Chapter 6 PDF: Periodontitis Questions

CHAPTER 6 17 Questions Periodontitis Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com.  Definition of Periodontitis Periodontitis is: A complex microbial infection that triggers host-mediated inflammatory response within periodontium...

CHAPTER 6 17 Questions Periodontitis Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com.  Definition of Periodontitis Periodontitis is: A complex microbial infection that triggers host-mediated inflammatory response within periodontium Results in progressive irreversible destruction of periodontal ligament and supporting alveolar bone Leading cause of adult tooth loss C o p According to CDC, about 47.2% of adults older than 30 suffer from periodontitis y r i Begins as biofilm-induced gingivitis g h t Reversible condition if managed appropriately and in a timely manner © 2 0 May progress to periodontitis if left untreated 2 4 b Once patient diagnosed with periodontitis, remains periodontitis patient for life y J o Even following successful periodontal therapy n e s Will require lifelong supportive care & B a r Disease Characteristics of Periodontitis Loading… Copyright © 2024 by Jones & Bartlett Le 06.F02: Disease Characteristics of Periodontitis. Periodontitis is initiated by the buildup of periodontal pathogens and the ensuing host-mediated inflammatory response within the supporting tissues of the teeth, leading to progressive irreversible destruction of the periodontal ligament and loss of supporting alveolar bone  Signs and Symptoms of Periodontitis Clinical signs and symptoms include: Accumulation of plaque biofilm and dental calculus Redness (erythema) and swelling (edema) Gingival bleeding C Suppuration (pus) o p y Periodontal pockets r i g h Clinical attachment loss and tooth mobility t © 2 Radiographic hallmark is the loss of alveolar crest and/or interfurcational bone loss 0 2 4 b y J o n e s & B a r  Alterations in Color, Texture, and Size of the Marginal Gingiva Reddish or purplish tissue – very obvious Pale-pink tissue – not so obvious Alterations in gingival contour and form Almost healthy-looking appearance evident Rolled, edematous gingival margins Blunted or flattened papillae Loading… © Wolters Kluwer Copyright © 2024 by Jones & Bartlett Le C o p y r i g h t © 2 0 2 4 b y J o n e s & B a r  Copyright © 2024 by Jones & Bartlett Le 06.F03C: Radiographic Evidence of Periodontitis. Dental radiographs of a patient with periodontitis reveal a horizontal pattern of alveolar bone loss. © Wolters Kluwer  Alterations in Color, Texture, and Size of the Margin Gingiva (cont.) Clinical appearance not reliable indicator of presence or severity of periodontitis Example: deep pocket revealed upon probing C o p y r i g h t © 2 0 2 4 b y J o n e s & B Courtesy of Dr. Don Rolfs, Periodontal Foundations, Wenatchee, WA. a r Courtesy of Dr. Don Rolfs, Periodontal Foundations, Wenatchee, WA.  Alterations in Color, Texture, and Size of the Margin Gingiva (cont.) Periodontitis exhibiting fibrotic appearance Copyright © 2024 by Jones & Bartlett Le © Wolters Kluwer © Wolters Kluwer  Characteristics of Periodontitis Bleeding, Crevicular Fluid, Exudate; Plaque Biofilm and Calculus Deposits Gingival bleeding (spontaneous or upon probing) Increased flow of gingival crevicular fluid or suppuration (pus) from periodontal pockets Periodontitis initiated by mature supra- and subgingival plaque biofilms and calculus deposits but Host response determines the pathogenesis and progression of disease. Clinical attachment loss (CAL) C o Measurement of amount of destruction affecting tooth-supporting structures destroyed around tooth p y r Characterized by: i g Apical migration of junctional epithelium h t © Destruction of gingival and periodontal ligament fibers 2 0 Loss of alveolar bone support around tooth 2 4 b Accompanying Features of Attachment Loss y J o Loss of alveolar bone support to teeth n e Periodontal pockets or apical migration of gingival margin s Furcation involvement in multirooted teeth & B Pathologic tooth migration a r  Loading… Copyright © 2024 by Jones & Bartlett Le 06.F08A: Pathologic Tooth Migration. An 18-year-old patient presented with increasing spacing between the maxillary incisors th have drifted apart over a 1-year period. A. Note the divergence of the two incisors. Deep probing depth of 6 mm was noted on the mesial aspects of both incisors with Class III mobility. B. Radiographic evidence of severe bone loss consistent with pathological migration or drifting of incisors due to periodontitis.  