appears to be responsible for generating the prostaglandin (PGE)
that is associated with inflammation. Note: The primary cells responsible for PGE2 production in the periodontium are macrophages and fibroblasts. Induction of MMPs and osteoclastic bone resorption is induced by PGE2.

. Bleeding upon probing

. Gingival color
. Pocket depths

. Stippling ofthe gingival

tissue

22
Copynghr

Cl20ll 2012

Dental Decks

In a clinically healthy periodontium, the

microbial flora is largely composed of:.

. Gram-negative obligate microorganisms

. Gram-negative facultative microorganisms
. Gram-positive

obli gate microorganisms

. Gram-positive facultative microorganisms

23
Coplaight O

201

l-2012 - Dental Decks

\
o

Inflammation, bleeding upon probing, and pocket depths are the most important diagnostic aids or signs of
gingival or periodontal disease. Gingiva may or may not be stippled whether healthy or inflamed. The presence or absence ofstippling is not diagnostic.

Clinical criteria used for diagnosing gingivitis:

. Color: normal gingival color ranges from coral pink to various stages ofpigmenration*** Erythema refers to an intense red color. Probably the most common color change notcd with piodontal disease is cyanosis (bluish-p rple hue).
. Contour: has

a mnge

ofnormal. This is influenced by missing teeth, posirion ofteeth, etc. Papillae should

fill the interproximal spaces. Gingival margins should be scalloped in lbrm.

. Tone (or Consistenc)r: the normal consistency ofthe gingival tissue should

be resilient and fibrotic in

nature from the free gingival groove apical to the mucogingivaljunction. Texture, stippling ofthe attached
gingtra (the so-called orafige peel appearance) may or may not be present.

. Siz:

the healthy gingival tissues should bc well-contoured to the undrlying osseous architecnrre with
the free gingival margin being ofsuch thinness to allow lor a "knife edge" thickness at the dentogingival

margin.

. Plaque, calculus:

the best way to evaluate the amount and distribution ofplaque is by the utilization
disclosing solution. Remember: without bacterial plaque there would be no gingivitis.

of

are no nutritional deficiencies that by

-there deficiencies ctn rlfect the condition
themselves can cause gingivitis or periodontitis. However, nutritional
ofthe periodontium.
. \'itamin A dficiency: vitamin A may play an important role in protecting against microbial invasion by
mainraining epithelial integrity. A deficiency can impact the barrier tunction ofepithelial cells.
. \'itamin D deticiency: vitamin D is essential for the absorption of calcium liom the GI trao and the of
the calcium-phosphorus balance. No human studies demonsfiate a rclationship between vitamin D deficiency and periodontal disease. Note: Vitamin D deficiency can contribute to osteoporosis ofalveolar bone
rn voung dogs.
. utamin B-complex dficiency: vitamin B complex includes thiamin, riboflavin, niacin, plridoxine, biorin. folic acid, and cobalamin- Deficiency ofthese as a group my contribute to gingivitis.
. \'itamin C deficiency: severe deficiency of vitamin C results in scuny. Bleeding, swollen gingiva and
loosened leeth are common features ofscuny,

Important: Tle impact of nutrition on periodontal disease

The gingival crevicc harbors bacteria in both health and disease. In a clinically healthy periodontium, the
microbial flora is largely composed ofgram-positive facultative cocci and rods, predominantly species
ofeenera such as Actinomyces and Streptococcus. Gram-negative species and spirochetal forms also
ma! be found, but they are considembly less prevalent and occur in much smaller numbers
The development ofgingivitis occurs in parallel with a tremendous incrase in the numbers ofbacteria
present in plaquc. A distinct shift in the bacterial composition ofthe plaque also occurs, with increasing
proponions ofgram-negative anaerobes. Note: Thehostresponse to plaque bacteria is fundamentally
an

inflammatory response.

Desprte a remarkable diversity ofbacteria found in the periodontal microbiota, only a few species have
been associated with Deriodontitis: These include:

. Porphlromonas gingivalis

. Fusobacterium nucleatum

. Tannerella fors),1hia
. Prerolella intermedia
. Campylobacter rectus

. Peptostreptococcus micros
. Treponema denticola

. Eikenella conodens

. Actinobacillus actinothempeutics

Important: Decreases in the prcvalence and numbers ofP gingivalis, T. fors)'thia. and T. denticola

are

associaredv,ith successftrl clinical treatment of disease.

\onspecilic Plaque Hypothesis: maintains that periodontal disease results from the "elaboration of
noxious products by the entire plaque flom." lnherent in this h)?othesis is the concept that control ofperiodontal disease depends on control ofthc amount ofplaque accumulation. This h)?othesis is contradicted by the finding that some patients with little plaque have severe periodontitis.
Specilic Plaque Hypothesisi states that only certain plaque is pathogenic, and its pathogenicity depends
on the prcsencc ofor increase in specific microorganisms. This conccpt predicts that plaquc harboring
spccific bacterial pathogens results in a periodontal disease because these organisms produce substances
that mediate the destructio[ of host tissues.Note: Acceptance ofthis h]pothcsis was spurred by the recognition ofA. actinomycetemcomitans as a pathogen in localized aggressive periodontitis.

. Gram-positive bacteria
. Gram-negative bacteria

. Both gnm-positive

and grarn-negative bacteria

. Neither gram-positive and gram-negative bacteria

24
Coptrighr O

201

Coplaiglr O

201 l -20

1,2012 - Dental Decks

. Minimal bleeding

.'?unched-out" papillae
. Painless
. Periodontal pocket formation

25
l2 - Dental Decks

The cell wall ofGram-negative bacteria consists ofa lipopolysaccharide base, also krown
as endotoxin, that has significant pathogenic potential. Typically, LPS containing Gram-

negative cell wall extracts are capable ofpromoting bone resorption, inhibiting osteogenesis, chemotaxis ofneutrophils, and other events associated with active periodontitis.

Important facts:
. Free endotoxin is present in dental plaque and inflamed gingiva
. Plaque accumulation has a direct effect on the severity ofgingivitis
. Plaque bacteria produce enzyrnes (hyaluronidase, collagenase, chondroitin sulfatase, elastase and proteqses) that may initiate periodontal disease.

l. Collagenase

(v,hich is produced by Bacteroides species) catalyzes the degrad.a(hydrolysist

tion
of collagen.
2. Hyafuronidase (which is produced by Streptococcus mitans tnd salivarius) and
chondroitin sulfatase (which is pt"oduced by Diphtheroids) may lead to the destruction ofthe amorphous ground substance.

Antibodies or immunoglobulins are produced by plasma cells in response to oral

bacteria or their byproducts. The most numerous are IgG which act to neutralize
bacterial toxins by enhancing phagocytosis.
. The most likely source of bacteria fourd in diseased periodontal tissue is subging-

ival plaque.
. The likelihood that bacterial endotoxins play a major role in gingival inflarnmation is evidenced by the following:
1. A reduction in inflammation by the removal ofplaque.
2. A reduction ofthe inflammatory state with antibiotic treatment.
Important: The predominant periodontal disease is gingivitis.

T\1o forms ofnecrotizing ulcerative periodontal diseases are necrotizing ulcerative gingivitis
Qr'uc)
and necrotizing uicerative priodontitis Qr'up). These conditions rcpre;enr acute rbrms
ofperiodonr
tal destruction typically associated with some form ofhost compromise.

The essential components ofNUG are:

. Interdental gingival necrosis: oftcn described as ..punched_out papillae
'

. Pain
. Bleeding

*** \briable features include a fetid oris

/oftzs ive otlor),lymphadenopathy, fever, and malaise.
Predominant organisms associated with NUG include p intermedia, Fusobacterium species, and
splroche*l microorganisms. Note: EM studies of NUG reveal a zonc oftissue infiltration ofspiro-

cheral microorganisms in advance ofthe region oftissue necrosis. NUG is usually associated
with pre_
disposing host factors, including stress, smoking. immunosuppression (as see, t,ith HlIt infectin),
and malnutrition.

\L-P is distinguished liom NUG by the ross ofclinical attachment and bone in affeued sites. but
rbe clinical presenration and eriologic factors are similar ro that ofNUG in the absence
of systemic
disease. In the presence of systemic immunosuppression, exemplified by HIV infection,
Nilp may
resulr in .apid and extensive necrosis to the tissues and underlying alveolar bone.
The treatment ofNUG or NUP includes debridement, hydrogen peroxide (or chlothexidine) inses,

and antibiotic rherapy aPer. I/) ifthere is systemic involvement

/ln anifested byfever malaise, and lym_
phadenopathr). lmportant: Patients with Hlv-associated NUG require gentte debridement
and an,
timicrobial rinses.

\ote: For patients with acute herpetic gingivostomatitis:

. If diagnosed within 3 days of onset, acyclovir suspension
should

be prescribed, 15 mg/kg

five

times daily for 7 days

. All patients, including those presenting more than 3 days alier
disease onset, may recelve palliative care, including plaque removal, systemic NSAIDS. and topical anesthetics
' Patients should be informed that herperic gingivostomaritis is contagious at certarn stages, such
as when vesicles are present

. Actinobacillus actinomycetemcomitans and Tannerella forsythia

. Slreptococcus

and Actinomyces species

. Treponema and Capnocytophaga species

. Prevotella intermedia and Porphl,romonas gingivalis

CopltiSht O 201l-201? - Dental Decks

Early microbiologic studies of localized aggressive perio dontitis (LllP)

provided clear evidence of a strong associatlon between disease and
a unique bacterirl microbiota dominsted byr

. Tannerella forsythia
. Prevotella intermedia

LAP Aa

. Porphyromonas gingivalis
. Actinobacillus actinomycetemcomitans

fla)

27
Cop)right O 20ll-2012 - Dental Decks

*** Gram-positive
aburdant in

cocci (Streptococci) and filamentousbacteria (Actinonflces) are most

healthy sulcus.

Normal inhabitants of the oral cavity:

Gram-positive:

Streptococcus

Gram-negative:
. Veillonella

. Actinomyces

. Campylobacter

. Peptostreptococcus

. Fusobacterium

. Lactobacillus

. Eikenella

*** Viridans streptococci

. Corynebactenum

consist ofa variety ofalpha-hemolytic streptococci, including

S. salivarius, mutans, sanguis, and mitis, all common

oral flora.

Important information:
LThe oral cavity is usually sterile at birth. Microorganisms appear about l0-12
hours after birth.
2. After one year, the following bacteria are present:
. Streptococci

- S. salivarius is most abundant

- S. mutans and sanguis do not appear until teeth are present

. Staphylococci
. Neisseria
. Achnomyces

. Fusobacterium

***

By the age of4-5, the oral flora resembles that ofan adult.

Important: The new classific|tion system for periodontitis is more descriptive and not as temporal as was
th previous system. The terms adult,juvenile, early onset, and prcpubertal have been replaced with various
l'orms ofchronic and aggressive diseas.
The majority ofpalients wilh chronic periodontitis are successfully managed with coDventional treatment reg_
imcns. Horvcver, a small proportion ofpatients do not rcspond to treatment and demonstratc conlinued clini_
cal periodonial desiruction. These individuals are referred to as "refractory periodontitis patients." In chronic
periodontitis the bacteria most often cultivated at high levels include P gingivalis, T. fors)'thia, P intemedia,
C. recos. E. corrodens, F. nucleatum, A. actinotherapeutics f,4d), P micros, and Treponma and Eubacterium
species. Dctectable levels ofP gingivalis, P intermedia, T. forsyhia, C. rcctus and A.actinotherapeuiics fldl
are associated *'ith diseasc progression and their elimination by therapy is associated with improved clinical
reipons.. \ote; Recent studies have documented an association between chronic periodontitis and viral mi_
.roorganisms of the herpesvirus group, most notably Epstein-Ban virus-1 and human c)4omegalovirus. The
presence of these subgingival viruses is associated with putative bactcrial pathogens, including P gingivalis,
T.

Ibr.!thra. P Intermedia. and f. denticola.

\ primary characteristic ofaggressive periodontitis that differentiates it fiom chronic periodontitis is lbe rapid
progression ofattachment and bonc loss that is evident. Aggessive periodontitis may be localized or generalized, The classic form oflocalized aggressive periodontitis was initially referred to as "periodontosis" and
then as 'local ized j uvenile periodontilis (lJP,. Localized aggressive periodontids fZ,4P,) is the new classification designated to replace LJP"
LAP is defined by several distinguishing characteristics: onset around the time of puberty, aggressive peri_
odontal destnrction localized almost exclusively to the incisors and filst molars, and a familial pattem ofoc_
curence. Aa is the dominant bacteria in LAP, other micrcorganisms that have been associatedwith LAP include
P gingivalis, E. conodens, C. rectus, F. nucleatum, Bacillus capillus, Eubacterium bmchy, and Capnocltophaga
species and spirochetes. Important The one outstanding negative featurc is the rlative absence oflocal fac_
lors (plaque) to explailn the severe periodontal desfiuction which is present.
ceneralized aggressive periodontitis (GlP) is differentiated from the localized form by the extent of involvement around most ofthe permanent teeth, and it is considered to include rapidly progressing periodontitis. Patients with GAP frequently have subgingival gram-negative rods, including P gingivalis, and exhibit
suppressed neutrophil chemotaxis.

. Lichen planus
. Pemphigoid
. Pemphigus vulgaris
. Leukemia

. Chronic ulcerative stomatitis

2A

Coprigh

O 20ll-201? - Dental Dects

. Periodontitis does not always begin with gingivitis

. Gingivitis and periodontitis cannot be induced without bacteria
. There are no radiographic features ofgingivitis
. The presence ofpockets cannot be determined from radiographs

. Chronic gingivitis

does not always lead to periodontitis

29
Cop)'riglrr O 201 I -2012 - Dental Dcks

The following diseases also present as desquamative gingivitis: Linear IgA disease, Dermatitis herpetiform, Lupus erythematosus and Erythema multiforme.
Desquamative gingivitis lDG) is only a clinical term that describes a peculiar clinical picnrre.
This term is not a diagnosis per se, and once it is rendered, a series of laboratory procedl[es
should be used to arrive at a final diagnosis. lt is important to be aware ofthis mre clinical
entity so as to distinguish desquamative gingivitis from plaque induced gingivitis which is an
extrernely common condition, easily recognized and treated daily by the dental practitioner.

DG is characterized by fiery red, glazed, atrophic or eroded looking gingiva. There is loss of
stippling and the gingiva may desquamate easily with minimal trauma. As opposed to plaque
induced gingivitis, DG is more common in middle-aged to elderly females, is painful, affects
the buccal/labial gingiva predominantly, frequently spares the marginal gingiva but can involve the whole thickness ofthe attached gingiva and its clinical appearance is not significantly
altered by traditional oral hygiene measrres or conventional periodontal thenpy alone.
\ote: The role ofplaque is vague in desqr.ramative gingivitis.

lmportant point: The multiplicity ofcauses ofdesquamative gingival lesions with a focus on
dermatologic disease makes it imperative that clinicians develop diagnostic skills and good
communication with physicians such as intemists and dermatologists. Because microscopic
evaluation is the foundation lor diagnosis ofdesquamative gingival lesions, clinicians must
rake the responsibility to biopsy all desquamative lesions.
The majority ofcases ofDG are now known to be due to mucocutaneous conditions, in parricular lichen planus, pemphigoid and pemphigus. DG can be mistaken for plaque induced gin-

siritis and this can lead to delayed diagnosis and inappropriate treatment of

serious

dermatological diseases such as pemphigoid or pemphigus.

Remember: Histologically, where non-ulcerated areas are found, the stratified squamous epirheliunr is significantly atrophic. Rete pegs are short or absent. Inflammatory cells, mainly
plasma cells, may be found on the basal layer.

Periodontitis always begins as a gingivitis which is usually due to local initation, pdmarily plaque, and
rhe inflammation then spreads from the gingiva and soft tissues into the underlying sfuctures. GingiviIjs and periodontitis cannot be induced withortbactetia (plaque).
Periodontitis is inflammation that affects and destroys thc attachment apparatus. The clinical fcature
thar djsringuishes periodontitis fiom gingivitis is the presence ofclinically detectable attachment loss.
This often is accompanied by periodontal pocket formation and changes in the density and height of
sub,iacent alveolar bone. Important: The progress ofperiodontitis may be arrested with proper the.apy.

Remember: lhere are do radiographic featurcs ofgingivitis. In periodontitis, radiographic changes

are noted. \\hich may includc thc lollowing:
. Ioss of lamina dura

. horizontal or vertical bone resorption

. thickening lrlllerlng) ofthe periodontal ligament

space

Clinicai signs of inflammation, such as changes in color, contour, and consistcncy and bleeding on probine. ma! not always be positive indicators ofongoing attachment loss. However, the prescnce ofcontinucd blecding on probing at sequcntial visits has provcd to be a reliable indicator of thc presence of
rntlammation and the potcntial for subsequent attachment loss at the bleeding site.

L Importantr The prescncc ofpockets cannot be determined from

\ote.

the cvaluation

ofra-

diographs.

:. Cingiviris

does not always lead to periodontitis. Chronic gingivitis may exist for long penods without advrncine to oeriodontitis.
3. Severe periodontal Jisease may be seen in patients with Chediak-Higashi syndrome, Papillon-Lefevre syndrcme, Down syndrome or?c/edsed letels ofP intermedia have been.found), lazy
leukoclte syndrome, and leukocfe adhesion deficiency (LAD)
4. Chronic stress appears to have effects on the periodontium. The most notable example is the
documented rclationship between stress and acute necrotizing ulcerative gingivitis /NUG/.
5. Hypophosphatasia, congenital heart disease, tetralogy ofFallot, and Eisenmenger's syndromc
may be associated u.ith increased severity ofperiodontal disease.
6. Ingestion ofheary met^ls (i.e., hismuth, lead, and nercury) may result ill changes in the periodontium.

. Gingivitis
. Occlusal trauma

. Early periodontitis
. Acute necrotizing ulcerative gingivilis

30
CopFighr

@ 201

1,2012 - Dental Decks

\
)
. Pocket depth
. Attachment loss

. Anatomical crown length

. Bleeding upon probing

31

CopriSht O

201 I,2012 - Dmtal Decks

Radiographic Changes in Periodontal Disease:

. Early periodontitis: areas of localized erosion ofthc alveolar bone crest (hfuntihg oJ the crest in
anleriol regiotis ahd a rounding ofthe ju ctio benreen the clest a d lanina dura in the poslerior
regions).

. Moderate periodontitis:

the destruction of alveolar bone extends beyond e.rly changes in the

alveolar crest and may includc buccal or lingual plate rcsorption, generalized horizontal erosion or
localized vertical defects and possible clinical evidence of tooth mobiliry.
.Advanced periodontitis: thc bone loss is so extensive that thc rcmaining teeth show excessive mobility and drifting and are injeopardy ofbeing lost. There is usually extensive horizontrl bone loss
or ertensive bony defects.
L In gingivitis, the radiographic appearance ofthe bone will be normal.
2. The crest ofthe alveolar bone is affected in oeriodontal disease. In health. it lies l-2 mm

below the level ofthe CEJS ofadjacent teeth.

3. A reduction of only 0.5 or 1.0 mm in the thickness of the cortical plate is sufficient to permit radioeraohic visualization of destruction ofthe inner cancellous tmbeculae.
a periodontal standpoint. It is a
complex metabolic disease characterized by chronic hyperglycemia. Individuals with diabctcs havc a
highcr prevalence and severity ofperiodontal disease than do those without diabetes. Diabetes does not
cause periodontal disease but studies show that it alters the response ofthe pcriodontal tissues to bacrerial plaque- Poorly controlled diabetics often have:

Important: Diabetes mellitus is an extremely important disease fiom

. Enlarged gingiva, sessile or pedunculated gingival polyps, polypoid gingival proliferations,

abscess

formation. and loosened teeth

. Pol! morphonuclear leukocyte deliciencies resulting in impaired chemotaxis, defective phagocyrosis. or impaircd adherence
. The chronic hyperglycemia adversely affects the sj'llthesis, maturation, and maintenancc ofcollagen and extracellular mat x. Numerous proteins and matrix molecules undergo a nonenrymatic glycosylation, resulting in accumulated glycation end products (,46tt.This inc.ease in AEGS affects
how colJagcn is normally repaired or replaced and may play a roJc in the progression ofperiodontal
dlsease.

Afiachment loss is much more significant than periodontal pocketinB fuclualb it is the most signllicant fac'
aor"/ because with attachment loss supportive structurs are being destroyed.
Pocket depth is lhe distance between the base ofthe pocket and lhe gingival margin. The level ofattachment
on lhe other hand. is lhe disla.ce betwecn the base ofthe pocket and a fixed point on the crown, such as the
CE-I. Changcs in the level ofattachment can be caused only by gain or loss ofattachmeni and thus providc a
belter indicstion of the degree of periodontal destnrction.

Important: The rwo most critical parametets for thc prognosis ofa periodontally involved tooth are attach_
ment loss (most crilical/ and mobility.
I. pe.iodontics, factors often considered in the generation ofa prognosis include, but are not Iimitcd to, tooth
JFe. fufcation involvcment, bone loss, pocketdepth, toolh mobiliry occlusal forcq, patient's home care, preserce ofststemic disease, and cigarette smoking.
Tle progrosis is usually classified as excelleft (no bone loss. gingival heallh. good patient cooperalion, no
;etondan svstenic or enri ronn ental .factors), good (adequate bone suppor| good patient cooperdtion. no
errtronmental factors, and well-controlled systemic fadols). Jair (less han adequate bone supporl, mobiliry-,
g,d.1e I./itrcation inyol,-emenl, g(,.)d patient cooperation, and limited enircnmenlal and/or syslemiclactors),
poor rnoderate lo atlvance bone lo.\s, mobilit! gade I an.l Illurcation inrolremenl, queslionable patient coLtperdtio . and presence of en$rcnmenlal and/or .\)-stemic factors), qu.estioa ble (adwnced bone loss, grade
I on,l II fun:ation int'ol|ements, mobilitt', and presence o.f environmental and/or s),stemic factors), and hopeless tudwnced bone los.r, inahility to establish maintainable siluation. and the presence ofunco trolled envi,onntentol and,tor st,sten ic factors
extr^.tion(s) is/are indicated/.

\otli:
.].... 1,

I - Pockeling can incrcasc or decrease, depending on the amount ofinflammation without attachment loss. On the other hand, extensive attachment loss and gingival recession may be accompanied by shalfow pockets (poor progtlosis oJ tooth).
2. When thc gingival margin is located on the anatomic crown, the level of attachmnt is determined by subtracting from the depth ofthe pocket the distance from the gingival margin to the
CEJ. Ifboth are the same. the loss ofattachment is zero.
3.When the gingival margin coincides with the CEJ, the loss ofattachment equals the pocket

deprh.
4. When the gingival margin is located apical to the CEJ, the loss ofaftachment is grcater than thc
pocket depth, and therefore the distance between the CEJ and the gingival margin should be added
to the Docket deDlh.

. A hormonal imbalance
. Inadequate oral hygiene

. Occlusal trauma
. A vitamin deficiency
. Aging

32
Coplrighr O

201 1-201 2

- Dmial Decks

Which of the folloring needs to be evident in order to

make a diagnosis of periodontitis?

. Bleeding
. Pocket depths of5 mm or more
. Radiographic evidence ofbone loss
. A change in tissue color and tone

copyriSht O 20ll-2012 - Dental Decks

The initial microbiota ofacute gingivitis consists of glam-positive rods, gram-positive cocci. and gramnegativc cocci. The transition to gingivitis is evident by inflammatory changes and is accompanied first
by the appearance ofgram-negative rods and filaments, then by spirochetal and motile organisms.
Thc microbiota ofchronic gingivitis consists ofapproximately equal proportions ofgram-posttive (56%o)
and gram-negative (ll%o/ species, as well as facllltative (59o/o) and.anaerobic fllZoJ microorganisms Predominant gram-positive species include S. sanguis, S. mitis, S. intermedius, S. oralis, A viscosus, A
naeslundii, and P micros. The gram-negative microorganisms are predominantly F. nucleatum, P intermedia, and V panula, as well as Haemophilus, Capnocltophaga, and Campylobacter species.

Comparing the microbiota in hcalth, gingivitis, and periodontitis, thc following microbial shifts can be
seen: . From gmm positive to gram negative 'From facultative anaerobes to obligate anaerobes
. From fermenting to proteolytic spccies
. From cocci to rods
. From nonmotile to motile organism

All surfaces ofthe oral cavity (both hard and soft lis re.s, are coated with a pellicle (initial phase of
plaque development). Within nanoseconds aftcr a vigorously polishing the teeth, a thin, saliva-dcrived
later. called the acquired pellicle, covers the tooth surface. This pellicle consists ofnumerous components. including glycoproteins fmrcirsl, proline-rich proteins, phosphoproteins (e.g., .tldthetin),histidinerich proteins. enrymes (e.g., alpha-amtlase), and other molecules that can ftinction as adhcsion sites for
bacteia (receptors).
BadBrelth (oral malodor). At]east 85yo of breath malodors have an oral source. Gingivitis, periodonritis and tongue coating are the predominant causes ofbad breath. The gram-negative anacrobic bacteria associated with gingivitis and periodontitis cause bad breath by their proteolysis, which produces
foul-smclling volatile sulfide compounds fflcsl.
dental plaque developrnent is a very characteristic shift
- L The overall pattem obse ed ingram-positive
facultative microorganisms to the later
predominance
of
the
early
from
Ioa{i-gmm-negative
anaerobic
microorganisms.
predominance
of
.:_ ..,r.t1.i

't@'t::"

2. The major factor in determining the different bacteria is oxygen. The redox potential
the gingival sulcus greatly influences thc bacterial composition.

of

to be most accurate in asscssing alveolar bonc resorption lfextensive bone

loss has occurred, vertical bitewings should be taken. They will reveal more of the periodontium. Bone
loss may be horizontal or vertical. AIso remembcr that more than 3070 ofthe bone mass al the alveolar crest
must be lost for a change in bone height to be recoglized on radiographs Rcmember: The clinical feature
that distinguishcs periodontitis from gingivitis is thc presence ofclinically detectable attachment loss.

\ote: Bitewing x-rays tend

Other cfinical criteria that should be evaluated during

dnll \i:e o-/ gitlgila):

periodont^l e\^tn

(besiales

color' tone cotttour

. Level of the free gingival margin in relation to the CEJ:

the normal levcl ofepithelial aftachment

should be on enamel or at the CEJ. This would place the hee gingival margin 2 to 3 mm coronal to this
rulcuLar base. on enamel.
. Periodontal pocket dpth: all measurements in cxcess of3 mm are rccorded for sulcular deplh, as
*** The loss
\\ eli as any reading rvhich locates thc free gingival crcst 2 mm or more apical to the CEJ.
ofthe
attachment
and
the
base
distance
between
the
CEJ
by
measuring
the
is
determined
ofatlachmenl
. Bleeding: physiologically, bleeding from the gingival sulcus should not be caused by gentle provocation. Bleeding in the absence oflocal irritants may indicate a systemic disease.
. Exudate: the presence ofexudatc, spcifically suppuration /wrlc h is due to the presence oJ larye numbet's al neutrophils it1 the pocket) is evaTuared by digital pressure on the buccal and lingual ofcach tooth.
. )lucogingival complications: this term indicates the involvement ofnot only the gingival componenl
in the disease state, but also the presence of imminent involvement ofthe alveolar mucosa

Tte follo\\'ing should

also be noted:

usually found on lhe cervical area oflhe facial surlace ofa toolh dt chemicals mostly
. Abrasion: loss oftooth structure by mechanical wear horizonlal toothbrushing with a hard toothbrush and abrasive dentifrice is the most common cause.
. Attrition: occlusal wear due to functional contacts with opposing tecth. Results in wear facets on the
occlusal surfaces of teeth. dt age mainly
. Abfraction: occlusal loading resulting in tooth flexure, mechanical microfractures, and tooth structule
loss in the cervical area. occ trauma
. Hyprsensitivify of roots: duc to exposure ofdentinal tubules to thermal changes following rccession
and removal ofcementum by toothbrushinS, root decay, or scaling and root planing.

