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When extensive SRP must be performed, the 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)

In root planning, where should the ideal working stroke begin?

The apical edge of the junctional epithelium (the base of the pocket)

Which of the following presents the most difficulty in performing a thorough SRP?

Trifurcations of the maxillary molars

What is the best criterion to evaluate the success of SRP?

no evidence of bleeding upon probing

Some degree of curettage is done unintentionally when SRP are performed; this is called ____.

inadvertent curettage

Curretage accomplishes the removal of the chronically inflamed granulation tissue that forms in the lateral wall of the periodontal pocket


The main objective of root planning is?

To remove etiologic agents from the root surfaces

Maximum shrinkage after gingival curettage can be expected from tissue that is?


A curette designed to SRP anterior teeth with deep pockets will have a?

long, straight shank

Which teeth are most likely to have flutings, which make SRP diffult?

maxillary premolars
mandibular incisors

What is a problem on the mandibular incisors that makes SRP difficult?

root proximity

Contraindications for gingival curettage include?

acute periodontal disease
firm, fibrotic tissue
intrabony pockets
mucogingival involement
lateral wall of gingiva is extremely thin

toothbrush trauma (abrasion) usually occurs on the:

canines and premolars

Tooth brush trauma most frequently occurs on teeth that are ___.

most prominent in the dental arch

Dentin is abraded 25 times faster than enamel
cementum is abraded 35 times faster than enamel


How is hard tissue abrassion damage produced?

abrasive dentifrices

How is soft tissue abrassion produced?

usually by the toothbrush alone

Trauma from tooth brushing may result in?

-recession from marginal gingiva
-lacerations of soft tissue
-v-shaped 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

The most accepted theory as to the cause of root sensitivity is the?

hydrodynamic theory

What is the hydrodynamic theory?

pain of root sensitivity results from indirect innervation caused by dentinal fluid movement in the tubules, which stimulates mechanoreceptors in the pulp

Active ingredients to treat hypersensitivity:

strontium chloride
potassium nitrate
sodium citrate

How do desenitizing agents work?

They act through the precipitation of crystalline salts on the dentin surface, which block dentinal tubules

The most important factor in the control of hypersensitive roots among patients with PD diease after gingival recession has exposed the cervical portion of the teeth is:

thorough daily plaque control

To desensitize, most likely the mechanism of action is the reduction in the diameter of the dentinal tubules so as to limit the displacement of fluid in them: This can be attained by:

-formation of smear layer produced by burnishing the exposed surface
-topical application of agents that form insoluble precipitates within the tubules
-impregnation of tubules with plastic resins
-sealing of the tubules with plastic resins

angular defects are classified on the basis of:

The number of osseous walls left surrounding the tooth

What is the most common pattern of bone loss?


vertical or angular defects

occur in an oblique direction, leaving a hollowed-out trough in the bone alongside the root; the base of the defect is located apical to the surrounding bone. In most instances, angular defects have accompanying intrabony periodontal pockets; intrabony pockets, however, always have an underlying angular defect

Osseous craters

concavities in the crest of the interdental bone confined within the facial and lingual walls. Craters have been found to make up about 1/3 of all defects and about 2/3 of all mandibular defects. They are more common in posterior segments than anterior segments. They are best treated with osseous surgery


loss of the buccal or lingual bone overlaying the root portion of the tooth, leaving the area covered by soft tissue only

intrabony defect

three-wall vertical defect that was originally caled an intrabony defect. The term was later expanded to designate all vertical defects


one-wall vertical defect

suprabony pockets

associated with horizontal bone loss, they are not intraosseous

When evaluating an osseous defect, the only way to determine the number of walls left surrounding the tooth is by:

exploratory surgery
-this is because a dense buccal and lingual plate of bone will tend to mask the defect, blocking it out on radiographs

Which type of pocket is formed by gingival enlargement without destruction of the underlying periodontal tissues

gingival pocket

Initially, the first group of cells to arrive at the site of injury are neutrophils. Later, ______ become more numerous. In certain parasitic infections, ____predominate. In viral infections, _____ rather than neutrophils usually predominate.

Macrophages, eosinophils, lymphocytes

What are the stages of acute imflammation?

1. vascular phase of inflammation
2. cellular phase of inflammation

What happens during Vascular phase of Inflammation?

1. vasoconstriction- immediately following tissue injury, there is a brief period of localized vasoconstriction
2. complement activation of mediator release
3. vasodilation
4. Increased vascular permeability

In the Vascular phase of inflammation, what is the complement activation of mediator release?

