Perio 1 DEN 039 SAS Module 11 Gingival Diseases Part I (2).pdf

DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________...

DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ LESSON TITLE: Gingival Diseases Part 1 (Inflammatory and Other MATERIALS: Lesions) Ballpens, erasers, pencils and module LESSON OBJECTIVES: At the end of the module, you will be able to: REFERENCES: 1.Know the different stages of gingival inflammation Carranza’s Clinical 2.List clinical signs of gingival inflammation. Periodontotlogy by 3.Correlate clinical signs and symptoms of gingivitis to Newman,Takeu, Klovvekold histologic/microscopic findings and Carranza PRODUCTIVITY TIP: Good day! You are about to start your module. Do short stretching and breathing exercises. After you are done, sit down, be comfortable and say a short prayer. You are now ready to start your work. Enjoy and learn! A. LESSON PREVIEW/REVIEW Introduction (2 minutes) Welcome to Periodontics 1! In the previous module you learned that destruction in the periodontium is not solely due to the presence of microorganisms but mostly due to the host response to its presence. Now, you move forward to gingival pathology. This topic is quite huge hence three modules are allocated for this. Knowledge of the various gingival diseases will help you in making a diagnosis of future patients. Activity 1: What I Know Chart, part 1 :Think on the questions found in the second column of the chart. Write your answers in the first column. Leave the third column blank at this time. What I Know Guide Questions: What I Learned (Activity 4) 1. What is gingivitis? 2.Give the 2 sub classification of gingival diseases? B. MAIN LESSON This document is the property of PHINMA EDUCATION  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ Activity 2: Content Notes (13 minutes) An experimental study has been made by Page and Schroeder wherein a group of people were made to not brush their teeth for a certain period of time. In the study, they found 4 stages of inflammation that occurs around the periodontium in the presence of the accumulation of dental plaque. Gingival Inflammation Stage 1 –Initial Stage Fig.6.1A Diagrammatic presentation of Stage 1 gingival inflammation of Page and Schroeder: The Initial Phase or Subclinical Phase Clinically, this initial response to bacterial plaque is not apparent and therefore referred to as subclinical gingivitis. ‰ It is the first manifestation of gingival inflammation. ‰ There are vascular changes in this stage consisting of dilated capillaries and an increase in blood flow. ‰ If the host response is good, the initial lesion would resolve rapidly, leaving the tissue to the normal state. ‰ But if the host does not respond well, then the lesion might take up a chronic form and there might be infiltration of macrophages and lymphoid cells. Histologically: ‰ There is increase in the number of leucocytes. ‰ There is increase in the gingival crevicular fluid (GCF) flow, due to increased accumulation of leucocytes within the gingival sulcus. ‰ Leucocytes increase within the junctional epithelium and the connective tissue. ‰ There is widening of the blood vessels. Lower picture; a clinical picture of the above : showing a seemingly normal appearance of gingiva This document is the property of PHINMA EDUCATION  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ Fig.6.1 Stage II- Early Lesion Fig.6.2 Stage 2 of Gingival Inflammation: The Early Stage ‰ Early lesion evolves form the initial lesion. ‰ This process starts in about one week after the beginning of plaque accumulation. ‰ This stage shows erythema due to the proliferation of capillaries and increase formation of capillary loops between rete pegs or ridges. ‰ Bleeding on probing also becomes evident. ‰ Between 6 and 12 days after the onset of clinical gingivitis, the gingival fluid flow and the number of leucocytes reach to the maximum level. ‰ About 70% of collagen is destroyed around the cellular infiltrate. ‰ The polymorphonuclear leukocytes (PMNs) are now evident in the gingival epithelium, since they leave the blood vessels and through chemotactic stimuli from plaque, migrate to the epithelium. ‰ Process of phagocytosis occurs, in which the PMNs engulf the bacteria. ‰ There is a decreased capacity of collagen production, and fibroblast shows cytotoxic alterations. Histologically : ‰ Seventy-five percent lymphocytes, mainly T lymphocytes are found in the connective tissue, just beneath the junctional epithelium. ‰ Neutrophils, macrophages and some amount of plasma cells and mast cells are also seen within the connective tissue. ‰ Rete pegs may be seen in the Junctional epithelium. Fig. 6.2 ‰ The features of initial lesion aggravate in early lesions. Lower picture: The clinical picture of an established gingivitis- mild to moderate gingivitis is shown, with erythematous gingiva and bleeding on gentle probing This document is the property of PHINMA EDUCATION  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ Stage III –The Established Gingivitis Fig.6.3 Stage III of