. Erosion:

. Grade 0
. Grade I
. Grade II
. Grade III

34
Cop).righr C 201 l-2012 - Dental Dcks

. Subgingival

and/or overhanging margins ofrestorations

. Carious lesions that extend subgingivally

. Calculus
. Furcations exposed by loss of attachment and bone
. Crowded and mal-aligned teeth
. Root grooves and concavities

CoplriBnt O 201 I -20 l2 - Denbl Decks

The degree ofgingival enlargement can be scored as follows:

. Grade 0: no signs ofgingival enlargement
. Grade I: enlargement confined to interdental papillae
. Grade II: enlargement involves papilla and marginal gingiva
. Grade III: enlargement covers three quarten or more ofthe crown

Using the criteria oflocation and distribution, gingival enlargement is designated as follows:
. Localized: limited to the gingiva adjacent to a single tooth or group ofteeth
. Gnralizd: involving the gingiva throughout the mouth
. Marginal: confined to the narginal gingiva
. Papillary: confined to the interdental papilla
. Diffuse: involving the urarginal and attached gingivae and papillae
. Discrete: an isolated sessile or pedunculated, tumorlike enlargement
Gingival enlargement may result from chronic or acute inflammatory changes; chronic changes
are much more common.Chronic inflammatory gingival enlargement odginates as a slight
ballooning ofthe interdental papilla and marginal gingiva. In the early stages it produces a life
presener-shaped bulge around the involved teeth. This bulge can increase in size until it covers part

ofthe crowns. The enlargement may be localized or generalized and progresses slowly

and painlessly.

\ote:

Chronic inflammatory gingival enlargement is caused by prolonged exposure to den-

tal plaque. Factors that favor plaque accumulation and retention include poor oral hygiene,
as

$ell

as irritation by anatomic abnormalities and improper restorative and orthodontic ap-

pliances.

lmportant: A pseudopocket is a pocket formed by gingival enlargement without apical migration of the junctional epithelium. It does not involve the loss ofbone. Pseudopockets are
also referred to as gingival, false, or relative pockets. All pseudopockets are suprabony (ie
base of the pocket is coronal to tlrc crcst o;f the alveolar bone).

Djsringuishing between the effccts of calculus and plaque on thc gingiva is difficult because calculus is always covcred with a nonmineralized layer ofplaque. The nonmineralized plaque on the
calculus surface is the principal irritant, but the underlying calcified portion may bc a significant
contributing factor. It does not initate the gingiva directly but provides a fixed nidus for the conrinu.d accumulation ofplaquc and retains it close to the gingiva.
Plaque iniriates gingjval inflammation. which starts pocket formation, and the pocket in tum providcs
a :helrered area for plaque and bacterial accumulation. The increased

flow ofgingival fluid associated

irh gingival inflammation provides the mincrals that convert the continually accumulating plaquc into
subging!\al calculus.
Calculus /xric, i.s rrineralized bucterial plaqreJ plays an important role in maintaining and accentuating periodonlal discase by keeping plaque in close contact with the gingival tissue and creating areas
\\here plaque removal is impossible.
O!her contnburing or complicating factors in periodontal disease includc:

Food impaction or retention: overlapping, malposcd, tiltcd or drilled teeth arc frequently assocIfnot removed. this will lead to inflammatory periodontal dis-

iared $ ith lood impaction or rctcntion.

ease.

. Open and loose contacts: leads to food impaction and possible retcntion.
. Overhanging margins of restorations and improperly designed prostheses: can contribute to
the initiation ofperiodontal disease. There is a direct correlation between surface roughness or mariginal inegularitics ofa restoration and the retention ofplaque.
. Soft or sticky consistency of dieti food debris tends to collect between the tecth and along the
gingiva and can be a prominent causc ofinflammation.
. \'iolation of the "biologic width": if margins of a restoration infringe upon thc biologic width
(ju ctional epilhelium and con ectite ti.tsue attachmenl), gingival inflammation, pockct formation,
and alveolar bone loss may occur. Note: The average biologic width is approximately 2 mm fapprormatcly 0.97 no for thejunclional epitheliuln and L03 mmlbr the connective tissue atlachment).

. Occlusal traumatism
. Orthodontic therapy:
numbers

ofP

has been shown to increase plaque retention and to result in increases in thc
melaninogenica, P intermedia, and A. odontolyticus.

During pregnancy there is an increase in levels of both

progesterone and strogen.
The so-called pregn|ncy tumor is not a neoplasm.

. The first statement

is hue; the second statement is false

. The second statement

is true; the first statement is false

. Both

statements are true

. Both

statements are false

Copyrighl O 20ll'2012 - Denbl Decks

.I
.II
.

III

37
CoplriShi C 20ll-?012 - Dental Dects

Pregnancy gingival enlargement may be marginal and generalized or may occur as single or multiple tumorlike masses. During pregnancy there is an increase in levels of both progesterone and estrogen. Tlese hor-

monal changes induce changes in vascular permeability, leading to gingival edema and an incrcascd
inflammatory response to dental plaque. Note: The subgingival microbiota may also under changes, including an increase in Prevotella iniermedia. These bacteria cmve steroid homlones for their o\r.n metabolism.
The enlargement is usually generalized and tends to be more prominent interproximally lhan on the facial and
lingual surf'aces. The enlarged gingivia is bright red or magenta, soft, and tiiable and has a smooth, shiny surface. Bleeding occurs spontaneously oron slight provocation. Note: Usually appears in second or third month.

Thc so-called pregnancy tumor is not a neoplasm; it is an inflammatory response to bacterial plaque and is
modified by the pateint's condition. h usually appears after the third month ofpre!$ancy but may occur carlier. The lesion appears as a discrete, mushroomlike, flattened spherical mass that protrudes from the gingival
margin or more often from the interproximal space and is attached by a sessile or pedunculated base.

Important: Most gingival disease during pregnancy can be prevented by the removal ofplaque and calculus,

as

well

as the

institution offastidious oral hygiene at the outset.

Cingival diseases modified by systemic factors: endocrine changes during pregnancy, puberty, and diabetes.
Blood dyscrasias fi.e., leukemia) may itltp ct lhe immun response as wellGingival diseases modified by medications: anticonvulsants, antih''peftensive calcium channel blockers, and
immunosuppressant drugs are known to cause gingival enlargement.

\on-Plaque-lnduced Gingival Lesions:

. Gingi!al diseases ofspecific bacterial origin: Neisseria gonorrhoeae, treponema pallidum, streptococcus
species.

. Gingi\al

discases of viral origin: Herpesvirus infections (Prinary, herpetic gingivostomalilis, Recurreht

oral herpes, I/aricella toster)
' cingival diseases offungal origin: Candidiasis (caused bv Candida albicons)
. Gingi\al discases ofgenetic origin: Hereditary gingival fibromatosis
' Gmgival manifestations ofsystemic conditions: may appcar as desquamative lesions, ulcerations ofthe
gingi\ a or both
. Traumatic lesions: may be factitious f']rr'rrtentionally produced) as in the case oftoothbrush trauma, ianagenic linduced by the dertlrtl as in the case ofrestorative car that may lead to traumatic injury ofthe
gingiva, or accidental, as in lhe casc ofdamage to the gingiva through minorbums fiom hot foods or drinks.

\eutrophils, or polymorphonuclcar lcukocles fPMNr), prcdominatc in the carly stagcs ofgingival inflammation,
kill plaque bactcria. Bacterial killingbyPMNS involvcs both intraccllular mcchanisms
tlttier phago.llosis ofbacteriu within nenbrune-bound stntdurcs i side rre.//) and cxtracc]lular mechanisms /]-r

and rhcse cclls phagoc)'tose and

.eled\e o/ PMN eitzlnes and oxvgen radicals outside the cell). Tl,csc cnzymcs include the MMPs fd ahx metanoras collagcnascs (MMP-8 and MMP-.,, which b.cak down collagcn fibcrs in the gingival and pcrirdonralrissues Note: oxygcnradicals buperotide and btlroge peroide) ptodnccdby PMNS and macrophagcs arc
ro\rc as q cll ro ccll s of thc periodontium having a dircct cffcct on ccll functions and DN A.

,lrorncdl/, such

Erfthema
Bleeding on
probing
Same as stage Il,
plus blood shsis

R+rdiu.ed

u nh

nemission, from Ncwman MC, Tak.i HH,

lok*elold PR, CaranaFA . Cafta":d

\ Clntal P.riodoatob$, I tl'

..1. Else-

Stage I v Gingivitis
Thc advanced lesion : cxtcnsion of thc lesion into ,lveolar bone charactcrizcs a fourth stagc
- lcsion or phase ofperiodontal brerkdown. Microscopically, lhcrc is fibrosis ofthc gingiva
knoNn as thc advanccd
and $idcsprcad manifcstations ofinflammatory and immunopathologic tissuc damagc. In gcncral at this advanccd
stagc. plasma cells continuc to dominatc thc conncctivc tissues, and ncutrophils continuc to dominatc thcjunctional
cpithclium and gingival crcvice.

i\-otcr Abno.malities in ncutrophil funclion found in paiicnts with neutropcnia, agranuloq4osis, Chcdiak-Higashi
syndromc, Papillon-Lefevre syndrome, leukocyte adhcsion deiicicncy t)?c 1 (LAD-1), andletkoctae adhesion deficicncy rypc 2 (l,AD-2) make the patient more susceptible to aggressive periodontitis.
Remember: Thc four stagcs ofthe periodontal lesion are: initiali arly! stablished and advanced.

. Coronary Heaxt Disease

. Atherosclerosis

Stroke

. Cirrhosis ofthe liver

. Diabetes mellitus
. Low-birth-weight delivery
38
Copright O 20ll-2012 - De alDeks

. On whether or not the patient feels that frequent visits will help maintain his/her
periodontiun
. On the appearance and clinical condition ofthe gingival tissues

. On the amount of attachment

. On the ability

loss prior to the periodontal treatment

and performance in home care

Copyrigh O2011,2012, Dental Dcks

Although the potential impact ofmany systemic disorders on the periodontium is well documented, reccnt evidcncc suggcsts that periodontal infection may significantly enhance the risk for certain diseases
or alter fhe natural course ofsystemic conditions (see chart belov).
Org'n

Systems snd Conditions Possibly Influenced

bv Periodon.al lnfeciion
Cardiovrscrlrr

Crcbrovlscuh. SystcD

Coronary hean diseasc (CHD)

Angrna
Myocardial infarcrion (Mt)
Ccrcb'ov&ular accident (siroke)

Endo.rlnSystem

Repmduced \nh pemision.

from Newnra. MC. T.kei HH.
Kloklerold PR. CamnTa F,\.
Clrtun:d s Cliht.al Perialo,/o/o!pr //" P/ Elscvicr. 2(J06

Reprodrctive System
Preiern low-birth-weishl (LBw) infatts

R$pirltory Systcm
Chronic obshrlive pulmonary disas (COPD)
Acutc bactcrial pncumonia

\oaes

1. The relationship between diabetes mellitus and periodontal disease has bccn cxtcnsivcly
examined. lt is clear that diabetes increases the risk for and severity of periodontal diseases. Thc incrcased prevalence and scvcrity ofpcriodontitis typically scen in patients with diabelcs, especially those with poor metabolic conhol, led to ihc dcsignation of periodontal
discasc as the "sixth complication of diabets." The others are retinopathy, nephropathy,
neuropathy, macrovascular disease, and ahered wound healing.
jt
2. Whcn considering f'actom that increase an individual's risk for developing periodontitis
(e.g.,
acquired
risks
factors
tohocco use), and
has bccn rccognized that genetic, environmertal
le.g., ststetric disease) can increasc a patient's suscptibilitl to dcvcloping this disease Risk
factors can affect onset, ratc ofprogression, and severi!v ofperiodontal disease, as well as .esDonse to theraDv.

and patient is the maintenance ofgood

Thc main goal of the
\\ ill prevent the recurrence of disease, which is the rnain objective of the maintenance phasc of peritrdonral therapy. The primary cause ofrecurrence ofdisease is the dental team's failurc to motivatc thc
parient Io practice effectivc plaque control.

Th. first !ear after treatmnt is a critical period, since the patient has alrcady demonst.ated susceptl-

b.ilil

ro pc.rodontal disease, the cause ofwhich tends to be persistent and recurrent. The appearance and
condition ofrhe gingival tissues rvill detemine ifthe patient is maintaining adequate plaquc control.

L Bleeding during circumferential probing indicates that the crcvicular epithelium is ulcer-

\or,s ated due to active periodontal disease'

l- Aiier periodontal treatment the first recall visit should bc scheduled at three months. with
'
c\cellent plaque control and maintenance ofperiodontal health. thc inter'"al may be lengthencdto4-6months.
Remmberi

l. Pubertr- is oftcn accompanied by an cxaggerated response ofthe gingiva to plaque. Gonadotropic

homones dudng pubcrty may lead to increased levels ofP intemedia and Capnoc)'lophaga species
in rhe denral plaque.
a general rulc, the nenstrual cycle is not accompanied by motable gingival changes, however,
increased gingival bleeding is often seen during this timc.
l. Hormonal contraceptives aggmvate the gingival rcsponse to local factors similar to that sccn in
pregnancy.
4. Oral disfurbances are not a common featurc ofmenopause. Some females may develop gingivos_
IOmatltls.
[a, e lrcpenia, agrrlnuloc]losis, lfuonboc\'
5. Patients with blood dyscrasias fi.e., leukemia, a
topenic put'purd, 1c./ often demonstratc disturbances to the gingiva and periodontium.

:. As

If

one of the steps in the fabrication

ofyour implant restoration is

rttaching an analogue to the impression post and then seating them
both lnto the set impression material, you have made a/an:

. Open-tray impression
. Closed-tray impression

. Either ofthe above

. Neither ofthe above

40
CopFighr O 2011,2012, Dental Decks

An "impl|nt level imprssion' merns that;

. The impression

oping (or impression post) was attached to the implant

. The impression coping was attached to the abutment at time of impression

. The impression captured or recorded the actual abutment attached to the implant
. None ofthe above

41

Copldghr O

201

l'2012 - Dental Deck!

A closed tray impression refers to the impression being made in a tray with no access hole
cut over the implant, and with an impression coping in place in the mouth attached directly
to the implant or abutment. When the impression tray and impression material is removed
lrom the mouth after setting, the impression coping remains in the mouth, still attached
to the implant or abutment. The copin g (also called the impression post) is removed from
the mouth, joined to an implant analogue (also called qn implant replica), and the analogue and impression coping are inserted back into the set impression material before the
cast is poured. This is also called an indirect transfer impression technique.
When making a pick-up impression, the impression coping is already attached to the
abutment by a retaining screw when the impression tray and impression material is placed
into the mouth. After the impression material has set, the retaining screw is released /azscrewed) through a hole in the tray and the impression coping is freed from the implant.
When the tray is removed from the mouth, the impression coping remains in the impression material. This technique is also called an open top tray pick-up impression.

Note: A pick-up impression may be used with divergent implants.

The master impression should accurately relate the implants and/or abutments to each
othe( the opposing occlusion and adjacent teeth. For the impression to be accurate, all of
the components must be properly seated at the time ofthe impression. Verification ofthe
proper seating ("down") of the abutrnents is difficult if the junction or the impression
coping-to-implant interface is subgingival. Radiographic verification of seating is reouired before the imoression is made.

The impression coping (or impression post) was atrached to the implant at the time ofthe
impression, thus recording the implant position at the "implant level". Ifthe impression
coping was instead attached to the abutment (which was attached to the implant) the impression is termed an "abutment level impression."

Ifthe impression is made ofthe already seated abutment without the use ofan impression
coping. just as a standard crown and bridge impression ofa prepared abutment, it is a direcr impression of the abutment.
is manufactured as an "external hex" design, this means that the antirotational component is part ofthe implant and seats into the abutment.

lfan implant

If the antirotational feature is a part of the abutment and seats into the implant body
\\'hen the abutment is seated, the implant is an "internal hex" design. Aprosthesis which
is anached to only one implant abutment (e.g., a single crowy' requires an antirotational
component between the abutment and the implant, and between the restoration and the
abutment, to prevent prosthetic component loosening secondary to the forces ofocclusion.

disadv

. The crown is retrievable

. The residual cement excess in the sulcus is avoided

. The occlusal surface ofthe crown is left intact
. A shorter abutment may be used

12
Coprighr O

201 1-201 2

- Denial Dects

an implant restoration is to:

. Check on healing progress

. Remove the implant for cleaning
. Uncover the implant and place an abutment

. Determine which components will frt

. All ofthe above

43
Coplriglr O 20ll-2012

- Denral Decks

Access to the retaining screw that holds the restoration onto the abutment requires an access hole through the crown. This access hole must be restored after the final torque is applied to the retaining screw. This restoration is subject to failure and may need replacement
periodically. In addition, this restoration is sometimes in the area ofthe crown that is in
occlusion. The hole and restoration in the occlusal surface can be undesirable because of
the esthetic compromise that results.

An abutment retaining screw should be tightened to a specified torque to minimize the

possibility of future loosening ofthe screw or the components. A torque wrcnch (or torque
controller) measures and controls the amount offorce or torque applied to the screw This
torque force applied to a screw is called preload. Implant manufacturers provide recommended torque values that are optimal for their particular components, materials and design.

Remember: In implant dentistry, ar 6'open tray" impression is used because the abutment
retention screw must be unscrewed after set.
The abutment retaining screw must be unscrewed after the impression material sets, but
before the tray is removed from the mouth, thus releasing the abutment from the implant.
Before the impression procedure, a hole is cut in the tray, usually directly occlusal to the
abutment retention screw, to allow access ofa hex driver or screwdriver to the head ofthe
scren'. This feature makes the tray an'6open tray" rather than a "closed tray" (no hole).
After the abutment retention screw is released, the tray is removed from the mouth with
the abutment still encased in the set impression material. This is also called a "pick up"
rmpresslon.

ln two stage implart syslems (also refefted to as two piece or submerged,rystans) the first
stage surgery is placement ofthe implant in the bone. Then a period of time is allowed for
healing, meaning osseointegration and healing ofthe gingiva over the top ofthe implant.
After this healing, the second stage surgery is performed to uncover the implant, make
sure there is access to it, and place an abutment e.g. a healing abutment. Another period
of healing is allowed for healing and maturation ofthe gingiva.
ln one stage systems (also called one piece or non-submerged r.l,s/ems), the implant is left
panly or completely exposed at the time ofsurgical placement and the second stage surgery is avoided.

. Flaring or enlarging the coronal end ofthe osteotomy

. Reversing the engine to remove the implant
. Placing the implant in

a counterclockwise rotation

. Torquing the abufinent to place

4
Cop''righr O20ll-2012 - Dental Dcks

Screw or cylinder shape

Surface texture

. Alloy composition

. Surface coatings
. None of the above

45
Copright O 20ll-2012 - Dental Deck

As one ofthe final steps in creation ofthe osteotomy to receive the implant body, a special bur is activated and inserted into the occlusal end of the osteotomy in order to increase the diameter ofthe opening slightly or to otherwise shape it. This step is referred
to as "countersinking." Countersinking the implant osteotomy is called for by some manufacturers to compensate for very dense cortical bone or to prepare the bone for a particular implant shape (e.g., a flared implant shape at the coronal end).
Another ofthe final steps in the creation ofthe osteotomy is to place a threaded bur into

ofthe osteotomy. This groove is

placed so as to receive and guide the threads on the side of the implant during surgical
placement and thus minimize the torque required and to minimize heat. This process of
creating the groove on the inside ofthe osteotomy wall is referred to as "tapping" the osteotomy.
the osteotomy so as to create a spiral groove on the wall

the osteotomy are used at relatively slow speeds (xp.m.) lo

prevent injury to the bone, especially overheating ofthe bone. Also, water or saline irrigation is used to cool the burs and the bone during drilling.

All ofthe burs used to create

Dental implants are manufactured in several categories ofdesign and shape such as blades
and root form implants. Root form implants are produced as a straight cylinder or as a
basic screw design having threads. This basic overall design is the macrostructure ofthe
implant. A cylinder shaped implant is pressed into a tight fitting osteotomy (pressJit). A.
screrv shaped implant is screwed into the bone and this provides added stability. Screw
shaped implants can be tapered. Implant macrostructure is also referred to as "implant

geometry'."
The microstructure of the implant is descriptive of the surface quality or surface alteration. Implant surfaces can be described as "machined" which is a relatively "smooth"
surface as produced by the original milling process. It is not as smooth as a "polished" surface such as the polished collar prepared lor gingival soft tissue attachment. Implant surface alterations are secondarily incorporated to produce surface roughness which has
been shon'n to be more advantageous thar smooth surfaces for promoting osseointegrarion. Sandblasting, acid etching, and titanium plasma spray processes are examples ofthe
roughening techniques. Chemical additives can be applied to enhance bone apposition
k. g., htdroxyapatite surface coatings).

. Established by keratinized mucosa

bone

. Established by non-keratinized mucosa

. Dependent on hemi-desmosomes

. Comparable with the interface on teeth

. All ofthe above

46
Coplri8hr e 201 I,20

12

, Dmral Deckr

The advantage ofusing a screw-shaped implant instead

ofa straight cylinder implant wlthout threods is:

. Easier osteotomy preparation

. lncreased initial stability
. Less force required to insert the implant
. No antirotational components are necessary

17
Coplaighr O

201

l-2012 - Dental Dcks

The irnplant or the abutment must pass through the gingiva to be utilized in the mouth.
The epithelial attachment to titanium cal be formed by keratinized gingiva or by nonkeratinized mucosa and is comparable to the analogous attachment of long junctional
epithelium to the tooth. The epithelial attachment is composed of hemidesmosomes and
a basal lamina. In addition, a sulcular epithelium forms. Between the junctional epithelium and the bone, a zone ofconnective tissue is present.

Implants have a "biologic width" of 3 to 4 mm. Connective tissue fibers are present as
circular fibers oriented parallel to the implart or abutment surface, but no connective tissue fibers insert into

titanium.

Note: Epithelium forms apically to approximately

I to 1.5 mm from the crestal

bone

around the imDlant.

A screw shaped implant engages the walls ofthe osteotomy and is therefore more likely
to be stable. The osteotomy preparation might be more difficult to accomplish if tapping
the site is required. ("Tapping" in this conte means producing thread grooves inside the
osteotomy that are meant to receive the threads of the inplant.) The clinician's control
over the vertical positioning of the implant is increased when using a threaded "screw"
implant as opposed to a "press lit" implant that relies more on precise preparation and sizing ofthe osteotomy for frictional holding ofthe implant.

Jote: Antirotational elements are incorporated to prevent rotation ofthe attached abutment or the restoration, not the implant itself.

. CEJ
. Apical end ofthe implant

. Ball tip ofthe probe

. Implant shoulder or other permanent physical structure

. Radiograph

48
Cop,,righr C 201 l'2012 - Dental Decks

.
...\
lmplants
-)

Ifthe implant to abutment interface consists ofa permanent

extension on the top ofan lmplant and a receptacle inside the
abuiment, the impl|nt connection is categorized as:

. An intemal connection

. An extemal connection
. A cone in a socket connection
. A non-engaging connection
. A rotational element

,19

Coptrighr C

201

l-2012 - Dental Decks

When detemining the attachment level on teeth, the CEJ is used as the landrnark to determine attachment level. Because an irrplant and its restoration have no CEJ, another
permanent and accessible structure must be selected to be the landmark. This is often the
shoulder of the implant or the restoration margin, The correct terminology for this
meas[rement becomes "relative attachment level," relative to the selected landmark,
instead of "clinical attachment level" on a tooth. Probing depths around implants are
determined with a standard shaped periodontal probes, with plastic probes generally recommended instead of metal orobes.

The junction ofthe abutment and the implant is important from an engineering standpoint
and a biological standpoint. The restorative platform ofthe implant forms an interface, or
a joint with the abutment. This area is also referred to as the microgap. The precision of

fit between these components influences how much movement will occur between
these pans and how well the associated screws will remain tightened over time. Precision
fit. internal or external connection, and antirotational elements are part of this juncrhe

iion and all require close manufacturing tolerances.

The closeness of the fit ofthe components plays a significant role in how much bacterial contamination occurs at the interiace. The term microgap emphasizes the space bet\\.een the components and the space available for bacterial growth and the resultant
inflammation at the location. Achieving a precise fit ofthese parts is unlikely if the abutment is cast in the laboratory rather than milled by the manufacturer. Minimizing bacterial contamination at this site influences how stable the bone will remain over time.

The healing reaction of the bone surrounding the microgap is determined by the
macrostructure of the implant, the precision of the fit, and the location of the microgap.
Bone remodels and adapts to different configurations and locations ofthe interlace during the first year after placement of a restoration, and a characteristic bony shape is established by that time. Following that time of initial bone remodeling, a very small
amount of bone loss should then be noticeable over time, in the order of0.2 mm per year.

Which of the following occlusal conditions would exert the

lowest amount dfbiting force under normal conditions?

. Complete dentures resting on soft tissue

. Complete dentures supported by implants
. Fully dentate occlusion
. Maxillary complete denture opposing natural teeth

50
Cop),right O 201l-2012 - Dental Decks

. Occlusal overload
. Bacterial plaque
. Micromotion during healing
. Excessive cantilevering ofthe prosthesis
. All ofthe above

5t
Cop)'rightO 20l l-2012 -

De

al Decks

Patients having complete denhrres supported by soft tissue only tend to apply about one
sixth ofthe occlusal force compared to the fully dentate occlusion or a complete denture
opposing natural dentition. Occlusal forces produced by full arch dentures supported by
implants produce about the same force as fully dentate occlusal schemes.

The two most common causes of peri-implantitis are considered to be plaque and occlusal overload. Excessive cantilevering of an implant-bome prosthesis will result in
excessive occlusal force on the implant as well as off-axis loading. Occlusal forces that
are within the long axis ofthe implant are best tolerated by implants. Lateral forces are
less-wll tolerated and can be harmful ifexcessive. Lateral forces on implants magnif
the amount of stress on the crestal bone surrounding the implant. Off-axis loading ofthe
implant is a term used to describe this situation.
Inplants $'hich have beenjudged to be a failure because ofinfection, bone loss and/or mobility must be removed. Ifan implant is mobile, it can probably be extracted fairly easily. Ifan implant needs to be removed but is not mobile, it is still osseointegrated to some
degree. Extraction may be possible, with effort, or the implant must be removed with a
special drill called a trephine drill. A trephine drill is a cylindrical, hollow, open ended
bur desigrred to fit over the implant and cut down the sides ofthe implant to release the
implant from the bone. This may cause a significant amount ofbone damage or bone loss
and a bone graft is sometimes placed following removal ofthe implant.

Ifan implant isjudged to be unusable from a prosthetic st^ndpoint (e.9., poor angulation
or location) but is not otherwise failing, it may be covered with soft tissue and allowed
to remain unused in the bone for an extended period of time. This is referred to as a "sleep-

ing" implant.

. Primary stability of the implant

. Limited micromotion during healing

. Minimization of surgical trauma

. Uncontaminated implant surfaces

.All ofthe

above

52
Cop).righr O 201 l'2012 - Dental Decks

"Site development" for implants includes all ofthe following

techniques l9XCl9PI one. Which one the EXCEPTIOM

. Guided

tissue regeneration

Socket grafting

. Bone grafting with cow bone

. Bisphosphonate supplementation for bone density

. Onhodontic tooth movement

Coplright O 20ll-2012 - Dental Decks

At the completion of surgical placement ofan implant, the implant must not be movable
in the osteotomy. This condition is termed "primary stability of the implant." If the implant is not protected from excessive forces during healing (e.g., occlusion) the implant
experiences movement relative to the surrounding bone. Ifthis "relative motion" or "mi-

cromotion" persists, osseointegration will be prevented.

Surgical trauma can prevent the formation of osseointegration by damage to bone cells,
often because ofexcessive heat generated during drilling procedures. Sharp burs, intermittent drilling pressures, ard irrigation for cooling of the burs and site prevent or limit
this injury to the bone. The limit ofheat is 4? C for less than one minute.
The implant is sterilized by the manufacturer and protected with packaging to preserve the
oxide layer @O) which is apassivization layer and critical for osseointegmtion. These

conditions must be maintained before the implant is placed into the osteotomy.

Bisphosphonates (e.g., alendronate) are used to treat osteoporosis and cancer Bisphosphonate therapy, especially a history of I.V. bisphosphonate therapy is one of the few
absolute contraindications for implant placement. BONJ, or bone osteonecrosis ofthe
.jau. is a serious complication and is difficult to manage successfully. It can occur folIorr ing dental surgery such as extractions and dental implant placement.
Guided tissue regeneration techniques have been adapted for bone augnentation in edentulous areas and the techrique has become klown as guided bone rgeneration. Several
bone graft materials, and combinations ofthese materials, are used in this procedure and
are often covered with a protective "membrane." Bovine (cow) bone processed as a particulate graft material is commonly used for oral bone grafting applications including
ridge augmentation and maxillary sinus augmentation or sinus "lifts." The bovine bone is
classified as a xenograft, or bone which is transplanted to the recipient from a member
ofanother species. It can be combined with an autograft fo r autogenous bone) from lhe
recipient patient, or combined with bone from another human being (an allograft), or
combined with a fabricated bone graft substitute material such as tricalcium phosphate or

hydroxyapatite, which are forms of alloplasts.