Tissue injury, or the presence of bacteria, activates complement. C3b molecules formed in this process bind to microbes and injured (opsonization). C3a and C5a (chemotaxins) trigger the release of histamine and serotonin from nearby mast cels. Tissue injury also triggers the formation of bradykinin and initiates the synthesis of prostoglandins and leukotrienes.

In the Vascular phase of inflammation, what happens during vasodilation?

Histamine, and other vasoactive mediators of inflammation, then cause relaxation of smooth muscle in arteriolar and capillary walls. Vessels dilate increasing blood flow to injured tissues. This manifests by redness (hypernia) and heat near the site of injury.

In the Vascular phase of inflammation, increased vascular permeability?

With vasodilation, the endothelial cells lining blood vessels contract slightly creating gaps between the cells that allow plasma to escape intp surrounding tissues. Plasma delivers antibodies and other antimicrobial substances to the site of injury. Fibrinogen from plasma also clots and serves as a temorary barrier to bacterial invasion.

What happens during the Cellular phase of inflammation?

1. Adhesion
2. Diapedesis and chemotaxis
3. phagocytosis

During the Cellular phase of inflammation; adhesion?

As blood vessels dilate, the velocity of blood flow slows allowing circulating WBC to accumulate on the inner surface of blood vessels. This process is called margination.

During the Cellular phase of inflammation; Diapedesis and chemotaxis:

The WBC then begin to squeeze between the contracted enothelial cells and migrate in an ameba-like fashion into the extravascular space (a process called diapedesis). Once in tissue, the WBC's are attracted by activated complement and and begin to migrate towards the site of injury or infection. WBC's (specifically PMN's) apparently have surface receptors for chemotactic agents. (C5a, TNF, IL-8, LtB4, IL-1, IFN-y) which causes them to move in the direction of increasing concentrations of the chemotactic substance (process is called chemotaxis). Intially, the first group to arrive at the site of injury are neutrophils (PMNs). Later, macrophages become more numerous. In certain parasitic infections, eosinophils predominate. In viral infections, lymphocytes rather than neutrophils usually predominate.

During the Cellular phase of inflammation; Phagocytosis?

When WBC (specifically PMNs) arrive at the site of tissue injury or microbial invasion they become very active and begin engulfing bacteria forming a phagosome which combines with lysosomal granules to form a phagolysosome, in which digestion of the engulfed particle occurs.


redness, caused by vasodilation from vessels dilating causing an increase in blood flow to injured tissues.

What cells line the blood vessels?

endothelial cells

With increases vascular permeability, what does plasma do?

gaps are created between the endothelial cells, and this allows plasma to escape into surrounding tissues. Plasma delivers antibodies and other antimicrobial substances to the site of injury.

Fibrinogen does what? Where does it come from?

It comes from plasma, and it clots and serves as a temporary barrier to bactieral invasion.

Adhesion is also called?


What happens during margination?

When blood vessels dilate or expand, blood flow slows down which allows circulating WBC to accumulate on the inner surface of the vessel wall

What happens during Diapedesis?

WBC squeeze between contracted endothelial cells and travel (migrate) in an ameba-like fasion into the extravascular space.

Which cells of the immune system possess receptors for the complement componene tof C3a, by which they participate in immediate inflammation?

Dermal dendrocytes (histocytes)

All cells in the immune system originate from what?

hematopoietic stem cell in the bone marrow.

The Hematopoietic stem cell in the bone marrow gives rise to two major lineages:

1. myeloid progenitor cell
2. lymphoid progenitor cell

These two progenitors give rise to the myeloid cells

dendrtic cells

These two progenitors give rise to lymphoid cells

T cells
B cells
Natural Killer cells (NK)

These cells make up the cellular components of the innate (non-specific) and adaptive (specific) immune systems.


What are cell receptors?

They are molecules on the cell surfaces that enable to cell to interact with other molecules or cells. Receptors reflect and dictate the function of cells.

Mast cells

important in immediate inflammation (anaphylaxis and allergic responses). They possess receptors for complement components (C3a and C5a) as well as receptors for the Fc portion of the antibody molecules IgE and IgG. They feature prominent cytoplasmic granules (lysosomes)-which store inflammatory mediators such as histamine and haparin.

cytoplasmic granules are also known as lysosomes, and they store:

stores inflammatory mediators such as histamine and heparin.

Two examples of inflammatory mediators

histamine and heparin

Dermal dendrocytes (histocytes)

distributed near blood vessels and possess receptors for the complement component C3a, by which they participate in immediate inflammation.