Gingival Inflammation by Page and (Subgingival Plaque Phase) Schroeder: The Established Gingivitis (Subgingival Plaque Phase) This lesion is predominated by plasma cells and B lymphocytes. ‰ B lymphocytes are mainly of immunoglobulin G1 (IgG1) and G3 (IgG3) subclasses. ‰ This stage occurs around 2–3 weeks of plaque accumulation. ‰ There is presence of localised gingival anoxemia which is due to engorged and congested blood vessels, impaired venous return and sluggish blood flow. ‰ Anoxemia leads to bluish hue on the reddened gingiva. ‰ Colour of the gingiva can deepen due to extravasation of erythrocytes and into the connective tissue and break down of haemoglobin into its component pigments. ‰ Collagenase is an enzyme which is normally present in gingival tissue it is produced by PMNs and also by some bacteria. ‰ The activity of this collagenase is increased in inflamed gingival tissue which causes destruction of the gingival connective tissue. ‰ In the chronically inflamed gingiva there is also increased levels of acid phosphatase, alkaline phosphatase, b-glucuronidase, b-glucosidase, b- galactosidase, esterases, aminopeptidase and cytochrome oxidase. Histologically: ‰ There is presence of a chronic inflammatory reaction. ‰ There is increase in the number of plasma cells and B lymphocytes. ‰ Intercellular spaces within the Junctional epithelium widens. ‰ Intercellular spaces are filled with granular debris, along with lysosomes derived from disrupted neutrophils, lymphocytes and monocytes. ‰ Tissue components can be destroyed, because of acid hydrolases released by lysosomes. ‰ Rete ridges can be seen in the Junctional epithelium Fig.6.3 that protrude into the connective tissue. ‰ Collagen fibres are also destroyed within the connective tissue, around, the infiltrate disrupted plasma cells, neutrophils, lymphocytes, monocytes and mast cells. This document is the property of PHINMA EDUCATION Lower picture ; Clinical picture moderate to severe gingivitis,with swelling of the gingival tissues..  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ Stage IV :The Periodontal Breakdown Fig.6.4 Stage IV of Gingival Inflammation by Page ( Periodontitis) and Schroeder: Irreversible Tissue Destruction Phase (Periodontitis) Extension of the lesion into the alveolar bone characterizes the advanced lesion; classified already as periodontitis. ‰ This lesion evolves from stage three gingivitis. ‰ It is characterized by extension of inflammation into the alveolar bone. ‰ Therefore, it is referred to as phase of periodontal break down. Histologically: ‰ Extensive inflammation and immunopathologic tissue damage were seen. ‰ Plasma cells continue to dominate the connective tissue. ‰ PMNs dominate the Junctional epithelium and crevice. ‰ Gingiva becomes fibrotic. Lower picture: Clinical picture of periodontitis. There is attachment loss, destruction of alveolar bone as shown by the lengthening of the tooth crown and gingival destruction Fig. 6.4 Clinical features of gingivitis are as follows: A. Color changes in the gingiva. B. Changes in gingival contour C. Changes in surface texture of gingiva. D. Changes in consistency of gingiva. E. Changes in position of the gingiva. F. A. Gingival bleeding on probing This document is the property of PHINMA EDUCATION  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ A. Color Changes in the Gingiva a. Acute Inflammation of the Gingiva >increased blood flow to the gingival tissue causes the tissue to appear bright red b. Chronic Inflammation of the Gingiva >the gingival tissue may appear bluish-red or purplish-red due to blood stagnation and burst of erythrocytes releasing the haemoglobin content into the area Color Change of gingival may also be seen in the following systemic conditions: ‰There are certain systemic factors which may influence the colour of the gingiva. ‰ There could be endogenous or endogenous source of pigments. ‰ Endogenous oral pigments are melanin, bilirubin and iron which can cause oral pigmentation. ‰ Melanin pigmentation is a normal physiologic process which is found in highly-pigmented ethnic groups. ‰ Following are the diseases in which there is increase in melanin pigmentation: Addison’s disease: Isolated patches of discolouration are seen in this disease, which is of varying degree from bluish-black to brown. h It is basically caused due to adrenal dysfunction. Peutz- syndrome: This disease causes intestinal polyposis. h Melanin pigmentation is seen in oral mucosa and lips. Albright syndrome: (fibrous dysplasia) and von reckling hausen’s disease (neurofibronatosis) produces areas of oral melanin pigmentation. h Bile pigments can also stain the skin and the mucous membrane. h Iron deposition seen in case of haemochro-matosis also produces a blue-grey pigmentation of the oral mucosa. h Disorders related to blood can produce colour changes of the oral mucosa such as anaemia, polycythaemia or leukaemia. h Disorders related to endocrine system and metabolic disturbance can also produce colour change such as diabetes and pregnancy. h Exogenous