Other site development techniques include orthodontic tooth movement to create space for
implants. The tooth movement could include orthodontic extrusion ofteeth to bring bone
volume occlusally with the tooth and thus increase bone volume at the site ofthe planned
imDlant Dlacement.

. Prevent rotation of multiunit restorations

. Prevent rotation ofthe implant
. Prevent rotation ofthe abutment in the implant

. Prevent over-torquing ofthe abutment screw

. All ofthe above

5'
Coprighr O 20ll-2012 - Denral Decks

. At the end ofthe surgical procedure

. Following the final torque application to an abutment

. Anytime the fit or seating ofa component must be verified

. Intraoperatively to verify implant position

. Al1 ofthe above

Coplright C 201 I -2012 - Dmtal Decls

The antirotational element is designed to prevent rotation ofthe abutment, and tlus
prevent loosening ofthe abutment screw which holds the abutment to the implant.

Antirotational elements between the implant and the abutrnent are described as "external"
or "internal." The extemal type consists ofa permanent extension ftom, as part of, the
implant which fits into a receptacle in the abutment. An "intemal" antirotational element
has the extension as a part ofthe abufinent which fits into a receptacle in the implant.
Antirotational elements are also added to abutments to prevent the rotation ofattached single unit restorations such as a single crown. Multiunit restorations do not require antirotational features to prevent them from rotation on the abutment since they are connected
to two or more imDlants or abutments.

Radiographic verification that the desired anatomic placement ofthe implant or implants
has been achieved is desirable at the completion ofthe surgery to make sure the implant
and any vital structures nearby are separated as planned. Also, positioning of the implant/s/ from a prosthetic standpoint can be assessed and corrections made at this time
necessary. In addition, the surgeon should have documentation ofthe successful implant

if

placement before the patient is dismissed. The surgical placement radiograph is an imponant baselin record that will be used for comparison at multiple time points during
rhe life

ofthe implant.

During the surgical procedure in which the implantfs) are placed, radiographs can be taken
of depth gauges, the drills, the implant itself or other markers in order to judge whether
the proper depth or anatomic location has been achieved before further drilling or implant
ad\ ancement is accomplished.

Alier the final torque is applied to a long-term healing abutment, an impression coping
/posr, or the final restoration, verification ofthe proper mating ofthe components is necessary. Impressions for fabrication of prostheses and the subsequent laboratory procedures that rely on the impressions cannot be accomplished accurately if any of the
components are not joined together completely, also referred to as being "down." Inaccuracy during the fabrication ofa restoration will prevent the prosthesis from fitting passively to all ofthe implants involved. This non-passive fit can lead to implant failure.

. Osteotomy
. Bone channel

. Smokestack
. Callus core

. Chimney

56
Cop)'righr O 201l'2012

'

Dental Decks

PERIODONTICS

Which of the following was/were included in the 1986 Albrektssou et al

criteria for functional implant success?

. Implant is immobile and has no peri-implant radiolucency

. Bone loss is less than 0.2 mm./year after the first year of service
. Absence ofpersistent and/or irreversible pain, infection, paresthesia or violation ofthe
mandibular canal

Success rates

All of the above

ofat least 85olo at year 5 and 80%

at year 10

Copyrigbr O 20ll'2012 - Dental Decks

The osteotomy is prepared with precision in order to make it the prescribed size that is appropriate for the implant being used. If the osteotomy is too small, either in width or
length, the implant may not go to depth or seat completely to the desired level in the bone.
The overall implant shape (macrostructure) and the bone "quality" at any site dictate how
the osteotomy must be prepared. Ifthe bone is very dense and a screw-shaped implant is
being used, the osteotomy may be "tapped" meaning that screw threads are created on
the walls of the osteotomy to receive the screw threads on the implant. A drill designed
as a "thread tap" is used for this purpose. Many implants are designed to be "self+apping,"
meaning that tapping ofthe bone as a separate step is not necessary because the threads
ofthe implant are designed to engage the bone and guide the implant forward.

Ifthe osteotomy is too large for the implant diameter, or ifthe osteotomy is over-prepared
or poorly-prepared, the implant will lack primary stability, an unacceptable result which
rvill cause osseointesration 10 fail.

This st ofcriteria is often quoted to help define or determine whether or not an implant
is successful.

Implant rnotrility indicates loss of osseointegration and irnplant failure. Implants with
only partial loss of osseointegraiion will still be stable. A peri-implant radiolucency indicates that bone is not in contact with the implant and it suggests loss of osseointegration. A peri-implant radiolucency often has the appearance of a distinctly widened
periodontal ligament on a natural tooth. Persistent pain, infection, or paresthesia are
not normal implant outcomes and indicate definite complications of implant placement.
-{ radiographic appearance of violation of the mandibular canal by an implant could be
misleading and would not, by itself, define failure. Radiographic confirmation ofthe implant malposition, particularly in combination with persistent pain, infection or paresthesia u'ould mean failure. Success rates are generally higher than 80-85% today, with 95%
and higher being expected.

. Pain

. Mobility

. Loss of osseointegration

58
Copyright @ ?01 1,2012 - Denral Decks

. A cold weld
. Ankylosis

. Osseointegration
. Metal callous formation

59
Copyright O 201 I -20

12 -

Dental Decks

Implants have become very predictable and successful from a functional standpoint and
failure of implants due to loss of osseointegration is not common. Satisfying patient expectations of esthetic outcomes is a most difficult aspect of implant treatment since
restoration ofbone, gingival contours and papillae is sometimes not possible. Absence of
a papilla between adjacent implants is a common problem and for this reason it may be
advantageous to avoid placing adjacent implants, ifpossible.
Note: "Black triangle disease" refers to an absence ofone or more papillae following implant therapy and restoration.

Osseointegration means direct bone-to-implant contact with no intervening periodontal

Iigament or any other tissue. There is no insertion ofconnective tissue fibers into titanium
meaning there cannot be a fi.rnctional periodontal ligament. Connective tissue presence
around an implant means failure ofosseointegration and implant failure. Epithelium does
attach to titanium via a'junctional epithelium" structure comprised of hemidesmosomes
and a basal lamina. Titanium is usually covered by an oxrde (TiO) which is biologically
inert and prevents host tissue access directly to titanium itself, and allows osseointegra-

tion.

-\t the light microscopy level, there is an intimate association of bone to the titarium.
\\'ithin a few weeks ofplacement ofthe implant, woven bone is laid down at the bone implant interface, Woven bone is characterized by a very random orientation ofits collagen
fibrils and it is the first bone to be established on the implant. Within a few more weeks,
rhe \I'oven bone becomes lamellar bone. The conversion to lamellar bone is thought to be

encouraged by the presence of functional forces placed on the implant to stimulate the
bone.

)r{ote: Roughened implant surfaces, for example those created by sandblasting and acid
etching etc. encourage ald accelerate the bone formation at the titanium surface.

. Relatively

soon after surgical implant placement

. Relatively late, following placement ofthe prosthetic restoration

. Either of the above
. None ofthe above

60

cop)rigll

O 20ll-2012 - Dental Decks

'..1'-.,r...

Implant

PERIODONTICS

. True
. False

61

Cop,-i8h C2011,2012

- Denlal Decks

lmplant failures are generally considered to be "early," meaning soon after surgical placement and before prosthetic loading, or "late," meaning after an extended period of time
following placement ofthe prosthetic restoration on the implant. Early failurs are related
to surgical trauma ard/or implant instability at the time ofplacement. Late failures are
most often related to microbial plaque accumulation equivalent to periodontal disease
and/or to excessive occlusal forces

"Peri-implant mucositis" denotes inflammation ofthe soft tissues surrounding the implant but with no loss of bone. "Peri-implantitis" refers to this inflammation but with
accompanying loss of implantsupporting bone. Both conditions require treatment.

Implants are essentially ankylosed structures and do not erupt or move physiologically
rrithin bone. If the growth ofthe individual has not been completed, the original positioning ofthe implant in the jaws may become increasingly unfavorable due to changed
shape or size of the surrounding tissues. Early successlul esthetic outcomes can be lost.
The implant may also prevent normal development ofthe jaws.

. Type I bone
. Type 2 bone
. Tlpe 3 bone
. Type 4 bone

62
Coplrighr A 201l-2012 - Denbl Decks

.35%

.50-60%
.74%
.

90

95o/o

.100%

Copfight ,

20 |

63
l'2012 - Dental Decks

Bone quality is categorized according to its cortical plate thickness and cancellous/trabecular density. The thicker the cortical plate and the higher the cancellous density, the
higher the quality ofthe bone in terms of implant stability and support. Type I bone is the
best quality and most suitable for retention of implants.
Type I bone occurs in the anterior mandible, for example, where the bone is mostly cortical bone. Type 2 bone is a thick layer of cortical bone and the cancellous bone core is
most dense. Type 3 bone is composed ofa thin layer ofcortical bone surrounding a dense
core of cancellous bone. Type 4 bone is characteristic ofthe posterior maxilla and has a
typically thin cortical plate and low density cancellous bone core, and thus is the least
well suited to promoting osseointegration and supporting occlusal loads.
The risk of implant failure is higher than normal in:
. Cigarette smokers
. Poorer "quality" bone
. The ma,rilla than in the mandible
. Uncontrolled diabetics

Risk factors for implant failure or complications include metabolic diseases which can influence systemic healing. Uncontrolled diabetes is one of these conditions as are bone
metabolic diseases, history of head and neck radiation therapy and immunosuppressive
medications. Implant failures are recognized to be more frequent in smokers. Failure rates
are highest where the bone is ofthe poorest quality, such as D4 bone quality bone in the
posterior maxilla.

In patients with normal healing capabilities, especially good bone healing capabilities,
and sufncient bone olgood quality, implant success rates are often quoted in the range of
90 - 95%.

Diminished healing capacity would possibly be encountered in patients with r.rncontrolled

or poorly controlled Diabetes mellitus, irrmunocompromised states, radiation treaftnents
and chemotherapy. Patients with well-controlled Diabetes do not have compromised implant outcomes. Patients with a diminished capacity for fighting infection could be expected to experience problems with oral surgical procedures including implants.

Smoking is not a contraindication for the placement ofdental implants, however, failure rates are higher in smokers. The failure rate is related to the amount of smoking on
.r daill ba'is and the paclvyears history for the patient.
Remembr: Implants should not be considered for children who are still experiencing
sro\r'th.

. High smile line, thick periodontal biotype

. Low smile line, thin periodontal biotype
. Low smile line, thick periodontal biotype

. High smile line, thin periodontal biotype

64
Coplriglu O

. Do not move in
. Do not have

. Can be placed

201

l-2012 - Derral Decks

response to orthodontic forces

periodontal ligament
and later removed

. Can be located to gain force advantage

. All ofthe above

65

Coplaiglt O 20ll-2012, Denral Decks

A low smile line indicates that the patient does not lift the lip upwards when smiling to
the extent that the gingival-restorative interface can be seen by the observer. Consequently,
esthetic compromises may be more acceptable to the patient because they are not routinely visible. A thick periodontal biotype indicates that the patient has thicker, denser
gingiva with a less pronounced scallop. This type oftissue is more resistant to recession
caused by restorative procedures and materials, a lower chance of "show-through" of

the implant or abutment ald a lower chance ofloss ofthe papillae adjacent to the implant.

Abutments can be made from metal or ceramic materials. Aluminum oxide and zirconium ceramic abuhnents can be fabricated by CAD/CAM (Co mputer Aided Desigtr/Computed Aided Manufacture) methods and milled by machine. Note: Ceramic abutments
may be more subject to fracture than titanium or other metal abutments under heavy occlusal loads.

Inplants do not move in response to orthodontic forces because they do not have a periodontal ligament. Thus, bone carnot be resorbed and replaced at the bone-implant interface, as around teeth, to make implant movement possible. Certain types of implants
can conveniently be placed for anchorage on a temporary basis and then removed later

fol-

lowing completion of the orthodontic treatment.

The periodontal ligament is responsible for proprioception around natural teeth. The
lack ofthe periodontal ligament around implants results in a much reduced tactile sense
of $ here the implants are in relation to the opposing occlusion. There is a phenomenon
thar develops with time called osseoperception which gives the patient a certain amount
of tactile sense regarding the implants in the bone.

. Direct palpation of the bony ridges

. Determination of any limitations of mouth opening

. Cross-sectional imaging

All ofthe above

66
Cop)aight O 20t l-2012 - Dntal

. Circular

course

Deck

ofthe intemal maxillary artery

. Maxillary sinus extension towards the canine tooth

. Course of the inferior alveolar nerve anterior to the mental foramen

. Necessity for angled abutments
. None of the above

Coplright O 20ll-2012 - Dental Decks

The assessment ofthe prospective implant patient should include direct palpation of the
bone contours in the area ofthe planned implant tojudge for adequate bone volune. It is
particularly important that the lingual contours ofthe mandible and any possible concavities such as the submandibular fossa be explored since surgical encroachment on such
areas can lead to life-threatening complications for the patient.
Cross sectional imaging is not absolutely rquired but it is far superior to two-dimensional radiography and will be considered the standard of care in many locations. Defense ofthe omission ofcross-sectional imaging analysis would seem difiicult in the event
of a surgical complication.

Note: Limitations of any mouth opening ability on the part of the patient can preclude
placement ofan implant due to the inability to accommodate the handpiece and drills.

When treatment planning mandibular implant locarions, the possibility that the inferior
alveolar nerve courses anterior to the mental foramen by as much as 4 mm before looping back distally to exit through the mental foramen must be considered. If imaging data
does not clearly identifu the canal ofthe inferior alveolar nerve as it approaches the mental foramen, the implant location should be planned to be at least 5 mm or more anterior
Io the foramen.

The inferior alveolar nerve also courses from lingual to buccal as it moves anteriorly.
\&'tren planning implant position, the osteotomy preparation should be planned to end a
minimum of 2 mm vertically away flom the mandibular canal, and 2mm away from ary
other vital structure.

\ote: Ifan implant system is designed to be surgically placed with part ofthe implant
body exposed to the oral cavity after flap closure, it is a one-piece or non-submerged
imnlant.

. True
. False

68
Cop}fighl O 201l'20t2

'

Denlal Decks

The heafing abutment placed at the stage Il (uncovering) strrgery

for a two-piece implant system should be:

. Approximately one to two mm "taller" that the height ofthe tissue

. Out ofocclusion
. Radiographically confirmed

as seated

. Designed to shape or mold the tissue

.

All ofthe

above

69

Coplriglir O 20ll-2012 - Denral Decks

This concept was adhered to in the early techniques for surgical placement oftwo-piece
(or tu)o-stage, or "submetged") implant systems. Two-piece systems typically involve
initial osseous placement ofthe implant ard coverage with primary closure ofthe gingival flaps.
Current surgical placement techniques for two-piece systems also include leaving the attached abutrnent exposed to the oral cavity at the time of implant placement. One-piece
systems (also called one-stage or non-submerged systems) are typically placed with the
implant exposed to the oral cavity, also called "transgingival" placement.
A "radiographic stent'or guide:
. Identifies proposed implant sites in the radiograph
. Positions opaque markers in the radiograph
. Correlates information on the radiographs, cast, & wax-up
. Can help identif distortion in the radiograph

It is possible for an implant that was surgically placed with primary stability and given adequate time to osseointegrate can subsequently be found to rotate in the osteotomy at the
time of the second stage surgery. This rotation is sometimes detected when the healing
abutment is attached to or torqued onto the implant. Although mobility ofan implart is
considered a sign of implant failure in other circumstances, the rotation ofthe implant at
second stage surgery may possibly be overcome by replacing the cover screw. covering
rhe implant with soft tissue and allowing the site to heal for an additional 3 months. The
irnplant is taken completely out of function for this period of time.

. Cone beam computed tomography

. Panoramic radiography

. Conventional linear tomography

. Cat scars

70

coplrigh

O 20ll-2012 - Dntal Decks

Soft tissue observation

. Radiographic assessment
. Probing

. Visual inspection of implant components

. All ofthe above

71
Copyright @ 20ll-2012 - Dntal Decks

Cone beam computed tomography is a 3 dimensional imaging modality that produces

digital data that can be reformatted to produce multiple cross-sectional slices and other
views ofthe jaws. Cone-Beam CT exposes the patient to a relatively low dose of radiation when compared to medical grade computed tomography. "Cat Scan" refers to computed tornography. Conventional linear tomography utilizes a radiation source and an
x-ray film which rotate in tandem around a single point to produce a cross-sectional view
left over after everything else is bluned out in the image. Image quality oflinear tomography is ofsignificantly lower quality than Cone-Beam CT.

Tissue observation around implants is based on many of the same parameters that are
used when assessing natural teeth. Bleeding on probing, or absence ofbleeding on probing, are useful indicators of inflammation. Purulence, edema, erythema, and loss ofattachment can be used to assess soft tissue health. Probing depths are generally deeper
than around teeth and can be difficult to interpret due to surgical variability. Deeper probhg depths tend to harbor a more pathogenic flora. Probing depths can be difficult to measure due to the size and access limitations of implart restorations. Changes in attachment
level around an implant are useful in recognizing progression ofperi-implantitis.

Remember: The term '6relative attachment level" is used when the attachment is calculated from a landmark beside the CEJ.

Important: The use of plastic probes has been widely recommended to avoid scratch-

ilg

of titanium cornponents.

. A minimum of3 mm of space between adjacent implants

. At

least 2 mm ofbone remaining between the implant and vital structues

. At least one mm ofbone surrounding the implant in all dimensions

. A minimum of l6 mm of implant length for stability
. Placement ofthe restorative platform apical to the CEJ's ofadjacent teeth

72
CoDright O 201 I -20

12

- Denlal Decks

Which of the following factors determine(s) which abutment the

restorrtive dentist should select:

Soft tissue (mucosal or gingival) height

. Interarch

space

. Implant angulation
. Esthetic requirements
. All ofthe above

73

Cop)righ O 20ll-2012 ' Dmtal Decls

Implants of10 to 14 mm length are routinely used successfully and achieve adequate primary stability. 16 mm ofavailable bone height (plus a 2 mm margin of safety from adjacent vitql structures) is not usually available or required. 10 mm implants are generally
considered the minimum recommended length, although 8 mm and shorter implants are
available.
The term

"vital structure" refers to any structure that the surgeon should avoid contact-

ing during implant placement (e.g., the inferior alveolar nene, the maxillory sinus, roots
of nearby teeth qnd blood vessels, especially on the lingual aspect ofthe mqndible). A2
mm margin of safety is usually allowed between the limit of the osteotomy and any vital
structure. Less than 3 mm ofbone between adiacent imDlants risks bone loss in the area
and esthetic consequences.

Primary stability is a primary objective at surgical placement ofthe implant. It depends

on the overall shape or geometry of the implant including the presence of threads, the
precision olthe osteotomy preparation and the quality ofthe bone at the site. For the implant to achieve osseointegration, primary stability must be achieved at th time ofsurgical placement.

Ideally, the abutment t)?e is selected during the treatment planning process for the implant
and restoration. "Stock" abutments (made in standard sizes) can be selected to accommodate a cemented or a screw-retained restoration. Abutments can be used to compensate
lor an irnplant angulation which must be different from the desired restoration angulation
or position. The abutment should be long enough to provide adequate retention, but short
enough to allow the combined abutment and restoration to fil into the space available benveen the occlusal aspect ofthe implant and the opposing occlusion. This space is refened
to as the "interarch space" or "restorative space." Different material compositions of
abutments can be selected for ootimum color effect.

. The abutment to implant connectlon

. The shape ofthe abutment's restorative paxt
r Prcs<-fif imnlrnic

. Threads on

a screw implant

. An implant milling machine

71
cop)righl C 20ll-2012 - Dental Decks

A "polished collar," or the smooth polished exterior surface ofthe

closest to or in the oral cayity is designed to:

. Provide

a location for epithelial attachment

. Make the exposed surface cleansable

. Keep plaque from gaining access to deeper sh:rrchlres
. Inhibit biofilm formation
.

All ofthe above

75

Copfighr C

201

l'2012 - Dental Decks

impl|nt

A Morse taper is a cone in socket type ofconnection design for the fitting ofthe abutment into the implart. As the cone is forced (tightened) tnto the socket, the connection becomes increasingly tight and resistant to movement ofthe abutment. This stability can be
incorporated as an antirotational element to keep the abutment from rotating in the implant. The cone in socket fit can also produce a very closejoining ofthe metal components
which inhrbits bacterial contamination ofthe ioint.

The soft tissue interface can be keratinized gingiva or non-keratinized mucosa, both
seem clinically acceptable. ln early implant designs, it was thought that the polished surface of the collar would allow for an epithelial attachment that would keep plaque form
reaching the non-polished or roughened surface in the bone. Plaque is less likely to form
olr a smooth surface than on a rough surface. Epithelium can also form an attachment on
a roughened surface.

Remember: The interface between epithelial cells and titanium is composed of

hemidesmosomes and a basal lamina. The epithelial attachment is identical to a natural
rooth. \\ ith a long junctional epithelial attachment. A sulcus forms lined by sulcular epithelium rvhich then transitions into oral epithelium

\ote:

Interposed between the epithelial attachment and the marginal bone is a dense zone
a somewhat limited vascularity.

of connective tissue with

. Cemenled crown to the abutmenL

Screw-retained crown on the abutment

. Restoration which fits to the implant with no abutment

. Abutment with a ball extension for a removable prosthesis

Coplrigh O 20ll-2012 - Dental Decks

. Powered toothbrushes
. End-tufted brushes
. Plastic curettes
. Conventional ultrasonic tips
. Floss, especially multifilament varieties

77
CopFi8hr C 201l-2012 - Dental Decks

This combination would take up the greatest amount of space vertically due to the requirements for adequate abutment length needed to provide retention for the cemented surfaces. Screw retained combinations can be shorter and take up less space, the same being
true for restorations which are designed to fit directly to the implant with no intervening
abutment.

Titanium

as a

metal is relatively "soft" and can be scratched on the surface fairly easily. Plas-

tic curettes. mther than metal curettes, are recommended for titanium surfaces on implants
and abutments, particularly subgingivally. The same applies in the case ofplastic periodontal
probes instead of metal probes on titanium. Powered toothbrushes have been shown to be acceptable on titanium surfaces. Floss is not harmful to titanium surfaces, nor are conventional
roorhbrushes and end-tufted brushes,

Conventional metal ultrasonic tips should not be used because they do significant damage to
rianium components. However, specially designed ultrasonic tips having plastic or other softer
coatings are available and these are acceptable. The underlying principle is that whatever is
selected to clean titanium surfaces must not scratch or pit those surfaces.

.\ll ofthe following

products can be used on implants and other titanium surfaces:

. Chlorhexidine mouth dnses

. Phenolic compound mouth rinses

. Water jet irrigators
. Rubber cup polishing with fine pumice
The reaction to plaque by the tissues surrounding an implant is very much like the tissue reaction to plaque by the tissues around teeth. Implant maintenance is based an the principles of
periodontal maintenance and patients ate thus instructed in cleaning methods to personally
remove plaque on a consistent basis. Patients are also advised to retum for cleaning ofthe surfaces ofthe implant system that are exposed to the oral environment. Titanium surfaces are
subject to the formation ofplaque and calculus. A suggested interval for implant maintenance
appointments is every thre months for cleaning ofthe surfaces and inspection of the pans

ofthe system which

can become loose with

flnction.

Peri-implantitis can form around implants in response to plaque. This process is very sitnilar to that ofperiodontitis with many ofthe same organisms involved in etiology.

. Diminished healing capacity ofthe patient's

tissues

. Current chemotherapy for the treatrnent of cancer dt decrease healing

. History ofradiation therapy to the maxillofacial complex

. Dysmorphophobia
. Advanced patient age

78
Cop)right O 201I -2012 - Dental Decks

. Replacing the implant to get a better abutment selection

. Changing to a wider abutment for molar contours
. Changing to

. Matching

a shorter abutment to hide margins

a smaller diameter abutment

with

wider diameter implant

. Converting a round abutment to triangular

7S

Coplrighr O 2011'2012 - Dental Decks

Advanced patient age is not a contraindication to implant treatment. The ability of the
patient to withstand surgical treatrnent, etc. is a decision resting on the systemic health

ofthe patient.
Any condition that causes an impairment ofthe patient's ability to heal should be considered as a contraindication to implant treatment. Serious psychiatric conditions such
as psychoses should be considered a contraindication to implant treatment. Dysmorpho-

phobia is

al extremely irrational

fear ofbeing disfigured by treatment. Psychiatric com-

plications can make the patient change his or her opinion about the acceptability

of

treatrnent which is difficult for the clinician to overcome.

Platform switching refers to combining an abutment ofa particular diameter with a nonmatching diameter implant. Typically, this is a smaller diameter abutment connected to a
larger diameter implant. This combination is advantageous in terms of reducing the
amount ofbone remodeling and bone loss that normally occurs following placement of
the abutment and the restoration on the implant.

Different designs of implarts have typical patterns of bone remodeling following final
placement ofthe abuftnent. The physical location and the design ofthe abutment to implant connection play a role in localization of inflammation in the adjacent bone and the
remodeling outcome. This connection has commonly been in the form ofa butt joint befir'een an abuhnent and an implant ofthe same diameter. This physical combination, even
under the best circumstances, allows some degree ofbacterial activity between the components, and ifthis abutment-to-implant interface (or "microgap") is located at or under
the bone crest, increased bone loss or remodeling can occur By combining the smaller diameter abuftnent with the larger diameter implant, this interface is moved slightly away
ftom the bone resultins in less crestal bone remodeline.

. The patient will have difiiculty cleaning the area

. Bone loss will probably occur between the implants
. The presence ofa normal papilla is unlikely

. Optimum esthetic contours will

be prevented.

. All ofthe above

EO

copyriehr O 201| -2012 - Dental Decks

. Plasma cells
. Red blood cells
. Leukoc).tes

. Sertoli cells

81
Cop,'righr O 20ll-2012 - Dental Decks

When adjacent implants are treatment planned, there should be sufficient space for a minimum of 3 mm of bone remaining between the implants. This distance will prevent or
limit the amount ofbone loss that occurs between the implants during the normal osseous
remodeling that occurs after abutment placement. If the implants are closer than 3 mrr,
bone loss is likely as the two remodeling processes coalesce. In addition, if subsequent
bone loss occurs due to peri-implantitis on one of the implants, this can affect the bone
on the adjacent implant ifthey are too close together The amount ofspace required to successfully position, restore and maintain the implant(s) must be calculated with the planned
implant diameters considered. If adjacent implants are too close to one another, oral hygiene efforts by the patient are compromised due to lack of access for hygiene measures. Peri-implantitis can result.

Maintaining or creating an esthetic papilla between two adjacent implants is a major challenge, and bone loss behveen the implants makes formation ofa full papilla even more unlikely. An unesthetic open space can easily result and is commonly referred to as a "black
triangle." The shape ofthe matured new papilla is dependent on the distance between the
implants. the bone remaining, the depth of the implant placement, ard the shape of the
restorations. Vertically, only 2, 3 or 4 mm ofsoft tissue height can be expected to form ben\ een two implants.

Implant placement adjacent to a natural tooth should allow a minimum of1.5 mm ofremaining bone between the implant and the tooth. To allow for an esthetic emergence profile. an implant should be surgically positioned 2 to 3 mm apical to the adjacent tooth
CEJ. The presence of a papilla between the implant and the natural tooth is largely dependent on the bone level remaining on the natural tooth.

Inflammation is an observable alteration in tissues associated with changes in vascular

permeability and dilation, often with the infiltration of leukocytes into affected tissues.
These changes result in erythema, edema, heat, pain, and loss of function that are the
"cardinal signs" of inflammation.
Typical inflammation can progress through three stages:

. Immediate
.,A.cute

***

Leukocytes, the white blood cells, control all three stages

. Chronic
Leukocytes originate in the bone marrow and exit from the blood by transendothelial migration under normal conditions, accounting for the resident leukocltes found in tissues.
Among the most important resident leukocytes are mast cells, peripheral dendritic cells,
and monoc)'te derivatives such as dermal dendrocyes /iilrrio.y/es). These resident leukocrtes transmit information that initiates the process of immediate inflammation.

Irnnediate inflarnmation is followed within minutes by a short-lived period /ap to seleral

lorasl ofacute inflammation that is characterized by an influx ofneutrophils to the area
after they exit the blood. Ifthe problem is not resolved, acute inflammation gives way to
a potentially unending period ofchronic inflammation dominated by the migration of
lvmphocytes and macrophages to the local tissues.