Deeper Probing Measurements Extent of probe penetration influenced by inflammatory status of periodontal tissue C o p y r i g h t © 2 0 2 4 b y J 06.F09A: Diagrammatic Representation of Probe Tip Penetration Relative to the Periodontal Tissues. The depth of probe penetration is o n influenced by the inflammatory status of the periodontal tissues. A. In a healthy sulcus, the probe penetrates about. one-third of the e s length of the junctional epithelium B. In moderate inflammation, the probe tip penetrates approximately half the length of the & B junctional epithelium. C. In severe inflammation, the probe tip penetrates through the entire length of the junctional epithelium and a only stops when it encounters the most coronal intact collagen fibers in the gingival connective tissue. r  Localized or Generalized Inflammation Localized inflammation may affect: One site or several sites on a tooth or Sites on several teeth Generalized inflammation may involve entire quadrant or entire dentition Site-specific nature of periodontitis may be apparent Contributing Factors: Environmental factors such as smoking Systemic factors such as diabetes or HIV Copyright © 2024 by Jones & Bartlett Le Genetic factors Local intraoral factors such as tooth crowding or overhanging restorative margin  Symptoms Symptoms: Usually painless Gingival bleeding while brushing Spaces occurring between teeth Teeth becoming mobile Complaints of food impaction, sensitivity to temperature, and/or dull pain radiating into jaw C o Onset of Periodontitis: p y r Dental biofilm-induced gingivitis: i g h Always precedes onset of periodontitis t © May remain stable for many years 2 0 Manifests after days or weeks of biofilm accumulation 2 4 Onset at any age, but most commonly affects adults b y J o n e s & B a r  Patient Education: The Warning Signs of Periodontitis: Red or swollen gingiva Bleeding during brushing Bad taste in mouth Persistent bad breath Sensitive teeth Loose teeth Pus around teeth and gingiva Various tools helpful in increasing public awareness Example: Copyright © 2024 by Jones & Bartlett Le Oral health self-evaluations distributed at health fairs or other events  Extent of Destruction in Periodontitis Extent is the distribution of periodontitis throughout oral cavity Based on percentage of affected teeth that exhibit periodontal breakdown divided by total number of teeth present in mouth at time of diagnosis Inflammation is localized or generalized Localized periodontitis C o Less than 30% of teeth exhibit attachment loss and/or bone loss p y r Generalized periodontitis i g 30% or more of teeth exhibit attachment loss and/or bone loss h t © 2 0 2 4 b y J o n e s & B a r  Disease Progression Disease progression = Changes that occur over time in periodontal tissues due to natural progression of disease Continuous disease hypothesis Untreated periodontitis progresses as continuous gradual process 0.05 mm to 0.3 mm of attachment loss per year Random burst model Untreated periodontitis progresses randomly and in episodic bursts of activity Some diseased sites dormant for long periods Other sites progress more rapidly, most frequently in interproximal areas Copyright © 2024 by Jones & Bartlett Le Asynchronous burst hypothesis Periodontitis progresses in relatively short bursts, followed by periods of extended remission Remains unclear whether periodontitis progresses gradually or in bursts Desired outcome is to halt progression  Examples of Before and After Periodontal Therapy C o p y r i g h t © 2 0 2 4 b y J o n e 06.F10B: Periodontitis: Before and After Periodontal Therapy. A. Note the tissue appearance before periodontal therapy. Clinical s inflammation is particularly pronounced on the mandibular anterior sextant. B. The same individual after treatment. Note the & B resolution of inflammation in the mandibular anterior sextant. a r © Wolters Kluwer  Examples of Before and After Periodontal Therapy (cont.) Courtesy of Dr. Ralph Arnold, San Antonio, TX. Courtesy of Dr. Ralph Arnold, San Antonio, TX. Copyright © 2024 by Jones & Bartlett Le 06.F11A: Periodontitis: Before and After Periodontal Therapy. A. Prior to therapy, very inflamed tissue is evident. B. Much improved clinical picture at 3-month follow-up appointment.  