factors which are responsible for colour changes in gingiva are as follows: » Irritants such as coal, metal dust and colouring agents in food and lozenges. » Tobacco leads to increase in melanin pigmentation and hyperkeratosis of the gingiva. » Amalgam implantation in the mucosa can lead to localised bluish black areas of pigmentation. ‰ If a patient wants to get his gingiva depigmented because of aesthetic concern, procedure known as gingival depigmentation can be performed. ‰ There are various ways of gingival depigmentation such and with the help of scalpels, chemicals, electrocautery and lasers. B. Changes in Tissue Contour (Size and Shape) In diseased tissue,the free gingiva is no longer flat but rolled and thickened as a result of edema (fluid) at the neck of the tooth >Papillae may be bulbous,blunted or cratered 1.bulbous-papilla is enlarged and appears to bulge out of the interproximal space 2.blunted-papilla is flat and does not fill the interproximal space 3.cratered-papilla appears to have been scooped out leaving a concave depression in the midproximal area. This document is the property of PHINMA EDUCATION  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ Fig.6.6: Stillman’s Cleft Fig.6.7: Mc Call’s festoon ‰ Change in the contour of gingiva is mainly seen in cases of gingival enlargement ‰ Normal contour of the gingiva is scalloped ‰ In cases of disease, the contour of gingiva becomes scalloped ‰ Inflammatory changes is in the marginal gingiva can lead to formation of and clefts ‰ Some suggest they occur because of traumatic occlusion and the treatment would be occlusal adjustments clefts and narrow, triangular shaped gingival recession ‰ As the recession progression apically, the cleft becomes broader, causing exposure of the root cementum ‰ McCall festoons (Fig.6.7) are rolled, thickened band of gingiva which is generally seen along the canines, when the recession approaches the muco gingival junction. C.Changes in Surface Texture of the Gingiva ‰ The normal surface of gingiva is usually stippled. ‰ Stippling, basically refers to an orange peel appearance of gingiva which is caused by numerous small depressions and elevations. ‰ It is seen in interdental gingiva and attached gingiva. ‰ Surface of gingiva can be either smooth and shiny or firm and nodular depending whether the changes are exudative or fibrotic. ‰ Nodular texture is seen in cases of drug-induced gingival overgrowth. Fig.6.8 Fig. 6.8 –Gingiva looks smooth and shiny This document is the property of PHINMA EDUCATION  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ D.Changes in Consistency ‰ Both the acute and chronic form of gingiva produce changes in the consistency of gingiva. ‰ In chronic gingivitis, both the forms, i.e. destructive which is oedematous and reparative which is fibrotic, coexists and the form which is predominated, will define the consistency of gingiva. E. Changes in the Position of Marginal gingiva Normal position of gingiva is usually at cementoenamel junction (CEJ) ‰ In cases of inflammation the gingiva can be above CEJ, due to increase in the size of gingiva ‰ Also in cases of gingival enlargement, the gingiva will be above CEJ, most of the times covering the clinical crowns as well Other Change in the Position of Gingiva ‰ In case of attachment loss, there can be shift in ‰ First is the actual position, which is the level of the position of gingiva apical to CEJ the epithelial attachment on the tooth ‰ This is referred to as gingival recession ‰ Second is the apparent position which is the level ‰ Recession is exposure of the root surface by the of the crest of the gingival margin apical shift in the position of gingiva ‰ Actual position of the gingiva would determine ‰ There can be two positions of gingiva in the severity of the recession and not the apparent recession position. This document is the property of PHINMA EDUCATION  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ > Causes of recession are as follows: Faulty tooth brushing techniques (gingival Abnormal frenum attachment abrasion) Iatrogenic dentistry Tooth malposition Trauma from occlusion Friction from soft tissues (gingival ablation) Orthodontic treatment Gingival inflammation Clinical Significance of Recession Gingival recession can lead to: ‰ Root caries ‰ Recession can cause abrasion or erosion of the cementum leading to hypersensitivity of dentin 5. Presence of Bleeding in Gingivitis ‰ Bleeding on probing is one of the clearest signs of gingival inflammation seen before the gingivitis is established, other being the increase in gingival crevicular fluid production rate. It may vary in severity duration and case of provocation. It has been seen that bleeding on pooling appears before visual signs of inflammation, thus it is a more objective sign that requires less subjective estimation by the examiner. ‰ Presence of bleeding is not a definite indicator of clinical attachment loss, but its absence definitely indicates an excellent negative predictor of future attachment loss. Factors causing gingival bleeding