\ote:

Cells ofthe inrnune system that are important in inflammation and host defenses
include mast celfs, dermal dendrocytes (ft istiocytes),peipheral dendritic cells, neutrophils,
monocytes/macrophages, T cells, B cells, plasma cells and natural killer (NK) cells.
Remember: Mast cells, dendritic cells, neutrophils and monocytes/macrophages are considered to be cells ofthe innate immune response (li'om birth). Lymphocytes (T cells, B
cells, and plasma cel/s/ are considered to be part ofthe specific immune response and develop antigen-specifi c responses throughout life.

. plasma cells, basophils, eosinophils

. macrophages, eosinophils, lyrnphocyes
. macrophages, lymphocy.tes, basophils
. lymphocytes, macrophages, eosinophils

a2
Cop)righr O 20ll-2012 - Denral Deks

ERIODONTICS

Z\
'

Which cells of the immune system possess rsceptors for the complement
component C3q by which they participate in immediate inflammation?

. Peripheral dendritic cells

. Dennal dendroc)tes (histiocytes)

. Monocytes
. Natural killer (NrKl cells

83
Copl'rjghrO

201 |

-2012 - Dental Decks

Stages of Acute

Inflammation:

l. Vascular

Phase of Inflammation
. Vasoconstriction - Immediately following tissue

injury there is a briefperiod oflocalized vasoconstict-

ion.
. Complement activation and mediator relNse -Tissue injury, or the presence ofbacteria, activates complemcnt. C3b mofeculcs formcd in this process bind to microbes and injl]Jed.tissve (opsonizatior.). C3a and
C5a (chemotaxins) trrggcr thc release ofhistamine and serotonin from nearby mast cells. Tissue injury also
triggers the formation ofbradykinin and initiates the slnthesis ofprosglandins alrd leukotrienes.
. Vasodilation - Ilistamine, and the other vasoactive mediators of inflammalion, then cause relaxation of
smooth muscle in arteriolar and capillary walls. Vcssels dilate increasingblood flow to injured tissues. This
is manifested by rdness (hlperemia) andheat near the site ofinjury
. lncreased vascular permability - With vasodilation, the endothelial cells lining blood vessels contract
slightly creating gaps behveen the cells that allow plasmato escape into surrounding tissues. Plasma delivers
antibodies and othcl antimicrobial substances to thc site ofinjury. Fibrinogen from plasma also clots and
serves as a tcmporary barrier to bacterial invasion.
2.

Cellular Phase oflnflammation

. Adhesion - As blood vessels dilate, the velocity of blood flow slows allowing circulating white blood
cells to accumulate on the inner surface ofvessel walls. This process is called margination,
. Diapedesis end chemotaxis - The wBC's then begin to squeeze between the contracted endothelial cells
and migrate in an amebalike fashion into the extravascular space fd process called diapedesis). Once in tissue, the WBC'S are attracted by activated complement and begin to migrate towards the site ofinjury or infection. wBC's (specifically PMNs) apparently have surface recepto$ for chemotactic agcnts fi.e., CJd,
TIE IL-8, LtB4.IL-1, IFN-I) which cause them to move in the direction ofincreasing concentrations ofthe
chemotactic substanc /?rocess is called chemora.nrr. Initially, the first group ofcells to arrive at the site
of injury are neutrophils fPMNs/. Latq macrophages become more numerous. In certain parasitic infections. eosinophils predominate. In viral infection, lymphocytes rather than neutrophils usually predominate.

. Phsgocytosis - wlen wBC's (specificalb, PMNS) anive

at the sitc oftissue injury or microbial invasion

they become very active and begin engulfing bacteria forming a phagosome which combines .r.ith lysosomal granules to form a phagolysosome, in which digestion ofthe engulfed particle occurs.

cells ofthe immune system originate from a hematopoietic stem cell in the bone marrorv, which
a myeloid progenitor cell and a lymphoid progenitor cell. These two
progenitors give risc to the myeloid cells f/ro, ocytes, macrophages, dendritic cells, meagakaryocytes and
granLlooles) andlJl|4phoid cells (T cells, B cells a d hatural killer (NK) cel/t, respectively. Theses cells
make up the cellular components ofthe innat. (non'specilic) and adaptive (.tpecifc) lrl.,rfline systems.
Cells possess receptors, which are molecules on the cell surfaces that enable the cell to interact with
orher molecules or celis. Receptom reflect and dictate the function ofcells.
. \Iast cffs: are important in immediate inflammation fanaphylatis and allergic rcsponses). They
possess receptors fot complement components (C3a and C5a) aswell as receptors for the Fc portion
ofrhe antibody molecules IgE and lgc. They feature prominent c,'toplasmic granules, termed lysosomes. \r'hich store inflammatory mediators such as histamine and heparin.
. Dermal dendrocytes (histiocyres)t these cells are distributed near blood vesscls and possess receptors for the complement component C3a, by which they participate in immediate inflammation.
. Periphral dendritic cells (DCs,): are leukocytes with dendritcs. Langerhans cells are DCs that reside in the suprabasilar portion s ofsquamous epithelium. DCs are important in antigen processing and
presentarion to cells ofthe specific immune response.
. \eutrophils and Mononcytes/macrophages: are phagocytic leukocyes. Neutrophils ate the predominant leukocyte in blood. Because neutrophils do not need to differentiate substantially to function, they are suited for rapid responses. They possess receptors for metabolites ofthe complement
molecule C3. Nlonocytes are referred to as macrophages when they leave the blood. They present
anrigen to T cells. Together, macrophages and lymphoc,'tes orchestrate the chronic immune response.
. Lymphocytes: the three main tlpes of lymphoc)'tes are distinguished on the basis oftheir receptors
for antigens: T lymphocytes, B lymphocytes, and natural killer (NK) cells.
- T cells: recognize diverse antigens using a low-affinity transmembnnous complex, the T-cell antigen receptor alCR/. T cells are subdivided based on whether they possess the co-receptors CD4 (?:
helper cells) or CD8 (T-cytotoxic cells).
-B cells: help control extracellular antigens such as bacteria, fungal, yeast, and virions. B cells recognize diverse antigens using the B-cell antigen receptor frcRl. After antigen exposure, some B
cells differentiate to form plasma cells which secrete IgM. Others differentiate into memory B cells.
- Natural killer (Nf) cells: recognize and kill certain tumor and virally infected cells.
-4.11

giles rise to two major lineages,

. Plasma cells

. Mast cells
. Neutrophils
. Macrophages

84
Coptrighr C

201

i,2012 - Dental Decks

has emerged as a unique immune cetl thst could be

activated by many non-immune processes, including rcute strss rnd

The

could par,icipate in a variety of inflammatory diseases in the

nervous system, skin. joints, as well as cardiopulmonary,
intestinal and urinary systems.

. Neutrophil

. Epithelioid cell
. Mast cell

. Eosinophil

85
Cop"ighr O 201I-2012'Dental Dcks

Inflammation that has a slow onset and persists for weeks or more is classified as being chronic. The
symptoms are not as severe as with acute inflammation, but the condition is insidious and persistent. The
main cells involved jn chronic infection are mrcrophages and lymphocytes. With the aid ofchemical
mediators such as l),rnphokines, macrophages do an excellentjob ofengulfing and neutralizing or killing
foreign antigens. Llanphocytes are the predominant cell in chronic inflammation. Note: Macrophages
and lymphoc)'tes are intcrdcpcndent in that thc activation ofone stimulates the actions ofthe othcr.
Chronic inflammation:

. Lymphoc],te, macrophage, and plasma cell infiltration

. Tissue destruction by inflammatory cells
. Aftempts at repair with ftbrosis and angiogenesis (nev vessel lormation)
. wlen acute phase cannot be resolvd
- Persistent injury or infection (ulcer TB)
- ProJonged toxic agent exposure fsllr.llJ
- Autoimmune disease states (M, SLE)

. Macrophages

Scattered all over (microglia, Kryffer cells, sinus histioq,tes, alveolat macrophages, etc.)
48 hrs and transform
as monoc)'tcs and reach site of injury within
. Become activated by T cell-derived cytokines, endotoxins, and other products of inflammation

24

. Circulate

.TandBlymphocytes
. Antigcn-activated fyia macrcphages and dendritic cells)
. Rclease macrophage-activating cytokines fln lurn, mac,ophages release lymphoqte-activdling
c|tokines until inflammalory stimulus is removed)

. Plasma

cells

. Terminally differentiated B cells

. Produce antibodies
. Eosinophils
. Found especially at sites ofparasitic infection, or at allergic

flgt-

ediated) sites

\{ast cells originate from pluripotent cells. The mast cells enter the bloodstream, migrate
throughout the body, and mature. They frequently locate at perivascular sites in tissues,
such as the lungs, where they interact with the extemal environment.

\last cells become activated when surface receptor-bound antigen-specific immunoglob',iin E (lgE) encounters an antigen that the IgE recognizes. This triggers mast-cell degranulation, Ieading to the rapid release of inflammatory mediators, such as histamine,
proteoglycans, and cytokines. Mast-cell activation also stimulates the arrival of other ina critical step in local inflammation.
flammatory cells

are not only necessary for allergic reactions, but recent findings indicate that
ihe) are also involved in a variety ofneuroinflarnmatory diseases, especially those worsened by stress. In these cases, mast cells appear to be activated through their Fc receptors
bl rmmunoglobulins other than IgE, as well as by anaphylatoxins, neuropeptides and cy-

\last cells

tokires to secrete mediators selectively without overt degranulation.

.
\ote{
'aa.*;

I . The mast cell content in human gingiva is high. The mast cell content ofinflamed gingiva increases as the severity of inflammation increases.
2. Remember: The anaphylactic response is characterized by the degranulation
of mast cells as a result of antigen-antibody complexes affixed to cell surfaces.

. Stop persistent bleeding

. Maintain the sutured position ofthe flaps

. Improve patient comfort

. Prevent mechanical injury to healing tissues

86
Copyrrghr O 2011,2012 - Dertal Decks

PERIODONTICS

Wbich one of the following will reduce the

abrasive action ofa polishing agent?

. Using an agent with nice large particles

. Using an agent containing particles that are dull and round

. Using a thick, viscous mixture ofpolishing

paste

. Applying the polishing agent with firm pressure and increasing to a heavy constant
pressure

. Polishing at a high speed with healy pressure

87

Copyridr

201l-2012,

Ddtll

Decks

Purposes of the periodontal dressing /periodontal packt):

. Provide mechanical protcction for the surgical wound and therefore facilitate healing
. Helps prevent post operative bleeding by keeping the initial clot in place
. Supports mobile teeth during healing
. Mechanically maintains post-surgical position ofthc flaps
. Helps in shaping or molding thc ncwly formcd tissue
. Provide patient comfort by isolating area from extemai irritations or injuries

Characteristics of acceptable dressing materiall

. Nontoxic or nonirritating to the tissue

. Conveniently prepared, placed and removed with minimal discomfort to patient

. Should maintain adhesion to itselfand to the teeth, kept in place mcchanically by interlocking in interdental spaces
T) ps ofDrcssings (pdcfs): usually contain zinc oxide and may be either eugenol- or non-eugenol con-

talnlng.

. \on-etgenol

(soft pack)
- 2 tubcs: . one tube contains: Zinc oxide, an oil (fot plasticir*), a gnm(for cohesiveness). and lorot-

hidol (a fungicide)

. one tube contains liquid coconut fatty acids thickened with colophony resin (or rosixJ
and chlorothymol i/rl racteriostatic agenl)
*** most widely used in the United Stales.

- Brand narnes: Coe-pak

. Zinc oride.Eugenol Packs: are supplied as a liquid (eugenol) and a powder (zi1c oxide).
l. Periodontal dressings have no well-defined effect on the processes ofwound healing or on
\oaes surgical outcomes (i.e., gains ofpeiodontal attachmenl or the reduclion in probing depths).

2. For first week postoperatively, patient should rinse with 0.12% chlorhexidine gluconate
nvice daily.
3. As a general rule, the pack is kept on for I week after surgery.
.1. Bcfore removing, make sure sutures are not cmbcddcd in the dressing and that the dressing is not locked interproxjmally.

*"*

Using a thin, watery mixture of polishing paste or polishing at a low speed with
light pressure will also reduce the abrasive action ofa polishing agent.
The use of abrasive polishing agents and/or a rotary polishing instrument may be contraindicated in the following cases:
. Patient with a communicable disease: the production of aerosols is likely to

occur.

lhich

may disseminate the disease

. Patient with respiratory problems

. Patient with "green stain": usually the tooth surface under the stain is demineralized

. Patient \yith newly erupted teeth: have not mineralized completely yet
..{ny patient who is at increased risk for dental caries: those with xerostomia,
amelogenesis imperfecta, ran.rpant caries, or receiving radiation therapy to the head

***

The use of a porte-polisher (manual polisher) may be helpful in some of the cases
Iisted abor.e.

***

Dental tape and finishing strips may be used to polish interproximal tooth surfaces.
polishing agent to remove generalized staining, consider the
following: tooth sensitivity, type of stain present, type of restorations present
and the condition of the tooth surface. *** Not all surfaces should be polI.

Notr.

When selecting

ished.
2. Flexing the polishing cup into proximal areas increases its effectiveness.

. ...

Gingival fibers conslst of:

. Type I collagen

. Type II collagen
. Type III collagen

. Type IV collagen

Cop)righr

88
20ll-2012 - Dental Decks

'\

. Gram-positive aerobic cocci

. Gram-negative aerobic rods
. Gram-negative anaerobic rods

. Cram-positive anaerobic cocci

89
Coplright O 20ll-2012 - Dental Decks

l. The corurective

tissue of the marginal gingiva is densely collagenous, containing a prominent system ofcollagen fiber bundles called the gingival fibers.
2. The gingival fibers are arranged in three groups: gingivodental, circular, and
transseptal.
3. The fype I collagen of gingiva, however, is not th same biochemically as
found in other parts ofthe body, including the skin.
4. The collagen tumover in normal gingiva is not as rapid as in the periodontal ligament but significantly greater than in other tissues such as the skin, tendons, and the palate.
5. The n.rajor components ofthe gingival connective tissue are collagen fibers
(about 600% by volume), fibroblasts (5o%), vessels, newes, and matrrx (about
35%).
6. The three t)?es of connective tissue fibers are collagen, reticular, and elas-

tic.
7. Collagen type I lorms the bulk ofthe lamina propria and provides the tensile
strength to the gingival tissues.
8. Tlpe IV collagen (argyophilic reticuhm.fiber) branches between the collagen type I bundles and is continuous with fibers ofthe basement membrane and
blood vessel walls.
9. The elastic fiber system is composed ofoxytalan, elaunin, and elastin fibers

distributed among collagen fibers.

Remember: Vitamin C is needed for hydroxylation of proline and lysine essential for
collagen formation.

Principal diffcrences between the periodontal abscess and the gingival abscess are location and history Abscesses confined to the marginal gingiva, causedby injury forcing oJJb,"ign material) to Ihe outer surface of
rhe gjngiva. and not involving the supporting structrues are called gingival abscesses. A periodontll abscess
is an infection located contiguous to the pcriodontal pocket and may result in the destruction ofthe PDL and
al\ eolar bone. Note: The pericoronal abscess is associated with the crown ofa panially erupted tooth.

Periodontsl abscesses can be cla\sified as:

. Acute: The most prevalent symptom that the patient will report with an acute periodontal abscess is one
of acurc pain. The nature ofthe pain is a constant, severe, dull throbbing. Thermal changes do not seem to
elicit or modiry the discomfon. The onset ofthis discomfort is rapid and becomes progressively more inrense. Exudate may be expressed with gende pressure. The patient may also notice an increase in mobiliq of an rndividual tooth. The patient probably will say that it is diflcult to close his,4rer teeth together
\!irhour sriking the involved toolh first filleh elevdte.l in lhe sockel.), causing incteased pain. There may
be ststemic involvment characterized by an elevated temperatur and lymphrdenopathy'
. Chronic: is usually characterized by no or a dull pain, slight tooth elevation, intermittent exudation, a fisrulous tract oftcn associated with a deep pocket, and without systemic involvement.
Tiearmenl for an acute periodontal abscess is determined initially by whether there is localization ofthe abicesi. Iflhere is. then the lreatment is to provide dt^i'ngige (either thmugh the periodontal pocket or through
d-rrerrdl ir.i-ilo/r, insrruct the patient to rinse with warm salt water and place chlorhexidine gluconatc on the
alTecred area \\ ith a cotlon{ippcd applicator Ifthere is systemic involvement the paticnt should be prescribed
arlibiotics ,,itl,e,",.,mo-r:icillin or ifallergic then Clindan))cin or Azithrom)cirll. lfthere is severe swelling and
inflafifiation lnot localr"edl, rhe paiient should be puton antibiotics and seen oDce the infection has localized.
\ote: Bacreia associatedwith abscesscs ofthe periodontium include F. nuclcatum, P intermedia, P gingivalis.
P micros. and T fors]1hia.
As \\'ith a periodontal pocket, the chronic abscess is usually trealed with scaling and root planing or surgical
rherapy.
Tlre radiographic findings associated with this abscess are not specific. There may be no change radiographically
in the early acute lesion- Often, ho{ever in a chronic abscess therc will be a localized discrete mdiolucency lateral
to the root or in a lircation, Note: It can cause rapid alveolarbone destruction.
Note: Microscopically, an abscess is a localized accumulation ofPMNS within the periodontal pocket wall.
Tle PMNS tiberate enztrnes that digcst the cells and other tissue structures, forming the liquid product known
as pvs (exudate)

. TMJ symptoms

. Muscle

soreness

. Periodontal pocket formation

. Cracked teeth or fillings
. Wear facets on teeth
. Widened PDL spaces on radiographs

90
Cop)'right C 20ll-2012 - Deotal Deck!

. When pulp chambers are small

. In the presence oftooth sensitivity
. When major occlusal discrepancies may require orthodontics or full mouth
reconsfiucuon

. In patients who are poor candidates for full mouth reconstruction because of
psychologic factors

91

CopFighr O 201 I '2012 - Dental Decls

Bruxism is defined as diumal or noctumal parafunctional activity that includes clenching,

bracing, gnashing, and grinding ofthe teeth. Although no causative association exists between
bruxism and gingival inflammation or periodontitis, bruxism can cause tooth mobility, tooth
wear and fracture, and periodontal and muscle pain and may contribute to masticatory system
disorders.

Important: A maxillary or a mandibular interocclusal appliance (occlusal splint/night guard)

is generally considered the most effective means ofmanaging bruxism. They are used to redistribute occlusal forces and to minimize excessive force on individual teeth.
. To stabilize the dentition
. To modifo the nature ofthe habit (bnrxrsrn)
. To act as a splint after pedodontal surgery
. To assist in conholling recurrence ofdrug-induced gingival enlargement

Note: Night guards are usually wom at night, but they may also be wom during the
day.

***

The primary purpose of a night guard in periodontal trauma is to modify and contlol bruxism or to redirect forces into a non-traumatic pattem.

\ight

guards should have the following characteristics:

. They should be made of hard acrylic

. There should be no sharp edges
needs to be comfortable
- occlusal surfaces ofthe maxillary
. They should fit well and cover the
cover the palate

teeth

should not

. They should occlude evenly with mandibular teeth and permit the patient to move the
mandible freely in all excursions

General objectives in selective grinding in the natural dentition:

. To achieve a more favorable direction and distribution offorces
. To coordinate the median occlusal position with the terminal hinge position of the
mandible
. To eliminate prematurities in excursive movements to either gain a group function
or canine protected occlusion
. To direct occlusal forces centrally along the long axis ofth tooth
. To improve or maintain masticatory performance
. To accomplish the occlusal adjustment without reducing vertical dimension and
by retaining an acceptable interocclusal distance
. To reduce or eliminate fremitus
The usual steps ofocclusal adjustment:

. Eliminate prematurities in centric relation

. Eliminate prematurities in protrusive movemnts
. Eliminate prematurities in lateral excursive movements
. Re-establishment of physiologic occlusal anatomy and careful polishing of all
ground surfaces

l{ote: For lhe periodontal patient, occlusal adjustment (coronoplasty) should be not be
done until inflammation is resolved.

Which of the foltowing is not correctly matched

wlth regards to a periodontal treatment pl.n?

. Preliminary Phase : Plaque Control

. Phase I : Mouth Preparation
. Phase II : Periodontal surgery
. Phase III : Restorative
. Phase IV : Maintenance

s2
Cop).righr O 201l-2012 - Dental Decks

PERIODONTICS

Which of the following statements regarding the

rssessment of tooth nobilitv is false?

. Teeth normally have

a very slight physiologic

mobility

. Mobility can result from multiple causes

. Mobility is unacceptable and should be treated

. Periodontal

disease can result in tooth

mobility

93
CoDright O 201 I -20

12

- Denbl Decks

*** Plaque control

is a part ofPhase I or initial therapy. The preliminary phase includes trcatment

ofemergencies only whether they bc pulpal, periodontal or any other.
Phese

I (initial

therapy) ofperiodontal heatment planning includes:

. Caries control, extraction of hopeless teeth

. Mouth preparatiotr
- lnjtial scalirg (full mouth)
- Definitive root planing
. Oral hygiene instructions: This is the most important aspect ofinitial therapy. The dental hygienist or dentist teaches, motivates, and guides the patient in the performance ofmeasures for
diseasc control. During a Fophy appointment, the hygienist or dentist can establish a rapport
with the patient and individualize instruction for the particular patient. Show the proper brushing and flossing techniques and have them repeat these techniques to see ifthey understand what
you are showing them.

. Occlusal adjustment
. Night guards (if bnLtism

eYjsts)

Spli

tng (stabilizing loose teeth)

. Re-examination (c,lrarting with probings)
Remember: Iforal hygiene is poor, swgery is contraindicated! !!
,u Phase
Phese

.-----1,- Reevatuation

--+-

Yn^r"

II (Periodont.l surgery)

w 1-uint"nrn""ly'/

\l

'

Phase

lll

{restorative)

Correct sequence of periodont.l treatment

\4obility should be heated if it is progressive (increasing), acting to contribute to progression ofperiodontal disease, or if it is associated with patient pain. Mobility in the absence of inflammation is not harmful. Not all mobility can be eliminated. Also, some
mobility is only transient.
\{obility beyond the physiologic rarge is termed abnormal or pathologic. It is pathologic
in that it exceeds the limits of normal mobility values; the periodontium may not necessarily be diseased at the time ofexamination.
lncreased tooth mobility may be caused by a variety offactors, including pregnancy, diseases (local and systemic), trarma (including orthodontic movement), and hypofunction
or hyperfunction. The two factors most often seen would be plaque induced inflammatory
disease and excessive occlusal forces (brttxism).

\ote: As a general rule, mobility

is graded clinically with a simple method. The tooth is

held firmly between the handles of two metallic instruments or with one metallic instrument and one finger, and an effort is made to move it in all directions; abnormal mobil-

ity most often occurs faciolingually. Mobility is graded according to the

of tooth movement, as follows:
. Normal mobility
. Grade I: slightly more than normal

ease and extent

. Grade lI: moderately more than normal

. Grade III: severe mobility faciolingually and mesiodistally, combined with vertical
disolacement.

. They mature in the bone marow and migrate to lymphoid organs

. They are found in the germinal centers ofthe spleen and lymph nodes
. They are progenitors of plasma cells
. They are involved in humoral (antibody-mediated) and cell-mediated immunity

94
Coprright O 20ll-2012 - Denhl Decks

. Cementum that

is resorbing

. Newly formed cementum

. That pan ofthe cementum that

is adjacent to the enamel

. Cemenfum that contains cementoc)tes

95
CoplriSht

@ 201 I -20 12

- Denral Decks

***

This is false; B cells are not involved with cell-mediated immunity.

Lymphocytes: the three main tlpes oflymphocles are distinguished on the basis oftheir
receptors for antigens: T lymphocytes, B lymphocytes, and natural killer (NK) cells.
. T cells: recognize diverse antigens using a low-afiinity transmembranous complex,
tissue
the T cell antigen receptor (TCR). T cells are subdivided based on whether they possess the co-receptors CD4 or CD8. Note: They are important in cell-mediated immunity Type 4 hypersensitivity reactions (contact dermatitis), and in the modulation of
antibody-mediated immunity.
. B cells: help control extracellular antigens such as bacteria, fungal, yeast, and virions.
B cells recognize diverse antigens using the B cell antigen receptor (BCR). After antigen exposure, some B cells differentiate to foIm plasma cells which secrete IgM. Others differentiate into memory B cells. Note: They are important in antibody-mdiated

immunity.
. Natural killer (NK) cells: recognize and kill certain tumor and virally infected cells.

\ote:

Patients with periodontitis often have T lymphocytes sensitized to plaque bacter-

ial antisens.

Cementum is the calcified, avascular mesenchynal tissue that forms the outer covering ofthe
anatomic root. The two main types of cementum are acellular (primary-) and cellular (secondaD) cementum, Both consist ofa calcified interfibrillar matrix and collagen fibers.

The two main sources of collagen fibers in cementum are (1) Sharpey's frbers (extrinsic),
*hich are the embedded portion ofthe principal hbers ofthe periodontal ligament and are
formed by the fibroblasts, and (2) fibers that belong to the cemer'ttrmmatrix (intrinsry' and are
produced by the cementoblasts.
The major proportion of the organic matrix of cementum is composed of tlpe I (90n and We
III tdboft so/a) collagens. Sharpey's fibers, which constitr.rte a considerable proportion ofthe
bulk ofcementum, are composed of mainly collagen t,?e L Type III collagen appears to coat

tbe qpe I collagen of Sharpey's fibers.

. Acellular cementum: is the fiISt cementum formed, covers approximately the cervical
rhird or half of the root, and does not contain cells. Sharpey's fibers make up most of the
srucrure ofacellular cementum, which has a principal role in supporting the tooth.
. Cellular cementum: is formed after the tooth reaches the occlusal plane, is more irregular and contains cells (cementoclrtes).It is less calcified than acellular cementum. Sharpey's
fibers occupy a smaller portion ofcellular cementum.

If\ital

cementum is resorbed or nicked in surgical procedures, the defect is repaired by the

deposition of new cementum. Repair carmot occur where pockets are present or where the
gingiva has receded and the cementum is exposed. Cementum that has become exposed, forming pan ofthe clinical crown, is often removed in the course ofscaling, root planing, or brushing.

Note: Cementum deposition is a continuous process that proceeds at varying rates throughout
Iife. Cementum formation is most rapid in the apical regions, where it compensates for tooth
eruption, which itself compensates for attntion.

. It

is produced by cells

ofthe periodontal ligament

. The main function is to compensate for tootl wear

.The deposition ofnew cemenhrm continues periodically throughout life whereby root
frach.res may be repaired

. The cementum is indistinguishable on radiographs

. It is lighter in color than dentin, contains 45 to 50yo inorganic substance, alld its permeability diminishes with age

96
Coplrighr O 20ll'2012 - Denral Decks

When trauma from occlusion results from reduced ability of the

tissues lo resisa tlle occlusal forces, it is known asi

. Primary occlusal trauma

Secondary occlusal trauma

. Tertiary occlusal trauma

97
Coplrighr O 201l-2012 - Denral Dects

***

This is false; the main function is the attachment ofprincipal fibers ofthe PDL.

Other functions include:

L Compensates for the loss oftooth surface due to occlusal wear by apical deposition
of cementum throughout life.
2. Protects the root surface from resorption during vertical eruption and tooth movement.

reparative function, allows reattachment ofconnective tissue following periodontal treatment. Note: Cementum repair requires the presence ofviable connective
tissue. If epithelium proliferates into an area ofresorption, repair will not take place.
Cementum repair can occur in devitalized as well as vital teeth.
3. Has a

The inorganic content of cementum (hydrotyapatite) is 45% to 50%, which is less than
that of bone (65%o), enamel (97o/o), or dentin (70%o).
The cementnn at and immediately subjacent to the cementoenamel junction (CEJ) ts of
particular clinical importance in root-scaling procedures. Three types ofrelationships inr.olving the cementum may exist at the CEJ. In about 60olo to 65% of cases, cementum
overlaps the enamel; in about 30o% an edge-to-edge buttjoint exists; and in 5% to l0% the
cementum and enamel fail to meet.

\ote: Unlike bone, which is continuously remodeled, the cementum grows slowly in
thickness, throughout life, by apposition of new cemenfum at the surface. While cementum can be resorbed, it is not continuously remodeled like bone.