Examples of Before and After Periodontal Therapy (cont.) C o p y r i g h t Courtesy of Dr. Ralph Arnold, San Antonio, TX. Courtesy of Dr. Ralph Arnold, San Antonio, TX. © 2 0 2 4 b y J o 06.F12A: Periodontitis: Before and After Periodontal Therapy. A. Very swollen gingival tissues pre-treatment. B. The same individual n e after treatment. s & B a r  Therapeutic Endpoints & Treatment Goals Therapeutic endpoints of Periodontal Therapy: Eliminate microbial etiology and contributing factors Preserve current state of teeth and periodontium in state of health, function, and stability Prevent disease progression and reoccurrence Reinforce behavioral modifications that favor long-term compliance, improve oral health, and decrease risk of reoccurrence (shared decision making) Treatment Goals: Reinforce daily self-care Perform effective periodontal instrumentation to remove microbial etiology Eliminate local intraoral factors contributing to disease Copyright © 2024 by Jones & Bartlett Le Perform periodontal surgery Set plan to adhere to maintenance regimen after disease is controlled.  Compromised Periodontal Maintenance Compromised periodontal maintenance = a treatment not intended to attain optimal results Designed to slow down, not eliminate or fully arrest, the progression of periodontitis in patients who do not respond favorably to active conventional periodontal therapy due C o p y to: r i g h Serious health conditions t © 2 0 Poor motivation/compliance 2 4 b Advanced age y J o n Severe periodontal disease e s & B a r  Recurrent Form of Periodontitis Recurrent form: Return of destructive periodontitis that had been previously arrested by conventional therapy Risk for anyone with history of periodontitis Recurrence is common if poor homecare or noncompliant with routine professional care Must refocus attention in arresting disease and re-establishing patient adherence to treatment, self-care, and frequent professional maintenance Refractory form: Seen in a patient previously treated and monitored over time who exhibits continuing attachment loss despite: Receiving appropriate professional periodontal therapy Copyright © 2024 by Jones & Bartlett Le Practicing satisfactory self-care Following recommended program of maintenance visits Etiology unknown Designation “refractory” is applied to cases of periodontitis that do not respond favorably to conventional treatment.  C o p y r i g h t © 2 0 2 4 b y J o n e s © Jones & Bartlett Learning & B a 06.B02: Refractory Form of Periodontitis r  Refractory Form of Periodontitis (cont.) Treatment includes: Patient education and behavior modification Periodontal instrumentation Use of systemic and/or local antibiotics Removal of periodontally hopeless teeth Correction of restorations contributing to plaque retention Copyright © 2024 by Jones & Bartlett Le Surgical therapy Strict adherence to periodontal maintenance regimen  Periodontitis Case Definition System Patient is periodontitis case if either: Interdental clinical attachment loss detectable at two or more nonadjacent teeth Facial or lingual clinical attachment loss of 3 mm or more with pocketing over 3 mm detected at two or more teeth CAL cannot be attributed to non-periodontitis reasons such as: C Gingival recession of traumatic origin o p Dental caries extending to or apical to the CEJ y r i Presence of CAL on the distal aspect of 2nd molar associated with malposition or extraction of a g h 3rd molar t © Endodontic lesion draining through the marginal gingiva 2 0 2 The occurrence of a vertical root fracture 4 b y J