could be local or systemic ‰ > Local factors causing gingival bleeding: Other than plaque, there are various other contributing factors for gingivitis. They can be anatomic and developmental tooth variations, caries, frenum pull, iatrogenic factors, malposition of teeth, mouth breathing, overhangs, partial dentures, lack of attached gingiva and recession. ‰ >Chronic and recurrent bleeding: Chronic inflammation is the most common cause of abnormal gingival bleeding Mechanical trauma can provoke gingival bleeding, either chronic or recurrent.Mechanical trauma could be from tooth brushing tooth picks, food impactions or biting into solid foods for example apples The severity of bleeding and the ease of its provocation depends upon the intensity of inflammation Once the vessels are ruptured and damaged, mechanism of hemostasis starts, which include contraction of the vessel wall, decrease in blood flow, platelets adhere to the edges of the tissue forming a fibrous clot which contracts, resulting in approximation of the edges of the injured area But when this area is irritated, bleeding starts This document is the property of PHINMA EDUCATION  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ again Bleeding on probing is a sign of active tissue destruction. Injury can lead to active episodes of gingival inflammation Injury could be laceration of gingiva during tooth brushing or by sharp pieces of hard food, gingival burns from hot foods or chemicals Spontaneous bleeding is also seen in acute necrotising ulcerative gingivitis as the inflamed connective tissue consists of engaged blood vessels, which get enrobed by ulceration due to necrotic surface epithelium. ‰ >Systemic factors causing bleeding: Certain conditions have common feature of a haemostatic mechanism failure which result in abnormal bleeding in the skin, internal organ and other tissues including oral mucosa. In such condition, the bleeding is spontaneous. Haemorrhagic disorders, in which there is abnormal gingival bleeding is seen are as follows: Vascular abnormalities like vitamin C deficiency or allergy like Schonlein- Henoch purpura, platelet disorders like thrombocytopenic purpura, hypoprothrombinemia like vitamin K deficiency, other coagulation defects such as haemophilia, leukaemia or Christmas disease, deficient platelet thromboplastic factor (PF3) resulting from uraemia, multiple myeloma and post rubella purpura. There are certain other. They can be effects of hormonal replacement therapy, oral contraceptives, pregnancy and the menstrual cycle. Fluctuation in certain hormones such as androgonic hormones have been associated in modifying gingivitis, especially during puberty. Certain medications also alter the gingivitis like, anticonvulsants antihypertensive calcium-channel blockers and the immunosuppressant drugs, cause gingival enlargements, which cause gingival bleeding, secondarily. >In diseased tissue, the sulcus lining becomes ulcerated and the blood vessels become engorged >When the gingival tissues are disturbed by probing or instrumentation, they can bleed easily >Severity of bleeding and ease of its provocation depend on the intensity of the inflammation Describing Gingival Inflammation 1.Duration >Acute gingivitis-gingivitis of sudden onset and short duration and can be painful >Chronic gingivitis-slow in onset, painless and of long duration >Recurrent gingivitis-reappears after having been eliminated by treatment or disappearing spontaneously 2.Extent of Inflammation >localized gingivitis-confined to the gingiva of a single tooth or group of teeth >generalized gingivitis-involves the entire mouth 3.Distribution of Inflammation >marginal gingivitis-involves the gingival margin and may include a portion of the contiguous attached gingiva >papillary gingivitis-involves the interdental papillae and often extends into the adjacent portion of the gingival margin This document is the property of PHINMA EDUCATION  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ >diffuse gingivitis-affects the gingival margin,the attached gingiva,and the interdental papillae Use of Descriptive Terminology Localized marginal gingivitis-confined to one or more areas of the marginal gingiva Localized diffuse gingivitis-extends from the margin to the mucobuccal fold in a limited area Localized papillary gingivitis-is confined to one or more interdental spaces in a limited area Generalized marginal gingivitis-involves the gingival margins in relation to all teeth Generalized diffuse gingivitis-involves the entire gingiva,the alveolar mucosa and attached gingiva are affected,so the mucogingival junction is sometimes obliterated. Activity 3: Skill-building Activities Check your answers against the Key to Corrections found at the end of this activity sheet. Write your score on your paper. Good Luck and Enjoy! I. Identify the particular change of the gingival tissue as seen here in the pictures. Describe. 1. 2. This document is the property of PHINMA EDUCATION  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ 3. 4.. 