\\'hen occlusal forces exceed the adaptive capacity ofthe tissues, tissue injury results. The resultant injury is te.med trauma from occlusion. Trauma from occlusion refers to tissue injury, not occlusal tbrce. An occlusion that produces such injury is called a traumatic occlusion.
Trauma from occlusion may be:
. -{cute: results from an abrupt occlusal impact, such as that produced by biting on a hard object. Restorations or appliances that interfere with or alter the direction ofocclusal forces on the
teeth rray also induce acute trauma. It results in tooth pain, sensitivity to percussion, and incrcased tooth nobility.
. Chronic: is more common than the acute form and is ofgrcater clinical significance. It most
oiien develops from gradual changes in occlusion produced by tooth wear, drifting movement,

and extrusion of teeth, combincd with parafunctional habits such as bruxism and clenching,
rather than as a sequela ofacute periodontal trauma.

\\'hen trauma l'rom occlusion is the result of alterations in occlusal forces, it is called "primary
trauma from occlusion." It occurs if trauma from occlusion is considered the primary etiologic
l'actor in periodontal dcsauction and if the only local altention to which the tooth is subjccted is
tiom occlusion. Important: Changcs produced by primary fauma do not alter the level of connectr\e tissue attachment and do not initiate pocket fonnation. This is probably because the
supracrestal gingival fibers are not affected and therefore prevent apical migration of the junctional epithelium.
Secondary trauma from occlusion occurs when the adaptive capacity ofthe tissues to withstand
occlusal forces is impaired by bone loss resulting from marginal inflammation. This reduces the pe.iodontal attachment area and altcrs the levemge on the remaining tissues. The periodontium becomes more lr:lncrable to injury, and previously well-tolerated occlusal lorces become traumatic.
Tissue response to traumatic occlusion occurs in three stages; injury, repaiq and adaptive remod-

eling of the periodontium.

. The periodontic component first

. The endodontic component first
. Both components at the same time
. Them any way you want to

98
Cop)right O 20ll-2012 - Dntal Decks

.Improve patient comfort ard to provide better control ofthe occlusion ifthe anterior
teeth are mobile

. Improve oral hygiene

Prevent a natural unopposed tooth from migrating

. Prevent maxillary central incisors from separating after closure of diastema

coplright Cr20ll-2012 - Dental ltecks

In patients with a dental abscess, the differential diagnosis between periodontal and endodontic origin can usually be established by the history clinical examination, and radiographs. The true combined lesion results from the development and extension of an
endodontic lesion into an existing periodontal lesion (pocket). The pain from the loss of
pulpal vitality is the most common presenting complaint ofpatients with combined lesions. The symptoms reported are those most often found with pulpal disease. Thermal
pulp testing provides information relative to the status ofthe pulp, and dental radiographs
can confirm the presence of apical changes and the extent ofbone loss. Careful probing
confirms the presence and morphology ofany periodontal pocket and permits location of
the conmunication with the apical lesion.
In combined endodontic-periodontic lesions, it is generally wise to treat the endodontic component first, because in many cases this will lead to complete resolution of the
problem.

After successful endodontic treatment, the residual periodontal pocket that remains can
be more predictably heated. The periodontal therapeutic objeclives vary with the extent
and conhguration ofthe residual periodontal lesion.
Important: The long-term prognosis lor a tooth with a combined lesion is closely related
to the extent and configuration ofthe periodontal attachment loss. With advanced horizontal bone loss, even an optimal endodontic result may not be sufiicient to retain the
rooth. Ifthe periodontal lesion is an advanced, multiwalled vertical defect, the success of
rherapy likely depends on the ability to fill or regenerate attachment to obliterate the defect.

Splinting therapy may be applied with bonded extemal appliances, intracoronal appliances, or indirect cast restorations to connect multiple teeth, with the goal ofimproving tooth stability. Unstable teeth may be caused by a lack of periodontal support from bone loss, a lack ofsupport from tooth
loss. or the need to splint abuhnent teeth to support pontics.
There is no reason for splinting non-mobile teeth as a preventive measure. Splinting is only one
measure used in the tratnlent ofperiodontal disease. Splinting should be used with other necessarl neasures such as root planing, oral hygicne insauctions, pocket elimination, and occlusal adiuslmenl. Loose teeth splinted to adjacent teeth may become stabilized. When many teeth are
loose. adjacent sextants should be included io the splint. Teeth tend to loosen buccolingually yet may
remain firm mesiodistally. Even whcn tecth do not tighten, the splint serves as an orthopedic brace
thal pc.mits useful function of loose teeth. A variety ofmeans may bc utilized to achieve temporar_r stabilization. Whatever means are used, special attention should be paid to making the splint
amenable to oral hygiene procedures and instructing the patient on plaque control around the splint.

.l.lndicationsforsplintingare(1)mobilityofteeththatisincreasingorthatimpairspa-

-\0:e3:

tient comfon, (2) migration ofteeth, or (3) prcsthetics where multiple abutments are

.' , .,tr' necessary

2. Before considering splinting, the clinician must identify the etiology of the instability. Any inflammation ofthe periodontal supporting apparatus must be controlled before making a decision on splinting, because inflammation can produce mobility in the
presence ofnomral occlusal forocs and normal periodontal support.
3. Adequate crown length on the teeth being splinted is critical so that the interproximal connectors do not impinge on the interdental papilla.
4. Adequate spacc must cxist between the connector and the papilla for access with
dental floss anteriorly and with an interproximal brush on posterior teeth.

Extrinsic dental stains include:

. Green to brown slains caused by erythroblastosis fetalis

. Brown, black, green, or orange stains caused by chromogenic bacteria in plaque
. Red to brown stain caused by congenital porphyria
. Gray or brownish stains caused by tetracycline

100
Cop).righr C 201 l'2012 - Dental Decks

Trauma from occlusion can produce radiographically detectatlle

cbanges in all ofthe followin g EXCEPT one.
Which one is the,EXCEPIION?

. Lamina dura
. Periodontal pockets
. width of the PDL

space

. Morphology ofthe alveolar crest

. Density ofthe surrounding cancellous bone

101

Coplriglr O 20ll-2012 - DenralDecks

Stains can be identified by location:

. Intrinsic - stains that occur within the tooth substance
. Extrinsic - stains that occur on the extemal surface ofthe tooth
Stains can be identified by sources ofthe discoloration:
. Endogenous - stain that originates from within the tooth. Endogenous stains are always intrinsic and frequently are discolorations of the dentin reflected through the
enamel.
Examples ofsourcesz drngs (tetacycline, systanic.fluoride), changes in pulp tissue of
pulpless teeth, imperfect tooth development (amelogenes is impet'fecta)
. Exogenous - stain that originates ftom an extemal source.

Brown, black, green and orange stains are generally seen on the labial surface ofanterior teeth and are usually caused by poor oral hygiene. Some theories attribute the
change in color to by-products of some bacteria. Black stain is generally seen in the cervical portion of molar teeth in children. Green and orange stains are supposedly associated rvith an increased amount ofcaries and actually they represent pigmentation of
dental plaque. Black line, tobacco, orange and green stains are all exogenous extrinsic stains, initially at least. After a period of time, both green and tobacco stains may
become incorporated with the tooth. At this point, their classification changes. They
become exogenous intrinsic stains.
Silver amalgam and topical fluoride are also examples ofexogenous intrinsic stains. An
e\ogenous intrinsic stain is one that originates from a source outside the tooth and subsequently becomes incorporated within the tooth structure.

***

Periodontal pockets are not caused by occlusal trauma. A local irritant and inflammation are necessary to cause apical shift of the epithelial attachment.
The most common clinical sign ofocclusal trauma is tooth mobility. Other clinical signs

of occlusal trauma include migration ofteeth and the tendemess of teeth to percussion.
Traumatic lesions manifest more clearly in the faciolingual aspects, because mesiodistallv the tooth has the added stability provided by the contact areas with adjacent teeth.
Radiographic signs of trauma from occlusion:
. \\'idening ofthe periodontal ligament space
. Thickening ofthe lamina dura
. -\ngular bone loss and infrabony pocket formation
. Root resorption
H)percementosis
\ote: Trauma from occlusion is reversible, that is, the body can repair the damage
the excessive occlusal forces are eliminated.

'

Other findings associated with excessive occlusal forces:

. ,A.ltemating areas ofresorption and repair ofthe alveolar bone
. Fibrosis olthe alveolar bone marrow spaces
. Cemental resorption leading to dentinal resorption
. Cemental tears
. Possible ankylosis
. Occasional pulpal necrosis and calcification

Radiographic changes that may be seen on teeth that are no longer in function:
. Reduced trabeculation ofbone
. Narrowing ofthe periodontal ligament space

if

. Eliminate plaque
. Clean nonadherent bacteria and debris fiom the oral cavity more effectively than
toothbrushes and mouth rinses.

. Disinfect pockets for up to

12 hours

. Prevent calculus formation

102
Coplrighr O

. Compose 5% to

l0o%

201

I-2012' De

al

Dcks

ofdentifrices

. Compose l0% to 20% ofdentifrices

. Compose

207o to 40%

ofdentifrices

. Compose

507o to 65%

ofdentifrices

103
Cop]'right O 20ll-2012 - Dental Decks

Oral irrigators for daily home use by patients work by directing a high-pressure, steady
or pulsating stream ofwater through a nozzle to the tooth surfaces. Most often, a device
with a built-in pump generates the pressure. Oral irrigators clean nonadherent bacteria
and debris from the oral cavity more effectively than toothbrushes and mouth rinses.
When used as adjuncts to toothbrushing, these devices can have a beneficial effect on periodontal health by reducing the accumulation ofplaque and calculus and decreasing inflammation and pocket depth.
Oral irrigation has been shown to disrupt and detoxify subgingival plaque and can be useful in delivering antimicrobial agents into periodontal pockets. Note: Daily supragingival
inigation with a dilute antiseptic, chlorhexidine, for 6 months resulted in significant reductions in bleeding and gingivitis compared with water irrigation and chlorhexidine rinse
controls. Irrigation with water alone also reduced gingivitis significantly, but not as much
as the dilute chlorhexidine.

immunocompromised

Important: Oral irrigators may be contraindicated in patients requiring antibiotic premedication prior to dental treatment since these devices have the potential for causing a
bacteremia. The patient's physcician should be consulted.

Remember: The pathology associated with gingivitis is completely reversible with the
removal ofolaoue and the resolution ofthe inflammation.

Dentifrices aid in cleaning and polishing tooth surfaces. They are used mostly in the form
of pastes, although tooth powders and gels are also available. Dentifrices are made up
ofabrasives (e.g., silicon oxides, aluminum oxides, granular polyvinyl chlorides), water,
humectants, soap or detergent, flavoring and sweetening agents, therapeutic agents
k.g.../luorides, pl,rophosphates), coloring agents, and preservatives.
-\brasives (conrpo se 20oZ to 40oZ ofdentifrices) arc insoluble inorganic salts that enhance
the abrasive action of toothbrushing as much as 40 times. Tooth powders are much more
abrasive than pastes and contain about 95% abrasive materials. The abrasive quality of
dentifrices affects enamel only slightly and is a much greater concem for patients with exposed roots. Dentin is abraded 25 times faster and cementum 35 times faster than enamel,
so root surfaces are easily wom away, leading to notching and root sensitivity.

\ote: Typically,
than on the right

more wear occurs on maxillary than mandibular teeth and on the left half
halfofthe dental arch.

Important: In dentifrices, fluoride ion must be available in the amount

pans per million (ppm) to achieve caries reduction effects.

of

1000

to 1100

"Calculus control toothpastes," also referred to as "tartar control toothpastes", contain

p).rophosphates and have been shown to reduce the deposition ofnew calculus on teeth.
These ingedients interfere with crystal formation in calculus but do not affect the fluoride ion in the paste. Dentifrice with pyrophosphates has been shown to reduce the formation of new supragingival calculus by 30o/o or more. Pyrophosphate-containing
toothpastes do not affect subgingival calculus formation or gingival inflammation. The
inhibitory effect reduces the deposition ofnew supragingival calculus but will not affect
existing calculus deposits.

. Stiffened end
. Spongy floss
. Regular floss

104

Coplriglt

2ol

2012 - Dtual Decks

. The amount and location ofplaque

. The caries experience

. The toothbrushing frequency

. The condition ofthe toothbrush

105
Cop)right O 20ll-2012 - Denial Decks

Super Flosso is ideal for cleaning braces, bridges and wide gaps between teeth. Its
three unique components - a stiffened end, spongy floss, and regular floss - all work
together for maximum benefits.

Three components:

. Stiff-end threader so you can floss under appliances

. Spongy floss cleans around appliances and between wide

spaces

. Regular floss removes interproximal subgingival plaque

Indications for use of Super

-''

Floss@ include plaque removal around the

following:

Isolated teeth
Teeth separated by a diastema
Wide embrasures where interdental papillae have been lost
Fixed partial dentures (bridgework)
Orthodontic appliances
ImDlants

Over the years, many different toothbrushing methods have been described and promoted as
being efficient and effective. These methods can be categorized primarily according to the
paftem of motion when brushing and are primarily ofhistorical interest. as follows:
. Roll: Roll method or modified Stillman technique
. f ibratory: Stillman, Charters, and Bass techniques
. Circular: Fones technique
. \'ertical: Leonard technique
. Horizontal: Scrub technique
Srudies evaluating the effectiveness of the most common techniques have demonstrated no
clear superiority for any method. The scrub technique is probably the simplest and most
common method ofbrushing. Patients with periodontal disease are most frequently taught a
sulcular brushing technique using a vibratory motion to improve access in the gingival areas.
The method most often recommended is the Bass technique because it emphasizes sulcular
placement ofbristles.
Bass method:
. Place tooth brush so that the bristles are angled approximately 45 degres from the tooth
surfaces. This allows the b stles to extend into the gingival sulcus when pressure is applied to the brush in a horizontal direction.
. Start at the most distal tooth in the arch, and use a vibratory. back-and-forth motion to
brush
Other methods dfbrushing, such as the modified Stillman and Charters, are variations ofthe
Bass technique also designed to achieve thorough plaque removal at the gingival margins.
They emphasize stimulation ofthe gingival circulation, which has not been demonstrated lo
achieve healing results beyond those achieved by good plaque removal.

lmportant: No matter what toothbrushing method is chosen, the manual toothbrush should have
soft nylon bristles and a small head. They should be replaced about every 3 months.

. Prescription solutions ofchlorhexidine digluconate oral rinse

. Prescription solutions oftehacycline oral rinse

. Nonprescription essential oil rinse
. Nonprescription solutions ofpenicillin oral rinse

copFiehr o

201

106
l-2012 - Dentai Decks

Which of the following oral hygiene aids is appropriate

for cleaning a Class If furcation?

. Stim-U-Dento
. Interproximal

brushes

. Interdental stimulator
. Perio

Aid@

. Oral irrigator

107
Cop),right O 201 l-2012 - Dental Decks

The agent that has shown the most positive antibacterial results to date is chlorhexidine, a
diguanidohexane wilh pronounced antiseptic properties. Thc 0.12y. chlorhexidine digluconate
preparation available in the United States for reducing plaque and gingivitis has been shown to bc
equally effective as the higher-concentratton prodlct (0.21% aEteous solution).
Localized, reversible side elfects ofchlorhexidine use may occur, primarily brown staining ofthe
teeth, tongue, and silicate and resin restorations and transicnt impairmcnt of tastc perception.
Chlorhexidine has very low systenic toxic activity in humans, has not produced any appreciable
resistance oforal microorganisms, and has not been associated with teratogenic alterations.
Note: 0.12% chlorhexidine contains l2% alcohol.
Chorhexidines effectiyeness may be explained by the f'act that it leaves the grcatest residual
conccntration in the moulh after its use. It is approved by theADA as an antimicrobial and antigingivitis agent. Examples include: Peridex and PerioGard,
Important: Substantivity is the ability of drugs to adsorb onto and bind to soft and hard tissues. The substantivity ofChlorhexidine was first described in the 1970s. Due to this property,
Chlorhexidine can maintain effective concentration for prolonged pcriods of time.

fssential oil mouth rinses contain thymol, eucalyptol, methanol, and methyl salicylatc. These
products also contain alcohol (up to

24

dependtugon the preparallanl. An example is Listerine.

A product containing triclosan has shown some effectiveness in reducing plaque and gingivitis. It
rs a|ailable in toothpaste form, and the activc ingredient is more effective in combination with zinc

citratc or a copolymer ofmethoxyethylene.

Other oral rinsc products on the market have shown some evidencc ofplaque rcduction, although
long-term improvement in gingival health has not been substantiated. These include stannous fluoride. cetylpyridinurn chloide (quaternary afimo ia compounds), and sanguinarine.

A tapered, round toothpick is inserted into the hole in the carrier and is then broken off.
The tip is left in and is used in a tracing motion along the gingival margins. It is also helpful in cleaning furcations that are accessible.
. Stim-U-Dento (balsa wood wedges): these are of primary importance in gingival
massage. They are also good for patients with interdental recession. These picks /rriangular in cross seclion) are small enough to fit into most interdental spaces. As a supplement to brushing, they are useful for dislodging interproximal debris often missed
bl meticulous brushing and for massaging the underlying interproximal gingiva.
. Interproximal b rushes (proxabrusft): are used for interdental cleansing when the interdental space is wide. The brushes are replaceable.
. Interdental stimulator: consists of a rubber tip of smooth or ribbed conical shape attached to a handle or to the end ofa toothbrush. Its action massages rnd stimulates circulation of the interdental gingiva and may increase the tone ol the tissue. It is not
recorlmended for areas in which the papillae are normal and fill the interproximal spaces.
It may cause injury to the gingival tissue.

Remember:
replaces brushing and flossing for removal ofor disruption ofplaque.
2. Frequent brushing and flossing helps to prevent calculus formation by breaking up
the matrix of plaque,
3. New plaque growth occurs shortly after brushing and flossing (starts interproxinrally and works its way arotnd the tooth).

l. Nothing

10o%

Doxycycline gel

. 2% Minocycline microspheres
.

25olo

Metronidazole gel

. Chlorhexidine (2.5 mg) in gelatin matrix

108
Copyrighr O 201l'2012 - Dental

Deks

. Periodontal ligament
. Cementum
. Alveolar bone
. Gingiva

109
Coplright O 201 I -20 12 - Dnhl Decks

The limitations ofmouth rinsing and irrigation have prompted research for lhe development ofaltemative
delivery systems. Recently, advances in dclivery technology have resulted in the controllcd relcase ofdrugs.
. Subgingival Doxycycline: The FDA approved l0% doxycline in a gel system usirg a syrin ge (Atridox.).
It is the only local delivery system accepted by the ADA.
. Subgingival Minocyclin: The FDArcccntly approved a neq locally delivcrcd. sustained-releasc form
ofminocycline micrcspheres f,1/erl,r,, for subgingival placement as an adjunct to scaling and root planing. The 2% minocycline is encapsulated into bioresorbable microspheres in a gel carrier
. Subgingival Metronidazole: A topical medication containing an oil-based metronidazole 25o dental
gel (glycerol mono-oleate and sesame oil) has been tested in a number of studies. This product is not
available in the U.S.
. Chlorhexidine in a gel.tin matrit: A resorbable delivery system has been tested lor the subgingival
placement ofchlorhexidine gluconate with positive clinical results. PerioChip is a small chlp (1.0 x 5.0
r 0.JJ ,in) composed ofa biodegadable hydrolyzed gelatin matrix, cross-linked with glutaraldehyde and
also containing glyccrin and water, into which 2.5 mg ofchlorhexidine gluconatc has been incorporatcd
per chipSt"stemic administration of antibioticsl
. Tetracycfincs: used to treat LAP f/oca lly aggressiw periodorlitrt, have the ability to concentrate in
the periodontal tissues and inhibjt the growlh ofActinobacillus actinotherapeulics AdJ. Notei Subanlimicrobial-dose doxycycline fSDDl is a 20-mg dose ofdoxycycline (Perioslat) lhal is apprcved and indicated as an adjunct lo scaling and root planing in the trealment ofchronic periodontitis. It is taken twicc
dajl-'.' for 3 months, up to a maximum of9 months continuous dosing.
. |\Ietronidazole: is effective against Aa when used in combination with other agents. It is effective
against anaerobes such as Porphlromonas gingivalis and Prevotella intermedia.
. Pnicilfins lamoxicill{n and anoxicillin-cla|uldnate potassiun fAugnentin|), may be useful in the
manacement ofaggressive periodontitis t'rotft localized and generali:ed Jbrms).
. Ccphalosporins: not often used to treat dental-related infections.
. Clindamycin: used when patients are allergic to penicillin.
. Ciprofloxacin: is the only antibiotic in periodontal therapy to which all strains ofAa are susceptible.
. Uacrolides /e,:'-/rmmycin, spiramycin, and azilhrom!-cin): only azithromycin is used and appears to
conccntrate in gingival tissues.

The periodontiurr consists ofthe investing and supporting tissues ofthe tooth: gingiva,
periodontal ligament, cementum, and alveolar bone. It has been divided into two parts:

l. Gingiva:
2.

the main function

ofwhich is protecting the underlying rissues

Attachment apparatus: composed ofthe:

. Periodontal ligament
. Cementum
. Alveolar bone

The cementum is considered a part ofthe periodontium because, with the bone, it serves
as the support for the fibers ofthe periodontal ligament.
The gingival fluid (sulcular.fluid) contains components ofconnective tissue, epithelium,
inflammatory cells, serum, and microbial flora inhabiting the gingival margin or the sulcus lpocket).In the healthy sulcus the amount ofgingival fluid is very small. During inflammation, however, the gingival fluid flow increases, and its composition start to
resemble that of an inflan'matory exudate.
The main route ofthe gingival fluid diffusion is through the basement membrane, through
the relatively wide intracellular spaces of the jrurctional epithelium, and then into the sulcus.

The gingival fluid is believed to:

. Cleanse material from the sulcus
. Contain plasma proteins that may improve adhesion ofthe epithelium to the tooth
. Possess antimicrobial properties
. Exert antibody activity to defend the gingiva

. From the gingival maxgin to the interdental groove

. From the free gingival groove to the gingival margin

. From the mucogingival junction to the iree gingival groove

. From the epithelial attachment to the cementoenamel junction

110

CoplriShr O 2011,2012 - Denkl Deck

The gingival fibers ar erranged in three groups. Which of the

following is not one ofthose groups?

. Circular group
. Gingivodental group
. Apical group

. Transseptal group

111

Coplright O 20ll-2012 - Denral Deck

ln an adult, normal gingiva covers the alveolar bone and tooth root to a leveljust coronal to the CEJ.
The gingiva is divided anatomically into marginal, attached, and interdental arcas.

. Marginal or unattached gingiva:

is the terminal edge or bordcr ofthe gingiva sunounding thc

teeth in collar-like fashion. In about 5002 ofcases, it is denarcated from tho adjacent attached gingiva by a shallow linear depressior, the free gingival groove. Usually about 1 mm wide, the marginal gingiva forms the soft tissue wall ofthe gingival sulcus.
. Attached gingiva: is continuous with the marginal gingiva. It is firm, resilient, and tightly bound
to the underlying periosteum ofalveolar bonc. Thc facial aspect ofthe attached gingiva extends to
the relatively loose and movable alveolarmucosa and is demarcated by thc mucogingival junction.

*** The width of the attached gingiva is an important clinical parameter. It is the distance betwcen thc mucogingival junction and the projection on thc extcmal surface ofthe bottom ofthe
gingival sulcus or the periodontal pocket. [t should not be confused with lhe width ofthe keratinizcd gingiva because the latter also includes the marginal gingiva.
*** The width ofthc attached gingiva on the facial aspect diffcrs in different areas ofthc mouth.
It is generally grcatest in the incisor region and narrowcr in the posterior segmcnts.
"** Because the mucogingival junction remains stationary throughout adult life, changes in the
\\'idih ofthe attached gingiva are caused by modifications in the position ofits coronal portion.
The width ofthe attached gingiva increases with age and in supraerupted teeth.
. Ilterdental gingiva: occupies

the gingival embrasurc, which is the interproximal space beneath

the area oftooth contact. The interdental gingiva can be pyramidal or can have a "col" shape. Thc
:hape ofthe gingiva in a given interdental space depends on the contact point between the two adjoining teeth and the presence or absence ofsomc degree ofrecession.

\ote: "Stippling" of the attached gingiva refers to the irregular surfacc texture of the attached
gingiva, similar to the surlace of an orange peel. Stippling occurs at the intersection of epithelial
ridges that causes the depression and the interspersing ofconnective tissue papillae between these
intersections giving rise to the small bumps.

Thc conncctive tissue ofthe marginal gingiva is densely collagenous, containing a prominent systern ofcollagen fiber bundles called the gingival fibers. They consist oftype I collagen. The ginsival fibers have the following functions:
1 To brace the marginal gingiva firmly against the tooth.
L To provide the rigidity necessary to withstand the forces of mastication without being deflected away from the tooth surface.
I To unitc the free marginal gingiva with the cementum ofthe root and thc adjacent attached gingi\ a.
The gingilal fibers arc arranged in three groups:
. Gingirodental group: thcsc fibers are those on the lacial, lingual, and interproximal surfaces.
They'are embedded in the ccmentum just beneath the epithelium at the base ofthe gingival sulcus.

. Circular group:

these fibers course through the connective tissue of the marginal and interdcntal gingivae and encirclc thc tooth in ringlike fashion. They resist rotational forces.
. Transseptal group: these fibers arc located interproximally and fonn horizontal bundles that
extend betrveen the cemenhrm of approximating teeth into which they are embedded. They lie
in the area between thc cpithelium at the base ofthe gingival sulcus and the crest of the interdental bone. They are sometimes classified with the principal fibcrs ofthe PDL.

. 1. The attachment apparatus is a term used to descibe lhese gingival fibers and the
\otetl epithelial attachment.
.:...,-.:.a; 2. Some studies have also described two more gingival fiber groups: (1) a group of
''*-''
semicircular fibers and (2) a group of transgingival fibers
3. Tractional forces in the extracellular matrix produced by fibroblasts are believed to
be the forces responsible lbr generating tension in the collagen. This keeps the teth
tishtlv bound to each other and to the alveolar bonc.

\
Beeause ofthe high turnover rate, the connective tissue

ofthe gingiva has a

remarkably good healing and regenerative capacify.

The reparative capacity ofthe gingival connective tissues is not as great as
that ofthe periodontal ligament or th epithelial tissue.

. The first statement is true; the second statement is false

. The

second statement is true; the fust statement is false

. Both

statements are true

. Both statements are false

112
CoD,riglrl O 20ll-2012 - Dental Decks

The principal libers ofthe periodontal ligament are arranged in four groups.

The molecular configuration ofcollagen fibers in the periodontal ligament

proyides them with a tensile strength greater than that of steI,

. The first statement is true; the second statement is false

. The

second statement is true; the first statement is false

. Both statements are true

. Both statements are false

113

Cop)righr O 20ll-2012 - Dntal Decks

The dominant cellular element in the gingival connective tissue is the fibroblast. Numerous
fibroblasts are found between the fiber bundles. Fibroblasts are of mesenchymal origin and
play a major role in the development, maintenance, and repair ofgingival connective tissue.

Mast cells are numerous in the connective tissue ofthe oral mucosa and the gingiva. Fixed
macrophages and histiocytes are present in the gingival connective tissue as components of
the mononuclear phagoclte system and are derived from blood monocytes. Adipose cells and

eosinophils, although scarce, also are present in the lamina propria.

In clinically normal gingiva, small foci of plasma cells and lymphocytes are found in the
corurective tissue near the base ofthe sulcus. These inflammatory cells usually are present in
smallamounts in clinically normal gingiva.
Three sources ofblood supply to the gingiva are as follows;
l Supraperiosteal arterioles: along the facial and lingual surfaces ofthe alveolar
from which capillaries extend along the sulcular epithelium and between the rete pegs
ertemal gingival surface.
2. Vessels ofthe PDL: which extend into the gingiva and anastomose with capillaries
sulcus areai. Arterioles: which emerge fiom the crst ofthe interdental speta and extend parallel
crest ofthe bone to anastomose with vessels ofthe PDL.

bone,

ofthe
in the
to the

The l1'mphatic drainage olthe gingiva brings in the lymphatics ofthe connective tissue papi!
lae. lt progresses into the collecting network extemal to the periosteum ofthe alyeolar process,
then ro the regional lymph nodes, particularly the submaxillary group.

\\'ithin the gingival connective tissues, most nerve fibers are myelinated and are closely associated with the blood vessels. Gingival innervation is derived from fibers arising fiom nerves
in the PDL and from the labial, buccal, and palatal nerves.