Peripheral dendritic cells (DCs)

are leukocytes of dendrites. Langerhans cells are DCs that reside in the suprabasilar portions of squamous epithelium. DCs are important in antigen processing and presentation of cells of the specific immune response.

Neutrophils and monocytes/macrophages are:

phagocytic leukocytes


predominant leukocyte in the blood. Do not need to differentiate substantially to function, they are suited for rapid responses. They posses receptors for metabolites of the complement molecule C3


are referred to as macrophages when they leave the blood. They present antigen to T-cells.

Together, macrophages and lymphocytes:

orcehstrate the chronic immune response

What are the three main types of lymphocytes?

-They are distinguished based on their receptors for anigens.
-Natural Killer Cells (NK)


recognize diverse antigens using a low-affinity transmembranous comples, the T-cell antigen receptor (TCR). T cells are subdivided based on whether they possess the co-receptor CD4 (T-helper cells) or CD8(T-cytotoxic 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 form plasma cells which secrete IgM. Others differeniate into memory B-cells

Natural-Killer cells (NK)

recognize and kill certain tumor and virally infected cells

Cells that are part of the compliment component C3a:

mast cells (also part of the C5a)
dermal dendrocytes (histiocytes)

B-cells become:

plasma cells - secreting IgM
Memory Bcells

The main cells involved in chronic inflammation are?

lymphocytes and macrophages

Chronic inflammation

slow onset and persists for weeks. The symptoms are not as severe as with acute inflammation, but the condition is insidious and persistent, the main cells involved are lymphocytes and macrophages.

What aid of chemical mediator works with macrophages?

-Macrophages do an excellent job of engulfing or neutralizing or killing foreign antigens.
-lymphocytes and macrophages are interdependent in that the activation of one stimulates the actions of the other.

What is the predominant cell in chronic inflammation?


Characteristics of chronic inflammation:

-lymphocyte, macrophage, plasma cell infiltration
-Tissue destruction by inflammatory cells
-Attempts at repair with fibrosis and angiogenesis (new vessel formation)

When acute phase cannot be resolved: persistent injury or infection example:


When acute phase cannot be resolved: prolonged toxic agent exposure:


When acute phase cannot be resolved: Autoimmune disease states


Examples of macrophages scattered all over

-Kupffer cells
-sinus histiocytes
-alveolar macrophages

Macrophages circulate as monocytes and reach the site of injury within:

24-28 hours and transform

Macrophages become acvited by T-cells derived from:

-other products of inflammation

T and B lymphocytes are:

antigen-activared (via macrophages and dendtric cells)
-Release macrophage activating cytokines

Plasma cells are:

terminally differentiated B-cells that produce antibodies

Eosinophils are found esspecially at the sites of:

parasitic infection, or at allergic reaction (IgE mediated) sites

The ____ has emerged as a unique immune cell that could be activated by many non-immune processes, including acute stress:

Mast cell

Mast cells originate from?

pluripotent cells

Mast cells are frequently located at?

perivascular sites in the tissues, such as:
lungs, where they interact with external environment

When do Mast cells become activated?

When surface receptor-bound antigen-specific immunoglobulin E (IgE) encounters an antigen that the IgE recognizes. This triggers mast-cell degranulation, leading to the rapic release of inflammatory mediators, such as histamine, proteoglycans, and cytokines. Mast cells activation also stimulates the arrival of other inflammatory cells- a critical step in local inflammation

Mast cells are not only necessary for allgeric reactions, but recent findings indicate that they are involved in neuroinflammatory disease; esspecially those worsened by stress:

In these cases, mast cells appear to be activated through their Fc receptors by immunoglobulins other than IgE, as well as by anaphylatoxins, neuropeptides, and cytokines to secrete mediators selectively without over degranulation.

The mast cell content in human gingiva is ___.

high; the mast cell content of inflammed gingiva increases with severity of inflammation increases.

The anaphylactic repsonse is characterized by:

The degranulation of mast cells as a result of antigen-antibody complexes affixed to cell surfaces.

Prevotella intermedia was formerly known as:

bacteroides intermedius

Smoking has been identified as a significant variable to predict the response to PD treatment. Smoking has a negative effect on PD therapy.

Both statements are TRUE

What is one of te most significant risk factors currently available to predict the developement and progression of periodontitis?


Smokers have an increase in which type of bacteria?