o n e s & B a r  Identification of the Form of Periodontitis Pathophysiology Study of pathologic manifestations of periodontitis Explains processes that result in signs and symptoms Does not deal directly with the treatment of disease Three forms identified based on pathophysiology: Necrotizing periodontitis Periodontitis as manifestation of systemic diseases Periodontitis Copyright © 2024 by Jones & Bartlett Le  Periodontitis Stage Stage I, II, III, or IV Staging category defined by: Disease severity (severity factors) Complexity of management of case (complexity factors) C o Things to keep in mind when determining stage: p y r i Severity of case is based on the interdental CAL at the worst affected site g h t © Individual complexity factors and/or severity factors – could shift stage to higher category 2 0 2 Example: maximum probing depth is 5mm but also Class II furcation then that would shift from 4 b y J stage II to stage III or IV irrespective of other severity factors like CAL, RBL, or tooth loss o n e Staging is a patient-based attribute; only a single stage is ascribed to an individual patient at a s & B a given time. r Periodontitis Stages Loading… Copyright © 2024 by Jones & Bartlett Le C o p y r i g h t © 2 0 2 4 b y J o n e s & B a r  Copyright © 2024 by Jones & Bartlett Le 19.T02: Scale for Rating Furcation Involvement © Jones & Bartlett Learning C o p y r i g h t © 2 0 2 4 b y J o n e s & B a r  Periodontitis Grading System Estimates future rate of progression of periodontitis Measures the responsiveness to conventional therapy and the potential impact of systemic health Primary criteria for grading are defined by: Direct evidence Longitudinal evaluation of the progression - Compare rate of attachment loss and/or bone loss over 5 years or more Indirect evidence based on: Percent of bone loss at worst affected tooth Case phenotype – defined by whether the level of destruction corresponds with the level Copyright © 2024 by Jones & Bartlett Le of plaque biofilm in the patient’s mouth Indirect evidence might be the more practical evidence since longitudinal evidence might not be available Individual risk factors may shift the grade to a higher level Smoking less than 10 cigarettes per day but no CAL over the last 5 years Grade B Periodontitis Grading System (cont.) C o p y r i g h t © 2 0 2 4 b y J o n e s & B a r  Periodontal Diagnosis Should include: Confirmation patient is periodontitis case Identification of form of periodontitis Description of presentation and aggressiveness of disease by stage and grade Copyright © 2024 by Jones & Bartlett Le  C o p y r i g h t © 2 0 2 4 b y J o n 06.B03: Case Example. Stage I Grade A Periodontitis e s © Jones & Bartlett Learning & B a r  Copyright © 2024 by Jones & Bartlett Le 06.B04_01: Case Example. Stage III Grade C Periodontitis © Jones & Bartlett Learning  C o p y r i g h t © 2 0 2 4 b y J o n 06.B04_02: Case Example. Stage III Grade C Periodontitis e s & B a r  Copyright © 2024 by Jones & Bartlett Le © Jones & Bartlett Learning 06.B05: Case Example. Stage III Grade C Periodontitis  C o p y r i g h t © 2 0 2 4 b y J o n e s © Jones & Bartlett Learning & B a 06.B06: Case Example. Stage III Grade C Periodontitis r  Copyright © 2024 by Jones & Bartlett Le © Jones & Bartlett Learning 06.B07: Case Example. Stage IV Grade C Periodontitis  C o p y r i g h t © 2 0 2 4 b y J o n e s © Jones & Bartlett Learning & B a r 06.B08: Case Example. Stage II Grade B Periodontitis  Copyright © 2024 by Jones & Bartlett Le © Jones & Bartlett Learning 06.B09: Case Example. Stage III Grade B Periodontitis  C o p y r i g h t © 2 0 2 4 b y J o n e s © Jones & Bartlett Learning & B a 06.B10: Case Example. Stage IV Grade C Periodontitis r  Copyright © 2024 by Jones & Bartlett Le 06.F21B: Clinical Findings. The photo shows a patient with Stage IV, Grade C periodontitis. Radiographic Characteristics. The patient’s radiographs reveal vertical bone loss (indicated by white arrows). © Wolters Kluwer Examples of Periodontitis Case Staging and Grading (cont.) Stage III, Grade C periodontitis C o p y r i g h t © 2 0 2 4 b y J o n e s & B a r