The most important elements ofthe periodontal ligament arc the principal fibers, which arc collagenous and ananged in bundles and follow a wavy course whcn viewed in longitudinal section.
The terminal portions ofthe principal fibers that are inserted into cementum and bone ar termed
Sharpe3-'s fibers.

fhc principal fibers ofthe pcriodontal ligament are arranged in six groups that develop sequentially
in the dcveloping root:
. Transseptal fibers: extend interproximally over thc alveolar bone crest and are embedded in
the cementum ofadjacent teeth. These fibers keep all the teeth aligned (they maintain the integrity
ol rhe dental arches). Note: These fibers may be considered as belonging to the gingiva because
rhe)' do not have osseous attachment.
. Alreolar crest fibers: extend obliquely from the ccnentum just beneath the junctional epirhelium to the alveolar crest. These fibers prevent the extrusion of the tooth and resist latelal
tooth movements.
. Horizontal fibers: extend at right angles to the long axis of the tooth from the cementum to
the ah eolar bone.

. Oblique Iibers: the largest group in the periodontal ligament, they extend from the cementum
in a coronal direction obliquely to the bone. They bear the brunt ofvertical masticatory stresses
and transform them into tension on the alveolar bone.
. Apical tibers: radiate in a rather ircgular manner from the cementum to the bone at the apical region ofthe socket. They do not occur on incompletely formed rcots.
. Interradicular fibers: fan out from th cementum to the tooth in the furcation areas of multirooted tceth.

\ote: Small collagen fibers associated with the larger principal collagen fibers have been found.
These fiben run in all directions, fonning a plexus called the indifferent fiber plexus.
Important: The molecular configuration of collagen fibers provides them with a tensile
strength greater than that of steel. Consequently, collagen imparts a unique combination of
flexibility and strength to the rissues

. The first statement

. The

is true; the second statement is false

second statement is true; the first statement is false

. Both statements are true

. Both statements are false

114
Coplright

201 1-201 2

- Denlal Decks

Csrvicrl line contours are closIy related to the att|chment

rt the neck of th tooth. The greatest contour

ofthe cervical lines and gingival attachments occur on:

of the gingiva

. The distal surface ofanterior teeth

. The distal surface ofposterior teeth

. The mesial surface olanterior teeth

. The mesial surface ofposterior teeth

115
Cop),right O 201 l-2012 - Denbl Decks

The junctional epithelium consists ol a collar-like band of stratifred squamous nonkeratinizing epithelium. It is thee to four layers thick in early life, but the number of layers increases with age to l0 or even 20layers. Also, thejunctional epithelium tapers from its coronal
end, which may be l0 to 29 cells wide to one or two cells at its apical termination, located at
the CEJ in healthy tissue. These cells can be grouped in two stata; th basal layer facing the
connective tissue and the suprabasal layer extending to the tooth surface. Not: The length of
the junctional epithelium ranges from 0.25 to 1.35 mm (ayerage is 0.97 mm).

Thejunctional epithelium is formed by the confluence ofthe oral epithelium and the reduced
enamel epilhelium during tooth eruption. However, the reduced enamel epithelium is not essential for its fonnation; in fact, the junctional epithelium is completely restored after pocket
instrumentation or surgery and it forms around an implant.

Thejunctional epithelium is attached to the tooth sudace (epithelial attachment) by means of

an internal basal lamina. It is attached to the gingival connective tissue by an xternal basal
lamina. The intemal basal lamina consists ofa lamina densa (qdjqcent to the enamel) anda
lamina lucida to which hemidesmosomes are attached. Hemidesmosomes have a decisive
roie in the firm attachment ofthe cells to the intemal basal lamina on the tooth surface.
In order for a new attachment to folm after periodontal treatment the following must occur:
1. Complte removal of calculus, altered cementum, diseased junctional epithelium, and

pocket epithelium

2. Need undifferentiated mesenchymal cells

lmportant: The junctional epithelium in disease (which

is referred to as a longjunctional epitheliunt) is different from the junctional epithelium in health. In disease, migration of the
junctional epithelium occun, along with degeneration in the connective tissue under the attachment; as the junctional epithelium prolilerates along the root surface /gers longer) the

coronal portion detaches. Barrier membranes, which are often used to treat bony defects, help
to pre\ enl this long junctional epithelium lrom forming.

***

The mesial surface ofthe maxillary central has the greatest curvature.

All teth generally have a greater proximal cervical line (CEJ) curvature on the mesial
rhan the distal. Also, the proximal cervical line (CEJ) cuwanres are grater on the incisors and tend to get smaller when moving toward the last molar, where there may be no
cun ature at all.
The cemento-enamel junction ofall teeth curves in two directions:
. Tolvards the apex on the facial and lingual surfaces
. Arra!'from the apex on the mesial and distal sufaces

ln the absence of periodontal disease, the configuration of the crest of the interdental
alr eolar seota is determined bv the oosition ofthe CEJ on adiacent teeth.
The rvidth ofthe interdental alveolar bone is determined by the tooth form present. RelatiYely flat proximal tooth surfaces call for narrow septa, whereas in the presence of an
extremely convex tooth surface, wide interdental septa with flat crests are found.

On the lingual surfaces of maxillary incisors and the facial surfaces of maxillary
first molars

. On the facial surfaces of mandibular second premolars and the lingual surface

of

canines

. On

the facial surfaces of the mandibular canine and

surfaces adjacent to the

lirst premolar

mandibular incisors and canines

. None ofthe above

'fi6
Cop) rieht O 201 l -201 2 - Dntal

Deks

. Buccal mucosa
. Vermillion border of the lips

. Hard palate
. Gingiva

117

Copright O20ll-2012

- Dental

Deck

and the lingual

*** Narrow gingival zones

may occur also at the mesiobuccal root of maxillary first

molars, associated with prominent roots and sometimes with bony dehiscences ard at the
mandibular third molars.
The width ofthe attached gingiva is determined by subtracting the sulcus or pocket depth

from the total width ofthe gingiva (gingival margin to mucogingival lize). This is done
by stretching the lip or cheek to demarcate the mucogingival line while the pocket is being
probed. The amount of attached gingiva is generally considered to be insufncient when
stretching ofthe lip or cheek induces movement ofthe free gingival margin.
The width of the attached gingiva on the facial aspect differs in different areas of the
mouth. It is generally greatest in the incisor region (3.5- 4.5 mm in maxilla, 3.3-3.9 mm in
mandible), and narrower in the posterior segmeats (1.9 mm in maxillary and 1.8 mm in
m an dib u I ar.fi rs t premo lars ).

Important: A "functionally adequate" zone of gingiva is defined as one that is keratinized, firmly bound to tooth and underlying bone, about 2.0 mm or more in width, and
resistant to probing and gaping when the lip or cheek is distended.

,. L The "attached" gingiva is structured

. foteq tication and brushing.
,

!*;

to withstand frictional stresses ofmas-

2. The alveolar mucosa appears to be well-adapted to permit movement but is

not able to withstand frictional stresses.

Ttre three functional types of oral mucosa are lining, masticatory and specialized mucosa. These
renns provide functional descriptions ofthe oral mucosa in specific locations.

. \Iasticatory mucosa: covers the gingiva and hard palate.

- Epithelium: it has a keratinized or parakcratinized stratified squamous epithelium.
Lamina propriar has two layers: a thick papillary layer ofloose connective tissue and
reticular layer ofdense connective tissue.
-

. Lining mucosa: coven all of soft tissue ofthe oral cavity except

deep

the gingiva, hard palate, and

donal surface ofthe tongue.

- Epithelium: genefallt the epithelium of the lining

mucosa is nonkeratinized. On the versubjcct to unusual frictional strcss, thc

epithelium may become parakeratinized or keratinized. Other cells found in the cpithelium of
rhe lining mucosa are Langerhans cells, melanocytes, and Merkel cells.
- Lamina propria: under the epithelium ofthe lining mucosa, a loose connectivc tissue with
thin collagen fibers forms a papillary larnina propria that caries blood vessels, lymphatic ves-

million border ofthe lip, however, it is keratinized.

lf

sels. and nerves.

- Submucosa: a distinct submucosa underlies the lining mucosa, except on the inferior ofthe
tongue. The submucosa contains large bands ofcollagen and elastic fibers that bind the mucosa
to the undcrlying muscle. The submucosa also contains the larger nerves, blood vessels, and
lymphatic vessels that supply the neurovascular networks ofthe lamina propria throughout the
oral cavity. In the lips, tongue, and cheeks, the submucosa contains many minor salivary glands.
- Specialized mucosa: is restricted to the dorsal surface ofthe tongue, and is characterized by
the presence of surlace papillae of several types and by tastc buds in the epithelium. Thc cpithelium is keratinized.
mucosa, whether keratinized, nonkeratinized or parakeratinized, is ofthe stratified squamous type ofepithelium and the underlying central core ofconnective tissue. Although
the epithelium is predominantly cellular in nature, the connective tissue is less cellular and composed primarily ofcollagen fibers and ground substance.

Important: All oral

Bone consists of:

. Two-thirds organic matter and one-third inorganic matrix

. One-third organic matter and two-thirds inorganic matrix
. One-halforganic matter and one-half inorganic mahix

. Two-thirds inorganic matter and one-third organic matrix

118

CopFighr

e 201I'?012 ' Dotd

Cop)'ighr

Decks

. Cementoblasts
. Osteoblasts

. Fibroblasts
. Macrophages

t19
201 I

'2012 - Dertal Decks

The alveolar process is the portion ofthe maxilla and mandible that forms and supports the tooth
sockets (alveoli).lt forms when the tooth erupts to provide the ossous attachment to the forming
PDL; it disappears gradually after the tooth is lost. The alveolar process consists ofthc lbllowing:

. An external plate ofcortical bone formed by haversian bone and compacted bone lamellae.
the alveolar bone proper, which is secn as
the lamina dura in radiographs. Histologically, it contains a series ofopenings f.'ribriform plute)
through which neurovascular bundles link the PDL with the central component ofthe alveolar

. The inner socket wall ofthin, compact bonc callcd

bone, the cancellous bone.

. Cancellous trabeculae, betwecn these two compact layers, which act as supporting alveolar
bone. The interdental septum consists of cancellous supporting bone enclosed within a compact border.
In addition, thc bones ofthejaw includc the basal bone, which is the portion ofthc jaw located apically, but unrelated to the teeth.

Most ofthe facial and lingual portions ofthe sockets are formed by compact bone alone; cancellous bone surrounds the lamina dura in apical, apicolingual, and interradicular arcas.
Osteoblasts, the cells that prcduce the organic matrix ofbone, are differentiated from pluripotent
follicfe cells. Alveolar bone is formed during fetal growth by irrrd membranous ossification and consists ofa calcified matrix with osteocytes enclosed within spaces called lacunae.
Bone consists oftwothirds inorganic matter and one{hird organic matrix. The inorganic matrix
is composcd principally ofthe minerals calcium and phosphatc, along with hydroxyl, carbonate, citrate. and trace amounts ofother ions, such as sodium, magnesium, and fluoride. The mineral salts
are in the form of hydroxyapatite crystals and constitute approximately two thirds of the bone
structure.
The organic matrix consists mainly of collagen type | (90%), with small amounts ofnoncollagenous proteins such as ostcocalcin, osteoncctin, bonc morphogcnetic protcin, phosphoproteins, and

proleoglycans.

Types ofcells identified in the periodontal ligament;

. Connective tissue cells: fibroblasts, cementoblasts. and osteoblasts. Fibroblasts are the most
comnlon cells, they synthesize collagen and possess the capacity to phagocytoze "old" collagen
fibers. Note: Cementoclasts and osteoclasts are also sen in the cemental and osseous surlaces

ol-thc PDL.

. Epithelial rest cells:

the epithelial rests of Malassez form a latticework in the periodontal ligament and are considered remnants of Hertwig's root sheath, which disintegrats during root
der elopment. They are distributed close to the cementum throughout the PDL ofmost teeth and
are most numerous in the apical and cervical arcas.
. Defense cells: include neutrophils, lymphocl4es, macrophages, mast cells, and eosinophils.
These cells. as well as those associated with neurovascular elements. are similar to the cells in
other connective tissues.

Tbe lunctions ofthe periodontal ligament are categorized into:

Ph!sical: attachment ofthe tooth to the bone via principal fibers and the absorytion ofocclusal
tbrces.
Formatiye: fonnation ofconnective tissue components by activities ofconnective tissue cells
r cent erttoblas ts, f brob lasts and osteoblasts).
Remodeling: by activities ofconnective tissue cells that are able to form as well as resorb cementum lcementoblasts or cementoclasts), the periodontal ligament (fibroblasts oljibrocldsts),
and the alveolar bone (osteoblasts or osteoclasts).
\utritive: through blood vessels that maintain the vitality ofits various cells.

Sensory: carried by the trigeminal nerve, proprioceptive and tactile sensitivity is impaded
th.ough PDL f.ler.ralion ofcontact behl,een leeth).
Note: The periodontal ligament also contains a large proportion of ground substance, filling the
spaces between the fibers and cells. It consists of two main components: glycosaminoglycans,
such as hyaluronic acid and proteoglycans, and glycoproteins, such as fibronectin and laminin.
Tbe PDL rnay also contain calcified masses called cementicles, which are adherent to or detached
from the root surfaces. These develop from calcified epithelial rests.

. The first statement is true; the second statement is false

. The

second statement is true; the first statement is false

. Both statements are true

. Both statements are false

120
Coplriglu O

201

l-2012 - Denrnl Decks

Although the average width ofthe periodontd ligrment space is documentad

to be about
considerable variation exists.

_,

. 0.002 mm
. 0.2 mm
. 2.0 mm

.20 mm

121
Coplrighr O

201

l'2012 - Dental Decks

Collagen is synthesized by fibroblasts, chondroblasts, osteoblasts, odontoblasts, and other

cells. The several tlpes ofcollagen are all distinguishable by their chemical composition,
distribution, function, and morphology. The principal fibers ofthe periodontal ligament
are composed mainly ofcollagen type I, whereas reticular fibers are composed ofcollagen type III. Collagen type lV is found in the basal lamina.

Collagen is a protein composed ofdifferent amino acids, the most important ofwhich are
glycine, proline, hydroxylysine, and hydroxyproline. The amount of collagen in a tissue
can be determined by its hydroxyproline content. Collagen is responsible for maintenance ofthe framework and tone oftissue.
1. Less regularly arranged collagen fibers are found in the interstitial connec-

lqo1"3; tive tissue between the principal fiber groups; this tissue contains the blood
vessels. lymphatics. and nerves.

2. Although lhe periodontal ligament does not contain mature elastin, two

immature forms are found; oxytalan and eluanin. The so-called oxytalan
fibers run parallel to the root surface in a vertical direction and bend to attach
to the cementum in the cervical third ofthe root. They are thought to regulate
vascular flow.
3. The principal fibers are remodeled by the periodontal ligament cells to adapt
to physiologic needs and in response to different stimuli.

***

The periodontal space is diminished around teeth that are not in function and in
unerupted teeth, but it is increased in teeth subjected to h,?erfunction.

ofa complex vascular and highly cellular connectile tissue that surrounds the tooth root and connects it to the irmer wall of the alveolar
bone. It is continuous with the connective tissue ofthe gingiva and communicates with
the marow spaces through vascular channels in the bone.
The periodontal ligament is composed

The periodontal ligament is abundantly supplied with sensory nerve fibers capable of
rransmitring tactile, pressure, and pain sensations by the trigeminal pathways. Nerve bundles pass into the periodontal ligament flom the periapical area and through channels from
the alveolar bone that follow the course ofthe blood vessels. The bundles divide into single myelinated fibers, which ultimately lose their myelin sheaths and end in one of four
qpes of neural termination:
1. Free endings, which have a treelike configuration and carry pain sensation.
2. Ruffini-like mechanoreceptors, located primarily in the apical area.
3. Coiled Meissner's corpuscles, also mechanoreceptors, found mainly in the midroot
region.
,1.

Spindlelike pressure and vibration endings, which are surrounded by a fibrous

capsule and located mainly in the apex.

\ote:

Orthodontic treatment is possible because the PDL continuously responds and

changes as a result ofthe functional requirements imposed upon it by extemally applied
forces.

. Thick, keratinized stratified squamous epithelium without rete pegs

. Thick, nonkeratinized stratified squamous epithelium with rete pegs
. Thin, keratinized nonstratified squamous epithelium with rete pegs

. Thin, nonkeratinized stratified squamous epithelium without rete pegs

122
Copright O 20ll-2012 - Dnbl Decks

. Decrease in the pH
. Increase in the pH

Decrease in the viscosity

. Increase in the viscosity

123
Cop)'righr @ 201 I '2012 - Dental Dcks

The epithelial component ofthe gingiva shows regional morphologic variations that reflect tissue adaptation to the tooth and alveolar bone. These variations include:

. Oral (outer) epithelium:

covers the crest and outer surlace ofthe marginal gingiva and
the sudace of the attached gingiva. On average, the oral epithelium is 0.2 to 0.3 mm in
thickness. lt is keratinized or parakeratinized. The oral epithelium is composed offour layen: stratum basale, stratum spinosum, stratum granulosum, and stratum comeum.
. Sulcular epithelium: lines the gingival sulcus, it is a thin, nonkeratinized stmtified squamous epithelium without rete pegs, and it extends from the coronal limit ofthe junctional
epithelium to the crest ofthe gingival margin.
. Junctional epithelium: consists of a collarlike band of stratified squamous nonkeratinizing epithelium. It is three to four layers thick in early life, but the number oflayers increases with age to l0 or even 20 layers. Also, the junctional epithelium tapers liom its
coronal end, which may be l0 to 29 cells wide to one or two cells at its apical termination,
located at the CEJ in healthy tissue. These cells can be grouped in two strata; the basal layer
f'acing the connective tissue and the suprabasal layer extending to the tooth surface. The
length ofthejunctional epithelium ranges from 0.25 to 1.35 mm,

lmportant: The attachment ofthejunctional epithelium to the tooth is reinforced by the ginsival fibers. which brace the marginal gingiva against the tooth surface. For this reason, the
junctional epithelium and the gingival fibers are considered a functional unit, refered to as the
dentogingiYal unit.

\ote: Histologicalll', the best way to distinguish the free gingiva from the epithelial attachment is the fact that the epithelium ofthe epithelial attachment does not contain rete pegs and
the free gingiva does. Rete pegs are epithelial projections that extend into the gingival connectir e tissue. Connective tissue projections that extend into the overlying epithelium are
called connective tissue papillae.

The theoretic mechanisms by which plaque becomes mineralized can be grouped into two
maln categofles:

L14ineral precipitation results from a local rise in the degree ofsaturation ofcalcium and
phosphate ions, which may occur through the lollowing mechanisms:
. An increase in the pH ofthe saliva causes precipitation of calcium phosphate salts by
lot\ ering the precipitation constants. The pH lnay be elevated by the loss ofcarbon dioxide and the formation ofammonia by dental plaque bacteria.
. Colloidal protins in saliva bind calcium and phosphate ions and maintain a supersaturated solution with respect to calcium phosphate salts. With stagnation of saliva. colloids settle out, and the supersaturated state is no longer maintained, leading to
precipitation of calcium phosphate salts.
. Phosphatase liberated from dental plaque, desquamated epithelial cells, or bacteria precipitates calcium phosphate by hydrolyzing organic phosphates in saliva, thus increasing
the concentration offree phosphate ions.
2. Seeding agents induce small foci ofcalcification that enlarge and coalesce to form a calcified mass. This concept is refered to as tbe epitactic concept, or more appropriately, heterogenous nucleation. lt is suspected that the intercellular matrix ofplaque plays an active
role as the seeding agent. The carbohydrate-protein complexes may initiate calcification by
removing calcium from saliva (chelation) and binding with it to form nuclei that induce
subsequent deposition of minerals.

\ote: Mineralization of plaque

starts extracellularly around both gram-positive and gramnegative organisms. Bacterionema and Veillonella species have the ability to form intracellular hydroxyapatite crystals.

Remember: Materia alba is a concentation ofmicroorganisms, desquamated epithelial cells,

leukocytes. and a mixture ofsalivary proteins and lipids, with few or no food particles, and it
lacks the regular intemal pattem observed in plaque.

. Desquamated epithelial cells

. Gingival crevicular fluid

. Phosphatases formed by bacterial plaque

. Saliva

121
Cop''righr C 20ll-2012 - Dental Dcks

. Microorganisms
. Water
. Minerals

. Tissue cells

125
Coptright O 20ll-2012 - Dnral Decks

Calculus is dental plaque that has undergone mineralization. lt forms on the surfaces of
natural teeth and dental prostheses. Saliva is the source of mineralization for supragingival
calculus, whereas the serum bansudate called gingival crevicular fluid fumishes the minerals for subgingival calculus.
. Supragingival calculus: is located coronal to the gingival margin. It is usually white or
pale yellow in color and is hard with a claylike consistency. lt is easily removed by a professional cleaning. The two most comrnon locations for supragingival calculus to develop
are the buccal surfaces of the maxillary molars and the lingual surfaces ofthe mandibular
anterior teeth. Saliva from the parotid gland flows over the facial surfaces ofthe maxillary
mola$ through Stensen's duct, whereas the odfices of Whadon's duct and Bartholin's duct
empty onto the lingual surfaces ofthe mandibular incisors from the submandibular and sublingual glands, respectively.
. Subgingival calculus: is located below the crest of the marginal gingiva. lt is typically
hard and dense and frequently appears dark brown or greenishtiack (due to exposure to gingival crevicular JIuidJ while being firmly attached to the tooth surlace
Differences in the manner in which calculus is attached to the tooth surface affect the relative
ease or dilfjculty encountered in its removal. lt has been shown that calculus can attach to
tooth surfaces through four modes:
l. Attachment by means ofan organic pellicle on enamel: most common mode
2. Mechanical locking into surface irregularities
3. Close adaptation of calculus undersurface depressions to the gently sloping mounds of
the unaltered cementum surface
,1.

Penetration ofcalculus bacteria into cementum

Important: A reduction in gingival inflammation and probing depths with

a gain in clinical

aftachment can be observed after removal ofsubgingival plaque and calculus.

Dental plaque is dcfined clinically as a structured, rcsilicnt, yellow-grayish substance that

fixed restorations.
glycoprotcins
primarily
and exhacellular
Plaquc is
composed of bacteria in a matrix of salivary
polysaccharides. The microorganisms exist within an intercellular matrix that also contains a few
adheres tenaciously to the intraoral hard surfaces, including removable and

host cells. such as epithclial cells, macrophages, and leukocltes.

Dental plaque is broadly classified as:

. Supragingival plaque: is fould at or above the gingival rnargin; when in direct contact with
the gingival rrargin, it is rferred to as marginal plaque. Gram-positivc cocci and short rods predominate at thc tooth surface, whereas gram-negative rods and filaments, as well as spirochctcs,
predominale in (he outer surfacc ofth matue plaque mass.
. Subgingival plaque: is found below the gingival margin, between the tooth and the gingival
pocket epithcliurn. In general, the subgingival microbiota diffcrs in composition from the
sr-rpragingival plaque, primarily because of the local availability ofblood products and the low
oxrdation-reduction lredo.r) potential, which characterizes the anaerobic envircnment. Cervical plaque:
- Tooth associated; gram-positive rods and cocci
- Tissue associated: gram-negative rods and cocci, filaments. flagellated rods and spirochetcs

. Deeper parts ofthe pocket:

- Tooth associated: gram-negative rods
- Tissue associated: gram-negative rods, flagellated rods and spirochetes. Filamentous organisms become fewer
Ke! point:The composition ofthe subgingival plaque depends on the pocket depth. The apical part
is dominated by spirochetes, cocci, and rods, whereas in the coronal part, more filaments are observed.
Important: The overall pattem obscrved in dental plaque development shows a shift from the early
aerobic environment characterized by gram-positive facultative specis to a highly oxygen-deprived environment in which $am-negative anaerobic microorganisms prcdominate.

. Adhesion

. Pleomorphism
. Coaggregation

. Orgarization

126
CoDright

201l-2012 - Dnhl Decks

. Porphyromonas gingivalis

. Tannerella forsyhia
. Treponema denticola
. Eikenella conodens

127
Coplright O 201 I -20 12 - Dental Decks

The process ofplaque formation can be divided into three major phases:
1. The formation of the pellicle on the tooth surface: all surfacs ofthe oral cavity are coated
with a pellicle (the initial phase ofplaque deNelopment). Within nanoseconds atler vigorously
polishing the tecth, a thin, saliva-derived layer, called the acquired pellicle, covers the tooth
surface. This pellicle consists ofnumerous components, including glycoproteins fnrrcins), pro-

line-rich proteins, phosphoproteins fe.g., .rtatherin),histidine-nch proteins, enzymes (e.g., alphaamylase.), and other molecules that can function as adhesion sites for bacteia (receptors).

Note: The mechanisms involved in enamel pellicle formation include electrostatic, van der
Waals, and hydrophobic forces.
2. lnitial adhesion and attachment of bacteria:

- Phase l: Transport to the surfacei involves the initial tmnsport of the bacterium to the

tooth surface.
- Phase 2: Initial adhesion: results in an initial, reversible adhesion ofthe bacterium, mediated through van der Waals and elecfostatic forces.
- Phase 3: Attachment: aftcr initial adhesion, a firm anchorage between bacterium and surface will be establishcd.

- Phase 4: Colonization ofthe surface and biofilm formationr read #3 below

Colonization and plaque maturation: When the firmly attached microorganisms sart growing and the newly formcd bactcrial clustcrs remain attached, microcolonics or a biofilm can develop. From this stage forward, new mechanisms are involved because new intrabacterial
connections may occur At least l8 genera from the oral cavity have shown some form ofcoaggregztion (cell-to cell recognition ofgenetically distinct partner cell types). Essentially all oral
bacteria (but especidlly Fusobacterium wcleatur, possess surface molecules that foster some
ty-pe ofcell-to-cell interaction. This process occurs primarily through the highly specific stereochemical interaction of protein and carbohydrate molecules located on the bacterial cell surl'aces. in addition to the less specific interactions resulting from hydrophobic, electrostatic,and
van der Waals forces.
3.

Recent studies ofplaque samples looking for 40 subgingival microorganisms using a DNA hybridizarion mcthodology, defined "complexes" ofperiodontal microorganisms. The composition ofthe diffcr-

enr complexes was based on the frequency with which djfferent clusters of microorganisms were
recovered. The e^rly (primaD,) colonizers arc cithcr indepcndent of defined complexes (Actinomlces
naeslLtndii, A. viscosus) or members ofthe yellow (Streptococcus spp.) or purple complexs f,4clir?om|ces odontolvticus).
The microorganisms primariJy considered secondary (/ate) colonizers fell jnto the green, orange orred
complexes. The green complex includes Eikenella corrodens, Actinobacillus actinotherapeutics serotlpe
a. and Capnoc)'tophaga species. The orange complex includes Fusobacterium, Ptevotella, and Campylobacrer species. The green and orange complcxes include species recognized as pathogens in periodontal
and nonpcriodontal infections. The red complex consists ofPorphytomonas gingivalis, Treponema denticola. and Tannerella fors)'thia. This complex is ofparticular interest because it is associated with bleeding on probing, which is an important clinical parameter ofdestructive periodontal diseases.

Plaque as a biofilm: The dental plaque biofilm has a similar structure to all biofilms fcomposed oJ micro(olonies e closed in a polysacchaide mdf,r. It is heterogenous in structure, with clear evidence of
open fluid-filled chsrrnels running through the plaque mass. These water channels pennit the passage
ofnutrients and other agents throughout the biofilm, acting as a primitive "circulatory" system. The inrercellular matrix consists of organic and inorganic materials derived Aom saliva, gingival crevicular
fluid, and bacteial products.

Important: In a biolilm, bacteia have the capacity to communicate with each othet (called quorum
sezsing,). This involves the rcgulation ofexpression ofspecific genes thrcugh the accumulation ofsignaling compounds that mediate inter-cellular communication. When these sjgnaling compounds reach a
rhrcshold levcl (cal/ed quorum cell density), gene expression can be activated.
Note: Tle high density ofbacterial cells in a biofilm also facilitates thc exchange ofgenetic information among cells ofthe same species and across species and even genera. Conjugation, transformation,
plasmid transfer, and transposon transfer have all been shown to occur morc easily in a biofilm.
Remember: Following a prophy, plaque is most likely to accumulate on the interproximal tooth surfaces first.

. Filaments
. Cocci
. Rods
. Vibrios

124
Cop)Tight @ 201l-2012 - Denlal Decks

At lasts two thirds ofthe inorganic component ofcalculus is cr;stalline

in structure. Of the four main crystal forms, whlch one is more common
in the mandibular anterlor region?