5.In your answer to no.4, what could be its clinical significance? II. Association Test: Write A if the statement is related to A; B if the statement is related to B; C if the statement is related to C; Combine letters if related to more than one; write X if the statement is not related to any. A. Stage I Gingivitis B. Stage II Gingivitis C. Stage III Gingivitis _______1. The blood vessel becomes engorged and congested, venous return is impaired and the blood flow becomes sluggish. _______2. Page and Schroeder termed this stage as advanced lesion. _______3. The predominant cell type are plasma cells. _______4. The initial response is dilatation of the blood vessels and clinically this stage is not apparent. _______5. The color of the gingiva in this stage is bluish red as a result of localized anoxemia. _______6. Seventy percent of collagen in this stage is destroyed. _______7. The junctional epithelium becomes densely infiltrated with neutrophils as does the gingival sulcus and the junctional epithelium may begin to show development of rete pegs or ridges. _______8. This stage will take place 4 days to one week after plaque has been allowed to accumulate. _______9. Subclinical type of gingivitis. _______10. Erythema,bleeding on probing are its clinical findings. Activity 4: What I Know Chart, part 2 (2 minutes) Go back to the “What I Know Chart” in Activity 1 and answer the “What I Learned” column. This document is the property of PHINMA EDUCATION  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ Activity 5: Check for Understanding (5 minutes) Please answer the short quiz as honestly as you can.Lets go! My Score: _____________ 1.In gingivitis, the position of the gingival margin is : a. coronal to the CEJ b. apical to the CEJ c. at the cervical area d. no change at all 2.Gingivitis in which the inflammation affects only a group of teeth is termed: a. localized gingivitis b. generalized gingivitis c. acute gingivitis d. chronic gingivitis 3.A papilla that is enlarged and appears to bulge out of the interproximal space is called: a. scooped b. cratered c. bulbous d. blunted 4.The earliest signs of gingival inflammation that precede established localized gingivitis include which of the following? a. increased gingival crevicular fluid production b. bleeding from the gingival sulcus on gentle probing c. suppuration on gentle probing d. A and B only e. all of the above 5.Localized marginal gingivitis normally; a. extends from the gingival margin to the mucobuccal fold in limited areas b. extends from the gingival margin to the mucobuccal fold in the entire mouth c. extends only in interpapillary d. extends on the lingual surfaces only Stop and check your answers against the Key to Corrections found at the end of this Activity Sheet. Write your score/s on your paper. C. LESSON WRAP-UP Activity 6: Thinking about Learning (5 minutes) A. Work Tracker You are done with this session! Let’s track your progress. Shade the session number you just completed. B.Think about your Learning: Please answer the following questions: This document is the property of PHINMA EDUCATION  DEN 039 PERIODONTICS 1 (Lecture) Student Activity Sheet Module # 11 Name: ____________________________________________________________ Class number: _______ Section: ____________ Schedule: _____________________________________ Date: _______________ 1) Please rate your activity today by placing a check mark (/) before a choice. Please explain your choice on the blank space beside the table: 1. Boring 2. Not informative 3. Challenging 4. Fair 5. Fun 2) “What details in the content and/or activities were not clear to you?” ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ D. FREQUENTLY ASKED QUESTIONS: 1.Does toothbrushing cause recession? Answer: Yes, overzealous toothbrushing may cause recession especially if you use the hard type of bristles. 2.Aside from removing plaque and debris from the teeth, what other advantages does one get from toothbrushing? Answer: There are various effects of tooth brushing on the consistency of gingiva such as: ‰ It promotes keratinisation of oral epithelium. ‰ Capillary gingival circulation is enhanced KEY TO CORRECTIONS: Activity #3: Test I. Answers: 1.A change in the size and shape of the interdental papilla, from thin knife-edge and pyramidal in shape in a healthy gingiva. In the diseased, it has become bulbous and enlarged. 2.There is a change in the shape and contour of the interdental papilla. In this picture, the interdental papilla has become cratered. 3.The change is on the contour of the interdental papilla. It has become blunted. Gingiva does not fill up the embrasures. 4. There is a change in the position of the marginal gingiva. There is recession or apical movement of the gingival margin. 5.The clinical significance of gingival recession is the exposure of the cementum or dentin in the area which can cause hypersensitivity. Test II. Answers: 1.c; 2.x ; 3.c ; 4.a ; 5.c ; 6.b ; 7.b; 8.b ; 9.a ;10.b Activity # 5. Answers : 1.a ; 2.a ; 3. c ; 4. d ; 5.a This document is the property of PHINMA EDUCATION