. Magnesium whitlockite

. Brushite
. Octocalcium phosphate
. Hydroxyapatite

129
Coptright O 201l'2012

'

Dnlal

Dek

Bacterial plaque is the primary etiologic factor for the initiation ofperiodontal disease. Plaque formation begins immediately after a tooth surface is cleaned. The rate ofplaque formation is affected by diet, age, salivary
flow, oml hygiene, tooth alignment, systemic disease and host factors. Changes in the q?es oforganisms occur

within plaque as the plaque matures. Days I to 2; young plaque consists primarily of cocci (i.e., Slreptococcus mutans and sanguis)
. Days 2 to 4: cocci still dominate but there are increasing numbers offilamentous forms and slcndcr rcds.
Gradually the filamentous forms replace many ofthe cocci.
. Days 4 to 7: filanents increase in numbers, and a mo.e mixcd flora begins to appear with rcds, filamentous forms. and fusobacteria.
. Days 7 to 14: vibrios and spirochctes appear, and the number ofwhitc blood cells increases. More gmmnegative and anaerobic organisms appear The signs ofinflammation are beginning to be observabl in the
grngrva.
. Dsys 14 to 2l: vibrios and spirochetes are prevalent in older plaque, along with filamentous forms. Gin-

givitis is evident clinically.

As plaque ages:
. Thc number ofcocci decreases and the number ofrods, fusiform, filaments, and spi.ochetes increases
. The number ofaerobic bacteria decreases and the number of anaerobic bacteria increases
. The number ofgram-positive organisms decrases and the number ofgram-negative orBani$ns increases
Key point: As the biofilm (plaque.) matures, there is a shift from a predominance of facultative, gram-positive bacteria to gram-negative, anaerobic bacteriaThe transition from gram-positive to gnm-negative microorganisms obscrvcd in the structural devolvement ofdental plaque is paralled by a physiologic transition in the developing plaque. The early colo-

nize$ (e.g., St/eptococci, Actinomyces species) lse oxygen and lower the redox potential of the
environment, which then favors the growth ofanaerobic species. Gmm-positive species use sugars as an
energy source and saliva as a carbon source. The bacteria that prcdominatc in mature plaque are anaerobic and asaccharolytic and use amino acids and small peptides as energy sources.
l. The organic constituents ofplaque include polysaccharides fdrtla n), proteirs (i.e., albunin),
glycoprotetns (fron saliraJ, and lipid material.
2. The inorganic components ofplaque are predominantly calcium and phosphorus, with trace
amounts ofother mincrals, including sodium, potassium, and fluoride.
3.The source ofinorganic constituents ofsupragingival plaque is primarily saliva.

Supragingival calculus consists of inorganrc (70%-90%) and organic components. The inorganic portion consists of 76%0 calcium phosphate, 3% calcium carbonate, and traces ofmagnesium phosphate, and other metals. The principal inorganic components are calcil]m (39%);
phosphon:s (19%o); carbon dioxide (l .9%,'l magnesium (0.8%o) and trace amounts of sodium,
zinc. strontium, bromine, copper, manganese, tungsten, gold, aluminum, silicon, iron, and fluorine. At least two thirds ofthe inorganic component is crystalline in structurc. The four main
c4stai forms are as follows;

. H! droxyapatite f582,)
. \Iagnesium whitlockile (2191,)
. Octacalcium phosphate (12%)
. Brushite (9?6)
Hydroxyapatite and octacalcium phosphate are detected most frequently (in 97% to 100% oJ all
Genemll-v. two or more crystal forms are typically found in a sample of calculus.

supragingival calculus/ and constitute the bulk ofcalculus- Brushite is more common in the
mandibular anterior region and rnagnesium whitlockite in the posteior areas.
The organic component of supragingival calculus consists of a mixture of protein-polysaccharide complexes, desquamated epithelial cells, leukocytes, and various types of microorganisms.

The composition of subgingival calculus is similar to that of supragingival calculus, with

some differences. Subgingival calculus has the same hydroxyapatite content, more magnesium whitlockite, and less brushite and octacalcium than supragingival calculus. The ratio of
calcium to phosphorus is higher subgingivally, and the sodium content increases with the depth
ofperiodontal pockets. Salivary proteins present in supmgingival calculus are not found sub-

gingivally.
Not: Calculus (bor, supragingival and subgingival) located on interproximal surfaces can be
seen on bite-wing radiographs as interproximal spurs.

. The number of osseous walls that were deshoyed by periodontal disease

. The number ofosseous walls left surroundins the tooth

. The number ofosseous walls that will remain after surgery

. Periodontal probe readings

't

30

Copyrighr O 201 l -?012 - Dntal Decks

. Periodontal probing
. Radiographs
. Exploratory surgery
. Testing for mobility

131
Coplright

@ 201

I,2012 - Dnral Decks

Horizontal bone loss is the most common pattem ofbone loss in periodontal

disease. The bone is reduced in height, but the bone margin remains approximatcly pc.pcndicular to thc tooth surface. The interdental septa and facial and lingual plates are affected, but not necessarily to an equal degree around
the same tooth.
Vertical or angular defects are those that occur in an oblique direction, leaving a hollowed-out trough
in thc bone alongside the root; the base ofthe defect is located apical to the surrounding bone. In most
instances, angular defects have accompanying intrabony periodontal pockets; intrabony pockets, however, always have an undcrlying angular defcct.
Angular defects are classified on the basis ofthe number of osseous walls. Angular defects may have
one, two, or three walls. The number of walls in the apical portion ofthe defect may be grcater than that
in its occlusal portion, in which case the telm combined osseous defect is used. Important: Surgical exposure is the only sure way to determine the presence and configuration ofvertical osseous dcfects.

l. Osseous craters arc concavities in the crest ofthe interdentalbone confined within the facial and lingual walls. Craters have been found to make up about one third (3 5.2o/o) of al], defects and about two thnds (62%o) of all mandibular defects. They are more common in posF
te.ior segments than in anterior segments. They are best heated with osseous surgery f,.econtouring).
2-The relative degree ofsuccess ofperiodontal bone grafting is reported to vary directlywith
the number of bony walls of the defect (vascularized, osseous sul.face arca) and invcrscly
u jth the surface area ofthe root against which the graft is implanted. Thus a narrow, threewalled angular defect usually yields the greatest success, a two-walled defcct the next best,
and a one-rvalled defect the least.
3. A dehiscence is a loss ofthe buccal or lingual bone overlaying the root portion ofa tooth,
leaving the area covercd by soft tissue only.
4. The three-wall vertical defect was originally called an intrabony defect, Thc telm inbabony was later expanded to designate all vertical defects.
5. The one-wall vertical defect is also called a hemiseptum.
6. Suprabony pockets are associated with horizontal bone loss. They are not intraosseous.

***

This is because a dense buccal and/or lingual plate ofbone will tend to mask the defect, blocking it out on the radiographs. This information can only be determined by ex-

ploratory surgery.
Important: Radiographs will not show:
L The number of walls left surrounding the tooth
2. The exact configuration ofthe defect
3. The location ofthe epithelial attachment
Remember: The two most critical parameters for the prognosis of a periodontally inr olved tooth are rnobility and attachmentloss (which is most critical). Angular defects
are classified on the basis of the number of osseous walls. Angular defects may have
one. t\r'o. or three walls. The number of walls in the apical portion ofthe defect may be
greater than that in its occlusal portion, in which case the term combined osseous defect
is used.

Pockt dpth is the distance between the base ofthe pocket and the gingival margin. The
lelel of attachmnt on the other hand, is the distance between the base ofthe pocket and
a fixed point on the crown, such as the CEJ. Changes in the level of attachment can be
caused only by gain or loss ofattachment and thus provide a better indication ofthe degree of periodontal destruction.
Pocket formation causes loss of attachment ofthe gingiva and denudation ofthe root sur-

ofthe attachment loss is generally, but not always, correlated with the
depth of tlre pocket. This is because the degree of attachment loss depends on the location ofthe base ofthe pocket on the root surface, whereas the pocket depth is the distance
between the base ofthe pocket and the crest ofthe gingival margin. Pockets ofthe same
depth may be associated with different degrees of attachment loss and pockets of different depths may be associated with the same amount of attachment loss.
face. The severity

Which type of pocket is formed by gingival enlargement without

destruction of the underlying periodontal tissues?

. Gingival pocket
. Periodontal pocket

. Suprabony pocket
. Intrabony pocket

132
Cop)righlO 20ll-2012 - Dental Deks

The principal differences between intrabony and suprabony pockets are the
relationship ofthe soft tissue wdl ofthe pocket to the alveolar bone, the
pattern of bon destruction, and the direction of the transseptal fibers
of the periodontal ligament.

In intrabony pockels, the base ofthe pocket is apical to the crest of the alveolar
bone, and the pocket wall lies between the tooth and the bone.

. The first statement is true; the second statement is false

. The second statement is truej the first statement is false
. Both statements are true
. Both statements are false
133

Coptrghr O 20ll-2012 - Dental Decks

Deepening ofthe gingival sulcus may occur by coronal movement ofthe gingival margin, apical displacement ofthe gingival attachment, or a combination ofthe two processes.
Pockets can be classified as follows:
. Gingival pocket (pseudopocket): this t)?e of pocket is formed by gingival enlargement without destruction ofthe underlying periodontal tissr.res. All gingival pockets are
suprabony (the base ofthe pocket is coronal to the crest ofthe alveolar bone).T\e sulcus is deepened because ofthe increased bulk ofthe gingiva.
. Periodontal pocket: this type of pocket occurs with destruction ofthe supporting periodontal tissues. Progressive pocket deepening leads to destruction ofthe supporting
periodontal tissues and loosening and exfoliation ofthe teeth. Two types ofperiodontal pockets exist:
. Intrabony (infrabony, subcrestal, or intraalveolar): in which the bottom of the
pocket is apical to the level ofthe adjacent alveolar bone
. Suprabony (supracrestal or supraalveolar): in which the bottom ofthe pocket is
coronal to the underlying alveolar bone.
a bluish red, thickbned marginal gingiva; a bluish red, vertical zone from the gingival margin to the alveo-

Clinical signs that suggest the presence ofperiodontal pockets include

iar mucosa; gingival bleeding and suppuration; tooth mobility, diastema formation; and
sl mptoms such as localized pain or "pain deep in the bone." The only reliable method of
Iocating periodontal pockets and determining their extent is careful probing ofthe gingir al margin along each tooth surface.

1. Base ofpockct is apical to crest ofalveolar bone so that

the bone is adjacent to soft tissue wall.

2. Pattem ofbone destruction is venical

i . Interproximally, transseptal fibets that are

renored dlrrirlg progressive periododal disease
ale armnged horizontally in the space betweel
the base of Docket and alvolar bone.
Oo facial and lin8ual surfaces, periodontal
ligament fibers beneath pocket follow thei.
normal horimnral-oblique cou6e betwen th
-1.

rooth and bone.

i:.r(ured \nh pedrssion, Iio'!

Neq,man

Vc,

largrldrl

3. Interproximally. transseptal fibers are oblique rather than

horizontal. Thcy exlend from cementum beneath base of
pockel along alveolar bone and over crest to
cementum of adjacent tooth
4. On facial and lingual surfaces, periodontal ligament fibers follow ang!lar pattem ofadjacent bone. They
extend liom cementum beneath base ofpockct along
jlveolar bone and over cre\l ro join with ouler perio.leum.

Iakei IIH, KloLkevold PR. C.ftanza l-A.

Cnah:n\ clinicol P.rio.lo"h|oAr701../. Eh.-

. The bone loss is vertical in nature

.

The bone loss is horizontal in nature

. Transseptal fibers are horizontal

. Supracrestal fibers follow the normal bone contour

l3,l
Coplriglr O

201 l -20 12 - Dental

Deck

. Incipient bone loss

. Partial bone loss (cul-de-sac)

. Total bone loss with through-and through opening ofthe furcation

. Similar to the above, but with gingival recession exposing the furcation to view

Cop),righr C 20ll'2012 - Dental Decks

P dio d on

t a l a s^,

lr " e,l.

Elsevier.2006.

Different t)?es ofperiodontal pockets. A, Gingival pocket. There is no destruction ofthe

supporting periodontal tissues. B, Suprabony pocket. The base ofthe pocket is coronal to
the level of the underlying bone, Bone loss is horizontal. C, Intrabony pocket. The base
ofthe pocket is apical to the level ofthe adiacent bone. Bone loss is vertical.

The term furcation involvement refers to the invasion of the biflircation and trifurcation of
multirooted teeth by periodontal disease. The denuded furcation may be visible clinically or
cor ered b1, the wall of the pocket. The extent of involvement is determined by exploration
\\ irh a blunt probe, along with a simultaneous blast ofwarm air to facilitate visualization.
Furcation involvements have been classified as grades I, II. lll, and lV according to the amount
oftissue destruction.
. Grade l: is incipient bone loss
. Grade ll: is partial bone loss (cul-de-sac)
. Grade III: is total bone loss with through-and-through opening ofthe furcation
. Grade I\': is similar to Grade IIl, but with gingival recession exposing tbe furcation to
r

ieu

Findings that complicate furcation involvement and account for some painful symptoms include caries ofthe cementum and dentin, tooth resorytion in the furcation, abscess formation
in the f'urcation, and involvement ofthe pulp via lateral canals in the furcation. Definitive diagnosis of furcation involvement is made by careful clinical probing. X-rays are helpful but
on11 as an adjunct to the clinical examination.
The major principle oftreatment ofinvolved furca is to eliminate the involvement whenever
possible. A variety ofmethods are available for treatment. Not all ofthem provide for elimination ofthe furcation; some provide only for increased accessibility for plaque removal. Bone
grafts haye relatively little effectiveness in treating furcations. Howevel guided tissue regeneration is used to treat Grade II furcations with good success. Note: Furcation involvement
of maxillary second molars have the poorest prognosis following therapJ.
presents no unique pathologic features.
is simply a phase in the rootward extension ofthe periodontal pocket.

Imponant: Microscopically, furcation involvement

It

. The first statement is true; the second statement is false

. The second statement is true; the first statement is false

. Both

statements are true

. Both

statements are false

136
Copyighr C 20ll'2012 - Dental Decks

When using the periodontal probe to measure pocket depth,

tbe measurement is taken from the:

. Base ofthe pocket to the CEJ

. Free gingival margin to the CEJ
. Junctional epithelium to the margin ofthe free gingiva
. Base ofthe pocket to the mucogingival junction

copFight O

201

137
l-2012 - Dental Dcks

Gingival enlargement is a well-knowr consequence of the adninistntion of some anticonvulsants, immunosuppressants, and calcium channel blockers. Clinical and microscopic features
the enlargements caused by the different drugs are similar.

of

The growth starts as a painless, beadlike enlargement ofthe interdental papilla and cxtends to the
lacial and lingual gingival margins. As the condition progresses, th marginal and papillary enlargments unite; they may develop into a massive tissue fold covering a considerable portion of
the crowns, and may interfere with occlusion.
When uncomplicated by inllammltion, the lesion is rnulberry shaped, firm, pale pink. and resilient, with a minutely lobulated surface and no tendency to bleed. The presence ofthe enlargement makes plaque control difficult, often resulting in a sccondary inflammatory process that
complicates the gingival overgrowth caused by the drug. Secondary inflammatory changes not
only add to the size of the lesion caused by the drug, but also produce a red or bluish red discoloration. oblitcrate thc lobulated surface demarcations, and incrcasc bleeding tendency.

Anticonyulsants; the first drug-induced gingival enlargements reported were those produced by
phenytoin (Dilantin). Other hydrantoins known to induce gingival enlargement are cthotoin
lPagatnne) arndmephenytoin (Mesanloin). Other anticonvulsants that have the same side effect are
the succinimides (eliosuximide lZerontin], nethsuxinimide lCelontinl, and valp,"oic acid lDepakenel).

lmmunosuppressants: Cyclosporine is a potent immunosuppressive agent used to prevent organ

rransplant rejection and to treat scveral diseases ofautoimmune origin. Cyclosporine-induced gingir al enlargement is more vascularized than phenytoin enlargement. Another immunosuppressive
drug. tacrolimus, has been used effectively and results in much less gingival overgowth.

Calcium channel blockers are drugs devcloped for thc treatment of cardiovascular conditions.
These dnrgs are the dihydropyridine derivatives (amlodipine fLotrel,

Norvascl,y'lod?nre fPlendil],
nicardiptue [Carden], nifedipine fAdalat, Procardia]): the benzothiazine derivatives (diltiazem
ICardizem, Dilacor XR, Tlazac]); and the phenylalkylaminc dcrivatives (verupantil fcalan, Isoptin,

\ erelan. Covcra HSI).

Periodontal probes are used to measure the depth ofpockets and to determine their cont.igurations. The typical probe is a tapered, rodlike instrument calibrated in millimeters,
* ith a blunt, rounded tip. Ideally, probes are thin, and the shank is angled to allow easy
insertion into the pocket. The probe is inserted along the long axis of the tooth into the
pocket lvith a firm, gentle pressure fapproximqtely l0 to 20 grdrrs) until resistance is met.
The probe is walked around each surface of the tooth. This method is less painful and
more eflicient, provides a complete and accurate assessment ofthe depth ofthe epithelial
anachment and will detect bony defects better.
Periodontal probing provides the most accurate assessment ofperiodontal pocket depth.
The true topography ofvertical osseous defects cannot be determined by radiographic examination alone. Bone levels may be high, yet pockets may be deep. Extensive bone loss
ma-u- exist and yet be unaccompanied by pockets if the gingiva has receded. The most
important rason for using the periodontal probe is that it determines the loss ofat-

tachment.

' ., l. Bleeding scores: bleeding is still the most reliable indicator ofthe
\ore*.:
,'
ofgingival or periodontal inflarnrnation.
'&i

presence

z. Plaque score: with plaque disclosing solution, used to help visualize plaque
for the patient and clinician. Also used at multiple visits to show patients improvement in their level of oral hygiene.
3. Recession is measured in millimeters from the CEJ to the marginal ginsiva ofeach tooth root.

. It should

be parallel to the long axis of the tooth at the point angle

. It should be parallel to the long axis ofthe tooth at the contact area

. It

should touch the contact area and the tip should angle slightly beneath and beyond

tle

contact area

. It should

be perpendicular to the long axis

'|

Coplrighr

ofthe tooth in front of the contact area

38

20ll-2012 - DentalDecks

How should the periodontal probe be inserted into th sulcus?

. Perpendicular to the long aris ofthe tooth

. With

. With

a short oblique stroke

firm pushing motion

. Parallel to the tooth surface

139

Copright O 20l l-2012 - D al Decks

***

The periodontal probe may be angled approximately l0"on each interproximal surface so that the tip ofthe probe is placed apical to the contact point of adjacent teeth and
may detect any interdental crater but, in most instances, the direction ofthe probing is parallel to the long axis ofthe tooth.

Periodontal measurements are taken by inserting the probe under the marginal gingiva
and gently moving it down to the junctional epithelium (bels soft, eldstic and resilient).
In a healthy site, the tip ofthe probe stops within the junctional epithelium and in a diseased site it penetrates into the connective tissue. In severe disease, the probe tip may
Denetrate to the alveolar bone

.,nnd
'&t

l. The clinical probing depth is always greater than the histologic sulcus or
pocket depth. Probing accuracy is only within I mm.
2. The calibrated periodontal probe should have a tapered shaft approximately

0.5 mm in diameter at the tip. It is important to have uniform instruments

throughout the practice in order to ensure as much standardization as possible.
3. Furcation areas can be best evaluated with the curved #2 Nabers probe.
4. The periodontal probe can also be useful in the detection ofsubgingival deDOSltS.

The tip ofthe probe should always be kept in contact with the tooth, thus preventing soft
tissue injury. The probe is gently "walked" along the junctional epithelium in an up and

do.*'n motion (called circumferential probing) always remaining under the gingival
margin. It is imperative that the probe be walked along the entire gingival sulcus since the
from
depth of the epithelial attachment varies. Six measurements are recorded
-three
the buccal and three from the lingual: disto-buccal, buccal, mesio-buccal, distolingual,
lingual and mesioJingual. These measurements are the distance in millimeters from the
base ofthe pocket (junctional epitheliuz) to the margin ofthe free gingiva.

, ]i..oto{

l.The most importart reason for using the periodontal probe is that it determines the loss of attachment. These measurements are taken both before and
after scaling and root planing procedures to evaluate the tissue response and
the effectiveness of treatment.
2. Probing is performed with firm, gentle pressure. The conect probe force (approximately l0 to 20 grazs) depresses the thumb pad approximately l-2 mm.

Ifyou should

meet resistance after inserting the

periodontal probe into the sulcus, you should:

. Rernove the probe and reinsert it in a different spot

. Lift the probe away from the tooth

. Force

and attempt to move it apically

the probe beyond the obstruction

. Remove the probe and select one with

. Record the measurement where

a narrower diameter

the probe stopped

IrO
Cop).righr O 20ll-2012 - DentalDecks

Which of the following is the most common error when

performing periodontal probing?

. Using the wrong type or probe

. Incorrectly reading

the periodontal probe

Excessively angling the probe when inserting

it

interproximally beyond the long

axis ofthe tooth

. Forgetting to also probe the lingual ofevery tooth

141
Cop)riglit O 201l-2012 - Dntal Decks

Often when probing, the passage of the probe may be blocked by a hard, unyielding
ledge. This is usually calculus. Gently lift the probe away from the looth, placing it
against the tissue wall of the pocket and attempt to proceed apically again. If the obstruction was indeed calculus and it has now been bypassed, then the probe should now
move deeper into the pocket until the junctional epithelium is reached. The tip of the
probe should be placed back against the tooth once the obstruction has been bypassed.

Remember: The probe should be inserted parallel to the vertical axis of the tooth and
"walked" circumferentially around each surface of each tooth to detect the areas of
deepest penetration.

L Recession is the measurement of the migration of the free gingival margin

apical to the CEJ ofthe tooth. Recession is measured as a positive value. The
recession measurement added to probe depth at a particular site indicates the
amount ofperiodontal attachment that has been lost at that site. When the gingival margin is coronal to the CEJ, the recession measurement has a negative
value.
2. To measure the amount ofattached gingiva: (l) Place the probe on the external surface ofthe gingiva and measure from the mucogingivaljunction to the
gingival margin to detemine the width of the total gingiva, (2) Insert the probe
and measure probing depth, (3) Subtract the probing depth from the total gingival measurement to get the width ofthe attached gingiva.

*"*

This will give greater probe readings than are actually present,

Tilting the probe could affect the accuracy of the measurements. If the probe is angled
too much, it will extend beyond the contact area and if it isn't angled enough, then it
$ ill be at the line angle instead of under the contact area. Both mistakes will result in
inaccurate readings. The tip should be flat against the tooth near the gingival margin
u ith the probe approximately parallel with the long axis ofthe tooth for insertion.
l\,lote: In the presence of inflammation, the probe may extend apical to the most coronal
extent ofthe junctional epithelium (bottom ofpocket) and give a slightly greater depth than
is actually present.

Important: Ifa patient is at risk for subacute bacterial endocarditis, he or

she needs to be

premedicated before performing periodontal probing.

Remember: Bacteremia can occur even with mastication or brushing. However, it does
not last long. The important consideration is the presence or absence of periodontal inflammation. The presence of inflammation leads to a longer duration of bacteremia with
resultant risks for natients at risk of acute bacterial endocarditis.

. Centrals

and laterals

. Canines and premolars

. Second and third molars
. First and second molars

142
CopFighr

20ll'2012

Cop,riShr

143
20ll'2012 " Dental Deck

- DenBl Decks

. Bayer's theory
. Chemiosomotic theory

. Hydrodynamic theory
. Quanhrm thory

*** Toothbrush tratma' (abrasion)

usually occurs on teeth that are the most prominent

in the dental arch,

The maintenance oforal health is enhanced by the use ofa soft-bristle toothbrush with a
dentifrice of optimum abrasiveness and a dental floss. A hard-bristle toothbrush is capable of causing gingival recession and abrasion of enamel and / or cementum and should
be avoided. The abrasive quality of dentifrices affects enamel, but abrasion is more ofa
concem for patients with exposed dentin because dentin is abraded 25 times faster and
cementr.rm 35 times faster than enamel. This can lead to root surface abrasion and root
sensitivity. Hard tissue damage from oral hygiene procedures is mainly due to abrasive
dentifrices, whereas gingival lesions can be produced by the toothbrush alone.
Trauma ftom toothbrushing may result in the following:
. Recession of the marginal gingiva
. Lacerations of the soft tissues including the attached gingiva and the alveolar mucosa

. \Lshaped notches in the cervical areas of teeth

. Gingival clefts: which are narrow grooves that extend from the crest of the gingiva
to the attached gingiva

lJote: The location of the above alterations is frequently inversely related to the rightor left-handedness ofthe patient.

Remember: ln gingival atrophy or recession, the tissue appears to be otherwise normal. The gingiva is thin, finely textured and pale pink in color with normal papillae. The
gingival sulci is very shallow. Plaque is minirnal.

The Hydrodynamic theory postulates that the pain

caused by dentinal

ofroot sensitivity results from indircct innervation

fluid movement in the tubules' which stimulates

mcchanoreceptors in the pulp.

lt may occur spontapocket

foimation, or it may
recession
or
exposed
as
a
result
ofgingival
lvhen
the
root
becomes
neouslv
appear after scaling and root planing and surgical procedures. The primary symptom is cold sensitiviq. Plaque and food debris, ifallowed to remain on exposed root surfaces, often lead to incrcased sensiriviq. Note: To reduce the sensitivity to thermal change after removal ofa periodontal dressing, it is
bejt to keep the rcots free ofplaque.
Root h-'-persensitivity is a relatively common pioblem in periodontal practice

The mosl common agents used by the patient for oral hygiene are dentifrices. Although many dentifrice
produfis contain fluoride, additional active ingredients for desensitization are strontium chlodde, potassium ninate. and sodinm cihate. The ADAhas approved the following dentifrices for desensitizing pur-

poses: Sensodyne and Thermodent, which contain strontium chloride, Crcst Scnsitivity Protection,
Denquel. and Promise, which contain potassium nitrate; and Protect, which contains sodium cifiate

Important: Desensitizing agents act through the Fecipitation of crystalline salts on the dentin surface,
\shich block dentinal tubules.
various oflce treatrnents for the desensitization ofhypersensitive dentin:

. Caviry vamishes
. Antiinfl ammatory agents
. Treatments that partially obturate dentinal tubules
- Fluoride compounds
ofdentin
. Sodium fluoride
- Silver nitrate
- Zinc chioride-potassium ferrocyanide . Stannous fluoride
- IontoDhoresis
- Formalin
- Strontium chlo de
- Calcium compounds:
. Calcium hydroxide
- Potassium oxalate
. Dibasic calcium phosphate
- Restorative agents
- Dentin bonding agents
- Bumishing

. Prescription of home fluoride rinses

. Minimal removal oftooth structure during root planing

. The application ofdesensitizing

agents that contain fluoride

. Thorough daily plaque control

114

copri8ht e

2011,2012 - Denral Deckr

When extensive scding ond root planing must

be performed, tle best approach would be:

. A series of appointments set up to scale and root plane a segment or quadrant of teeth
at a time (thoroughly and completely)

. Gross debridement (sub and supragingival) of the entire mouth, followed by

appointments for fine scaling and polishing
. Perform everything in a single appointment
. None ofthe above

CoDright

145
20ll-2012 - Denhl Deck

a series

of

Sometimes these areas will become sensitive ifthe root is exposd. Th patient will complain
of cold sensitivity. The hypersensitivity will sometimes subside in time with daily plaque
removal using a soft brush (this will help desensitize the root surface b), qllowing reminer-

slization ofthe root surface). Remember: Gingival recession can also occur, secondary to periodontal therapy. This may have additional significance in the older patient, namely, increased
risk for cervical abrasion, dentinal sensitivity, and most importantly, predisposition to root
canes.
The acids and toxins produced by the plaque organisms are very irritating to the pulp by way
ofthe odontoblastic processes. This irritation ofthe pulp heightens its sensitivity to other stimuli. No attempt to reduce hypersensitivity will be successful unless the roots are consistently
kept free ofplaque.

Desensitizing agents can be applied by the patient at home or by the dentist or hygienist in the
dental office. The most likely mechanism ofaction is the reduction in the diameter olthe dentinal tubules so as to limit the displacement offluid in them. This can be attained by:
. formation ofa smear layer produced by bumishing the exposed surface
. topical application ofagents that form insoluble precipitates within the tubules
. impregnation oftubules with plastic resins
. sealing of the tubules with plaslic resins
The hygienist or dentist should evaluate the brushing technique and monitor hard and soft tissue conditions at each recall visit. Faulty placement, overaggressive movement or pressure,
or the use ofa hard toothbrush can lead to hard and soft tissue damage.

The most common cause ofgingival recession is tooth injury (abrasion). Thrs type ofrecession is common on the left canines ofright-handed persons (or right canines ofleft-handed per-to/ls,/,

L There is potential for abscess formation in a deep pocket when only a superficial scaling is periormed.
2. OHI may be more effective if a patient can see healing tissue in an area
which has been completely debrided and compare it to tissue in an untreated
area.

3. A patient who has had a gross debridement will see a marked visual improvement of the oral cavity and may not understand the importance and necessity ofthe deep scaling and root planing appointments. This may cause
the patient to not follow through with the scheduled treatment, and the patient's periodontal condition will be allowed to deteriorate further.
4.Important: Clinical evaluation ofthe soft tissue response to scaling and root
planing, including probing, should not be conducted earlier than 2 weeks post
operatively. Reepithelialization of the wounds created during instrumentation
takes I to 2 weeks. Until then, gingival bleeding on probing can be expected
even when calculus has been completely removed because the soft tissue wound
is not epithelialized.
5. Ifany bleeding or swelling is noted in localized areas ofthe mouth during

the reevaluation appointment, check for and remove any residual calculus
deposits that might remain.
6. In root planing, ideally, the working stroke should begin at the apical
edge of the junctional epithelium frft e base ofthe pocket).

. Mesial surfaces of maxillary premolars

Proximal surfaces of mandibular incisors

. Trifurcations of maxillary molars

. Distal surfaces ofmandibular molars

't46
Copright O 20ll-2012 - Dental Decks

Some degree of curettage is done unintentionally when sealing and

root planing are performed; this is called inadvertent curettage-

Curettage accomplishes the removal of tbe chronically inflamed granulation

tissue that forms in the lateral wall of the periodontd pockct.

. The first statement

is true; the second statement is false

. The second statement

is true; the first statement is false

. Both statements are true

. Both statements are false

147
Coplright O 201I-2012 - Dntal Decks

Mesial surfaces of maxillary premolars and the proximal surfaces ofmandibular incisors are most likely to have flutings. Also, root proximity is a major problem when performing scaling and root planing on mandibular incisors. Trifurcations on maxillary
first molars are the most difficult of all to root plane.

*** Key point:

anatomic features ofteeth frequently limit the effectiveness and efficiency

ofcalculus removal.
Remember: If while root planing you find only a thin ring ofcalculus in the bottom third
ofa deep pocket, you can assume that the calculus previously extended the full length of
the pocket but the top part was previously removed. Likewise, if after scaling and root
planing, the patient retums in one week with hard, black deposits of calculus around the
gingival margin, this indicates that a reduction in inflammation occurred after the procedure and old calculus is now exposed.

,\otes

1. The best critrion to evaluate the success ofscaling and root planing is no evidence ofbleeding upon probing. Remember: Bleeding upon probing indicates

.,,--;i.- inflammation in the tissue. The amount of inflanrnation present is used to determine the effectiveness ofperiodontal instrumentation and home care by the
patient.
2. Cementum, dentin, and calculus are removed during root planing.
3. Tactile sensitivity refers to the ability to distinguish degrees ol roughness
and smoothness on the tooth surface.

The word curettage is used in periodontics to mean the scraping ofthe gingival wall ofa periodontal pocket to separate diseased soft tissue. Scaling refers to the removal ofdeposits from
rhe root surface, whereas planing means smoothing the root to remove infected and necrotic
tooth substance.

-\ differentiation has been made betwen gingiyal and subgingival curettage.

. Gingival curettage: consists ofthe removal ofthe inflamed soft tissue lateral to the pocket
ir all

. Subgingival curettage:

refers to the procedure that is performed apical to the epithelial

arrachment, severing the connective tissue attachment down to the osseous crest.

Indications for curettage are very limited. It can be used after scaling and root planing for the
lbllo* ing purposes;
) . Curettage can be performed as part of new attachment attempts in moderately deep inrrabonv pockets located in accessible areas where a type of"closed" surgery is deemed adr isable.
2. Curettage can be done as a nondefinitive procedure to reduce inflammation before pocket
elimination using other methods or when more aggressive surgical techniques (e.9., Jl"pl
are contraindicated.
3. Curettage is also frequently perlormed on recall visits as a method ofmaintenance treatment for areas ofrecurrent inflammation and pocket depth.

Important; Curettage does not eliminate the

causes

of inflammatiorr (i.e., bacteriql plqque

ond deposits). Therefore, curettage should always be preceded by scaling and root planing.

Note: Gingival curettage always requires some tlpe of local anesthesia

The aurette is selected so that the cutting edge will be against the tissue fe.g., Gracey#13-14
#11-12 for distal surfaces). Clrettage can also be performed with
a 4R-4L Columbia Universal curette.

for mesial sutfaces, Gracey

. To remove cfuonically inflamed tissues

. To change the bacterial microflora
. To remove etiologic agents from the root surface
. To eliminate pockets

l,{8
C.plright O 201l-2012 - Dental Deck

. Fibrotic

. Edematous
. Fibroedematous
. Formed within an intrabony pocket

149
Copyriglt

@ ?01

1-2012 - Dental Decks

The major objective of scaling and root planing is to renove etiologic agnts which promot gingival inflammation in the periodontal tissues. Removal of plaque, calculus and endotoxins rcsults in a subsequent
shift liom disease-associated, gram-negative anaerobes to health-associated, gram-positive, facultative microorganisms. Important: By providing smooth root surfaces there willbe areduced potential forbacterial accumulation. which is done in an attemot to achieve soft-tissue reattachment.
Scaling and root planing are techniques ofinstrumentation applied to th root surface to divest it ofplaque, cal-

cified deposits and softered or roughend cementum. When thoroughly performed, lhese techniques produce
a smooth, clean, hard polished root surface. Scaling and root planing is the primary treatment for pe.iodontal inflammation. In simple cases, this fieatment is useful in reducing shallow pockets and reducing the number ofbacteia within these shallow pockets and may be the only treatment necessary In severely advanced
periodontal disease where surgery may not be possible, scaling and root planing are the only treatment fasible. Since the removal ofplaque and deposits is th definitiv treatment for periodontal inflammation, rool
planing and scaling are more frequently used than any other type of therapy.
The most effctive instrument for subgingival scaling and root planing is a sharp curtte. They are generally
smaller than scalers and are designed to permit atraumatic entry to the subgingival spac. The tactile sensiiiviry ofmost curettes is greater than scalers, and, as such, curcttes are well suitcd for subgingival calculus deteclion. calculus removal, and rootplarling. Each working end has acufting edge on both sides ofthe blade and
a rounded toe. There are two basic qpes ofcurcttes: univefial and area spccifrc (Gracer- curetles).

Double ended Gracey curetts are paired in the following manner:

. GraceJ #l-2 and 3-4: anterior reeth
. Gracey #5-6: anterior teeth and premolars
. Gracey #7-8 and 9-10: posterior teeth: facial and lingual surfaces

. Gracey #11-12: posterior teeth: mesial surface

. Gracey #13-14:posterior teeth: distal surface
Extnded-shank curttes: have a longerterminal shank, a thinnedblad, and a large-diameter terminal shank.
Ther- are available in finishing (for light scaling) or igid (br remotalofhedr), or tenacious calcalus.) designs.
Itinibfaded curettes: have shorter blades dra lf the length) whtcll allows easier insertion and adaptation.

cureltes: are mini-bladed curettes with a morc curved blade.

Langer and mini-Langer curetles: combine the shank design ofGracey curettes with dre universal blade design lg0-degrce angle oftlleface and lower slnnk).

GraceJ_

Indications for curettage are very limited. It can be used after scaling and root planing for the
tbllorving purposes:
I . Curettage can be performed as part of new attachment attempts in moderately deep inirabony pockets located in accessible areas where a type of"closed" su4ery is deemed adr isable.
2. Curenage can be done as a nondefinitive procedurc to reduce inflammation before pocket

elimination using other methods or when more aggressive sugical techniq,res (e.9., Jlaps)
are contraindicated.
3. Curettage is also frequently performed on recall visits as a method ofmaintenance treatmenr for areas ofrecunent inflammation and pocket depth.

Contraindications ofgingival curettage

as a

definitive procedure include:

. Acute periodontal inflammation

. Firm. fibrotic tissue

. Intrabony pockets
. Nlucogingival involvements
. \\'hen the lateral gingival wall is extremely thin

L Patients with edematous and granulomatous inflammation rspond better to

\oten

curettage than do those with conditions offibrous hyperplasia.

mesenchymal cells must be present, (2) Complete removal ofjunctional and pocket
epithelium must be accomplished, as well as, (3) The complete removal of calcuIus and/or altered cementum.

Important: It is recommended that all students read The American Academy ofPeriodontology Statement Regarding Gingival Curettage. This can be found on the intemet at:
http ://www.perio.org/resources-products/pdf/38-curettag.pdf

. Heavy touch ard light pressure, keeping the tip perpendiculal to the tooth surface and
constantly in motion

. Light touch and healy

pressure, keeping the tip parallel to the tooth surface and stat-

lonary

. Light touch and light pressure, keeping the tip parallel to the tooth surface and constantly in motion

. Heavy touch and healy pressure, keeping the tip perpendicular to the tooth surface and
stationary

150

Coprigh

O 201l-2012 - Dental

Deck

. Curette

. Sickle scaler
. Hoe
. File

151

Coplright C 201 l -20

12 -

Dental Decks

Ultrasonic instruments have been widely used as a valuable adjunct to conventional hand instrumentation for nany years. The selection ofeither ultrasonic or hand instrumentation should be determined by the clinician's preference and experience and the needs of each patient. The success
ofcither treatment mcthod is determined by the time devoted to the procedure and thc thoroughness ofroot debridement. ln practice, clinicians typically use a combination ofboth ultrasonic and
hand instrumentation to achicve thorough debridement.
Ultrasonic instrumentation is accomplished with a light touch and light pressure, keeping the tip
parallel to the tooth surface and constantly in motion. Leaving thc tip in one place for too long
or using the point ofthe tip against the tooth can produce gouging and roughening o{-thc root surt'ace or overheating ofthe tooth. The working end ofthe ultrasonic instrument must come in contact $'ith the calculus deposit to fracture and remove it. The working tip must contact all aspects of
the root surf'ace to removc plaquc and toxins thoroughly. Although as much as 10 mm or morc of
the length of the ultrasonic tip vibrates, only a small portion of it can be adpated to contact the
cu^ed root suface at any one time or point. As with hand instruments, a series of focused, overlapping strokes must be activated to ensurc complete root coverage.

Important: Subgingival root surface roughness does not seem to interlere with healing after scaling and.oot planing. Thus it does not appear useful to rcinstrument root surfaces with hand insrruments after a clinically detectable smooth surface has been crealed with sonic or ultrasonic
scaler

Contraindications to the use of ultrasonic and sonic scaling devices:

. Oldcr cardiac pacemakers

. Known comnrunicable diseases that can be transmitted by aercsols
. Patients at risk for respiratory disease, including patients who are immunosuppressed or have
chronic pulmonary disorders
. Patients with titanium implants, porcelain or bonded restorations (unless you

use

plastic- tipped

,lserts)

ofa curette has a cutting edgc on both sides ofthe bladc and a rounded toe The curette
is finer than the sickle scale$ and does not have any sharp points or comcrs other than the cutting edges
of the blade. Thereforc, curettes can be adapted and provide good acccss to deep pockets, with minimal
ioli rissue trauma. [n cross section the blade appears semicircular with a convex base. The lateaal bord.r ol thc convex base forms a cutting edge with the face of the semicircular blade Therc are cufting
edges on both sidcs ofthe blade. Therc are two basic types ofcurettes:
Each rvorking end

. Lnilersal curettes: have cutting

edges that may be inserted in most areas ofthe dentition by altering and adapting the finger rest, fulcrum, and hand position of the operator. The bladc size and the
anglc and lengrh ofthe shank may vary but the face ofthe blade of everyuniversal curefte is at a 90degree angle (perpendlcrrlar) to the lower shank when seen in cross section from the tip The blade
olthe universal curctte is curved in onc direction from the head ofthe blade to the toe
. Area-Specific cu rettes: Gracey curettes are represcntative ofthe area-specific curettes, a set ofseveral instruments designed and angledto adaptto specific anatomic areasofthe dentition The Gracey
curenes also diffcr from the univcrsal curettes in that the blade is not at a 90-degree angle to the lower
shank. The term offset blade is used to describe Gracey curettes, because they are angled approxinlately 60 to 70 degrees from the lower shank.

.\.oler'

L Using curcttes with short, even working strokes followed by longcr ones is the most effcctive and efficient way ofperforming root planing. The correct cutting edge can be secn as
a largcr. outer curve.
2. Final root planing strokes are longer and lighter than scaling strokes.1. Root planing strokes become lighter as the cementum becomcs smoother.
4. Exploratory scaling and root planing strokes differ in angulation, pressure, length, and
dircction.

Remember: To establish the correct working angle once a curet is inserted subgingivally, the shank
must be moved away liom the tooth in order to open the angle ofthc bladc to the tooth surface At proper
working angulation f/ ess lhan 90o but more lhan 15"), the lowet shank of a Gracey curet is parallel to
the tooth surface being scaled. The lowcr shank ofa universal cu ret would be tilted slightly towtrd the
tooth.

. The first statement is true; the second statement is false

. The

second statement is true; the first statement is false

. Both statements are true

. Both statements are false

152
Coplrighr

2011'?012 - Denial Decks

Proceeding to another tooth and then returning to the sensitive tooth later in the
apporntment

. Moving the instrument slower

. Making necessary adjustments to the water spray

. Tuming up the power ofthe device

. Using less pressure

't

CopriShi

O20ll

53
2012 - Dental Decls

The two g?es ofultrasonic units are magnetostrictive and piezoelectric. In both t'?es, altemating electrical curent genemtes oscillations in materials in the handpiece that cause the scaler tip to vibrate. Depending on the manufacturet these ultrasonic vibrations at the tip of the instruments ofboth lypes range
liom 20,000 to 45,000 cycles per second. In magntostrictive units the pattem ofvibration ofthe tip is
elliptic, which means that all sides ofthe tip are active and will work when adapted to thc tooth. In
piesoelectric units the pattem ofvibration ofthe tip is linear, or back and fonh, meaning that the two
sides ofthe tip are the most active.

Sonic units consist ofa handpiece that attaches to a compressed-air line and uses a vadety ofspecially
designed tips. Vibrations at the sonic tip range from 2000 to 6500 cps, which provides less power forcalculus removal than ultrasonic units.
Ultrasonic and sonic tips are designed to operate in a wet field with a water spray directed at the end of
the tip. Within the water droplets ofthis spray mist are tiny vacuum bubbles that quickly collapse, releasing energy in a process known as cavitation. The cavitating water spmy serves to flush calculus,
plaque, and debris dislodged by the vibrating tip ftom the pocket. Magnetostdctive ultrasonic tips generate heat and require this water for cooling. Sonic and piezoelectric units do not generate this heat but
still utilize water for cooling frictional heat and flushing away debris.

Dental Endoscope: this device consists of a reusable fiberoptic cndoscope over which is fitted a disposable steriie sheath. It fits onto periodontal probes and ultrasonic instruments that have been designed
to accept it. This device allows clear visualization deeply into subgingival pockets and furcations. It permits operaton to detect the presence and location ofsubgingival deposits.

EJA system (enhanced isual assessment):this system

uses motor-dtiven diamond files to correct over-

hanging or overcontoured proximal alloy or resin restorations.

Prophy-Jet air-powder polishing device: was the first specially designed handpiece to deliver an airpor|ered slurry of warm water and sodium bicarbonate for polishing. lt is very effective for the removal
oferrrinsic stains and soft deposits. Note: Polishing powdets containing aluminum trihydroxide orother
substances mthcr than sodium bicarbonate are being used to offset the abmsive effect of sodium bicarbonate on restorations as well as dentin and cementum. Contraindications to the use ofair-powered polishing devices are those patients with rcspiratory illncsses, hemodialysis, hlpertension and infectious
dlseases.

***

The opposite ofthese is true!! All ofthe rest are appropriate actions to be considered
in that situation.

If sensitivity is encountered during

. Lighten the pressure

use:

. Adjust the water spray: increase water flow to cool the tip
. \4ove to another tooth and then retum later to the sensitive tooth
. Decrease the power
Power driven instruments work best with quick hand movement
moYements.

Remember:
\\'aves.

*** The ultrasonic principle

rapid, controlled

is based on the use of high-frequncy sound

. Supragingival calculus
. The CEJ

Smooth root surfaces

. Subgingival calculus
. Inflammation

154
Copyright O 20ll-2012 - Dental Drcks

. Hoe

scalers

. Files
. Chisel scalers
. Quetin furcation curettes

155

CoplriSh

@ 201

1-2012 - Dental Decks

One of the uses of the air syringe is to detect calculus, both supra and subgingival.
Supragingival calculus is often seen more easily when it is dry (saliva often conceals it),
deflecting the free gingival margin slightly makes subgingival calculus easier to detect.
When using the explorer to detect calculus, a light instrument grasp should be utilized to
increase tactile sensitivity. The lateral side ofthe tip ofthe instrument should be placed
in contact with the tooth surface when exploring for calculus. Dried calculus is easier to
detect than wet calculus with the explorer because it is less slippery.

The five basic scaling instruments are as follows:

. Curette: the curette is the instrument ofchoice for removing deep subgingival calculus,
root planing altered cementum, and rcmoving the soft tissue lining the periodontal pocket.
Each working end has a cutting edge on both sides of the blade and a rounded toe. The
curette is frner than the sickle scalers and does not have any sharp points or comers other
than the cutting edges ofthe blade. Therefore, curettes can be adapted and provide good access to deep pockets with minimal soft tissue damage.
. Sickle scalers fJrpragingival scalers)i have a flat surface and two cutting edges that conr erse in a sharply pointed tip. The shape ofthe instrument makes the tip strong so that it will
not break off during use. The sickle scaler is used primarily to remove supragingival calculus.
. Files: have a series ofblades on a base. Their primary function is to fractwe or crush large
deposits of tenacious calculus or bumished sheets of calculus. Files can easily gouge and
roughen root surfaces when used improperly. Therefore, they are not suitable for fine scalind cn.l r^^f nl,nino
. Chisel scalers: are designed for the proximal surfaces ofteeth too closely spaced to permit the use of other scalers, and are usually used in the anterior part ofthe mouth. They are
double-ended instruments with a curved shant at one end and a straight shank at the other;
the blades are slightly curved and have a straight cutting edge beveled at 45 degrees. The
chisel is inserted from the facial surface. The instrument is activated with a push motion

rvhile the side ofthe blade is held frrmly against the root.
. Hoe scalrs: are used for scaling ofledges or rings ofcalculus. The blade is bent at a 99degree angle; the cutting edge is formed by thejunction ofthe flattened terminal surface with
the inner aspect ofthe blade. The cutting edge is beveled at 45 degrees. Note: McCall's #3,
4, 5, 6, 7, and 8 are a set ofsix hoe scalers designed to provide access to all tooth surfaces.
Each instrument has a different ansle between the shank and handle.

. Use a push stroke to force the tip out ofthe sulcus

. Gently examine the gingival sulcus

. Take a periapical radiograph of the area

Place the patient in an upright position

156
CopltiSht O 20l l-2012 - Denlal Deck

It

is impossible to

. The first statement

. The

carry out periodontal procedures efficiently

with dull instruments.

is true; the second statement is false

second statement is true; the first statement is false

. Both statements are true

. Both statements are false

157

Coprighr O 20ll-2012 - Dental Decks

*** Never use a push stroke, this could force the tip further into the sulcus. Gently examine the
sulcus using a curcl in a spoon-like stroke, attempting to pull the fragment out.
The procedure should be stopped immediately and the patient placed in an upright position. Before proceeding subgingival, check the floor ofthe mouth and the mucobuccal fold lbr the fragment.
A periapical radiograph should then be taken bcfore going any further to locate thc fragment. Try
not to alarm the patient. The last thing you want is for the patient to bccome frantic.

Thc best way to prevent curet breakage is to use proper sharpening techniqucs to maintain thc
original instrumcnt dcsign and discard inshuments when the blade starts to thin out. Athinner blade
is weaker and will break more easily.

Remember: The Schwartz Pedotrievers arc highly magoctized instruments designcd for the retrieval ofbrokcn instrument tips from the periodontal pocket.

Set ofmany curettes, designed

specific areas and surfaces

One cutting edge used; work

outer edge only

for

with

One curette designed for all arcas and surfaces

Both cutting edges used; work with either outer

or inner edge

Curved in two planes; blade curves

up and to the side
Offset blade; facc ofblade beveled Blade not oflset; face ofblade beveled at 90
at 60 degrees to shank
degrees to shank
R.:rrdu.ed urrh pemision, fronr NeMnrn MG, Takr IIII, Klokkevold PR. Camnz. FA. (-dfta4:ai Clini.al P.nodont.lop,I ll" al. Else-

To do its job at all, a dull instrument must be held more firmly and pressed hardcr than a sharp
lnstrument. This reduces tactile sensitivilv and increases the possibilitv that th instrument will in-

advertently slip.
Thc objective of sharpening is to restore the fine, thin, linear cutting edge ofthe instrument. This
is done by gnnding the surfaccs ofthe blade until theirjunction is once again sharply angular rather
rhan rounded. It is important to restore the cutting edge without distorting thc original angles ofthe
instrument. When these angles have been altered, the instrument docs not function as it was de5r!:ned lo funclion. \rhich limits its clfcctircncss.

Principles of sharpening:

. Choosc sharpcning stone appropriate for instrument (/a1 cone, coarse, etc.)
. L se a sterilizcd sharpening stone if the instrument to be sharpened will not be resterilized belbre it is used on a patient
. Establish the proper angle between the stone and the surface ofthe instrument
. \'lainlain a stable, firm grasp ofboth the instrument and the sharpcning stone
. .\r'oid excessive pressure

.\oid formation of a "wire edge" which is produced when the direction of the sharpening
strokc is away from, rather than into or toward, the cutting edge. When back-and-forth or up-anddown sharpcning strokes are used, formation of a wire edge can be avoided by finishing with a
do$n stroke toward the cutting edge.
. Lub cate the stone during sharpening. Oil should be used for natural stones and water for s).nthetlc stones
. Sharpen instrumcnts at first sign ofdullness

\otei The technique for sharpening a universal curette can be used to sharpen a Oracey curette,
horvever, bear in mind that thc Gruccys cutting edge is offset and it also curves, unlike the universal's cutting edge.
Remember: India and Arkansas oilstones are examples olnatural abrasive stones. Carborundum.
ruby, and ceramic stones are synthetically produced.

. Only when using

. When using

a coarse

artificial stone

a mounted ruby stone

only

. When no oil is used for lubrication ofthe stone

. When the last stroke ofthe stone

is drawn away from the cutting edge

158
- Denial Decks

Coplrighr O

201 1-201 2

Coplright

201l-2012 - Denial Decks

. Short, straight shank

. Long, shaight shank
. Short, angled shank
. Long, angled shank

159
@

Avoid formation of a "wire edge" which is produced when the direction of the sharpening
stroke is away from, rather than into or toward, the cutting edge. When back-and-fbrth or upand-down sharpening strokes are used, fonnation ofa wire edge can be avoided by finishing
with a down stroke toward the cutting edge.

The cutting edge of an instrument is formed by the angular junctiqn of two surfaces of its
blade. The cutting edges of a curett, for example, are formed where the face of the blade
meets the lateral sufaces. When the instrument is sharp, thisjunction is a fine line running the
length ofthe cutting edge. As the instrument is used, metal is wom away at the cutting edge,
and the junction of the face and lateral surface becomes rounded or dulled. Thus the cutting
edge becomes a rounded surface rather than an acute angle.

Sharpening stones can be categodzed by their method ofuse;

. Mountd rotary stones: these stones are mounted on a metal mandrel and used in a motordriven handpiece. They may be cylindrical, conical, or disc shaped. These stones are genemlly not recommended for routine use because they (1) are difficult to control precisely,
(2) tend to wear down the instrument quickly, and (3) can generate considerable frictional
heat. which may affect the temper ofthe instrument.
. Unmounted stones: come in a variety of sizes and shapes. Unmounted stones may be
used in two ways: the instrument may be stabilized and held stationary while the stone is
drarvn across it, or the stone may be stabilized and held stationary while the instrument is

dra*n

\ote1

across it.
1. The optimal internal angle between the face of the blade and the lateral surface ofa universal curette and a Gracey curette is 70" to 80o.
2. An instrument whose cutting edge is 90o or more will slip over calculns deposits and requires heavy lateral pressue to remove calculus deposits.
3. The best grasp to use when holding an instrument to be sharpened is the palm

grasp.

How an instrument shank is designed influences the intended use ofthe instrument. It is recommended that an instrument with a rigid shank be used for removal ofheavy calculus deposits. *** Straight shanks are used in the anterior areas and contra-angled shanks are used in
the posterior areas.

Rigid, thick shank:

. Stronger

. Less flexible
. Provides less tactile sensitivity
. Stronger instruments are needed for healy calculus removal
Less rigid, more flexible shank:
. Pror ides more lactile sensirivit)

. Lsed for removing fine calculus and for root plal|ing

Important: The Gracey curettes ditler from

the universal curettes in that the blade is not at a

go-degree angle to the lower shank. The term offset blade is used to describe Gracey curettes,
because they are angled approximately 60 to 70 degrees from the lower shank.

-{ngulation refers to the angle between the lace ofthe bladed instrument and the tooth surface. It may also be called the tooth-blade relationship. During scaling and root planing, optimal angulation is between 45 and 90 degrees. with angulation of less than 45 degrees, the
cutting edge will not bite into or engage the calculus properly. Instead, it will slide over the
calculus, smoothing or "bumishing" it. lfangulation is more than 90 degrees, the lateral surface ofthe blade. rather than the cutting edge, will be against the tooth, and the calculus will
not be removed and may become bumished.

Note: When gingival curettage is indicated, angulation greater than 90 degrees is deliberately
established so that the cutting edge will engage and remove the pocket lining.

. Vertical strokes
. Oblique shokes
. Horizontal stokes

. Circular strokes

t60
Copy.igh O

201 l-2012 -

D.rt l Dccb

There are three basic atrokes used during instrumentation. Any ofthese basic strokes may be activated
by a pull or a push motion in a vertical, oblique, or horizontal direction. Vertical and oblique strokes are
used the most frequently. Hodzontal strokes are used selectively on line angles or dep pockets that cannot be negotiated with vertical or oblique strokes. The direction, length, pressure, and number of strokes
necessary for either scaling or root planing are determined by four major factors: (1) gingival position
and tone, (2) pocket depth and shape, (3) tooth contour, and (4) the amount and nature ofthe calculus or
roughness.
. Exploratory stroke: is a light, "feeling" stroke that is used with probes and explorc$ to evaluate
the dimensions ofthe pocket and to detect calculus and inegularities ofthe tooth surface. The instrument is grasped lightly and adapted with light pressure against the tooth to achieve maximal tactile

sensitivity.
. Scalilg strok: is a short, powerful pull stroke that is used with bladed instruments for the removal
ofboth supragingival and subgingival calculus. The scaling motion should be initiated in the forearm
and hansmifted from the wrist to the hand with a slight flexing ofthe fingers. Tte scaling stroke is
not initiated in the wrist or fingers nor is it carried out independently without the use ofthe forqarm.
. Root planing stroke; is a moderate to light pull stroke that is used iio final smoothing and planing
ofthe root surface. With a moderately firm grasp, the cuette is kept adapted to the tooth with even,
lateral pressure. A continuous series oflong, overlapping shaving stoks is activatd. As the surface
becomes smoother and resistance diminishes, lateral pressue is progressively reduced.

,- ,---_

l, "Pulling" strokes are safer than "pushing" shokes because the push stroke may force calculus
into the supponing tissues. lts use, especially in an apical direction, is not recommend,. 11o3"4!|

g ^ * ..
2. Probing stroke: upward and downward movement within a periodontal pocket.

3.

Tle modilied pen grasp

is the most useful grasp for periodontal instrumentation.

third ofthe working end, which is the last few millimeters adjacent to the toe
or tip, must be kept in constant contact with the tooth while it is moving over the tooth.
5. For subgingival insertion ofa bladed instrument such as a curctte, angulation should be
as close to 0 degree as possible. During scaling and root planing, optimal angulation is be4. The lower

tween 45

rnd 90 degrees.