Tannerella Forsythia; and more orange and red microbial complexes

Some autoimmune disesease have been associated with periodontal disease:

Crohn's disease
rhematoid arthritis
lupus erythematosis
CREST syndrome - scleroderma

Mediators produced as part of the host response that contribute tissue destruction include:


What are the Primary proteinases involved in the periodontal tissue destruction by degradation of extracellular matrix molecules?

Matrix metalloproteinases or MMPs

What are Matrix metalloproteinases or MMPs?

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

Matrix metalloproteinases- eight or MMP-8 is:

released by infiltrating neutrophils

Matrix metalloproteinases-1 or MMP-1 is:

expressed by resident cells, including fibroblasts, monocytes/macrophages, and epithelial cells.

MMP-8 and MMP-1 are BOTH?


MMPs are also produced by periodontal pathogens ____ and ____.

P. gingivalis
A. actinomycetemcomitans

What are Cytokines responsible for?

Imporant signaling molecules released from cells. The properties of cytokines that relate to tissue destruction involve stimulation of bone resorption and induction of tissue-degrading proteinases.

Which cytokines have a central role in periodontal desctuction?

Interleukin-1 (IL-1)
Interleukin-8 (IL-8)
tumor necrosis factor alpha (TNFa)

Interleukin-1 (IL-1)

potent stimulant of osteoclasts proliferation (bone resoprtion), differentiation, and activation

Interleukin-8 (IL-8)

Is important in attracting inflammatory cells

tumor necrosis factor alpha (TNFa)

Similar affects of IL-1, but much less potent
ALSO it is important in activating macrophages

Prostoglandins are:

biochemically synthesized from the fatty acid, arachidonic acid of cells and membranes in response to cylooxygenases (COX-1 and COX-2).

Macrophages are recruited to the area of inflammation and are activated by binding to LPS, to produce ____.

(Prostoglandin E2, PGE2)


is upregulated by IL-1. TNF, and bacterial LPS and appears to be responsible for generating the prostoglandin (PG2) that is associated with inflammation.

The primary cells responsible for PGE2 production in the periodontium are ___ and ____.

macrophages and fibroblasts.

Induction of MMPs and osteoclastic bone resorption is induced by ____.


What is the least important diagnostic aid in recognizing the early stage of gingivitis?

stippling of the gingival tissue
-The presence of stippling is NOT diagnostic
-Inflammation, bleeding upon probing, and pocket depths are the MOST important diagnostic aids or signs of gingival or periodontal disease.

The normal tone or consistency of gingiva should be?

resilient and fibrotic in nature from the free-gingival groove apical to the MGJ.

No nutritonal deficiencies by themselves cause gingivitis or periodontitis. However, nutritonal deficiencies can affect the conditon of the periodontium.


Vitamin A deficiency

play an an important role in protecting against microbial invasion by maintaining epithelial integrity, A deficiency can impact the barrier function of epithelial cells

Vitamin D deficiency

essential for the absorption of calcium from the GI tract and the of the calcium-phosphorus balance. No human studies demonstrate a relationship between Vitamin D defiency and PD. Vitamin D deficiency can contribute to osteoporosis of alveolar bone in young dogs.

Vitamin B-complex deficiency

thiamin, riboflavin, niacin, pyridoxine, biotin, folic acid, and cobalamin. Deficiency of these as a group by contribute to gingivitis

Vitamin C deficiency

Severe deficiency results in Scurvy, bleeding, swollen gingiva and loosened teeth are common features of scurvy.

In a clinically healthy periodontitum, the microbial flora largely is composed of:

gram-positive facultative microorganisms

What are the predominant species of a healthy periodontium?

cocci and rods;

Bacteria found in the composition of plaque are?

gram-negative abaerobes

The host response of plaque bacteria is fundamentally an ___.

Inflammatory response

Decreases in the prevalence and numbers of which Three bacteria are associated with successful clinical treatment of disease?

P. gingivalis
T. forsythia
T. denticola

Endotoxins are the lipopolysaccaride component of the cell of:

gram-negative bacteria

lipopolysaccaride (LPS) containing gram negative cell wall extracts are capable of:

promoting bone resorption
inhibiting osteogenesis
chemotaxis of neutrophils
other events associated with PD

Free endotoxin is present in:

dental plaque and inflamed gingiva

Plaque accumulation has a _____ effect on the severity of gingivitis.


plaque bactera produces enzymes ____, ____, ___, ____, and ____ that may initiate periodontal disease

chondroitin sulfatase


produced by baceroides species
-catalyzes the degradation or hydrolysis of collagen


produced by streptococcus mitans and salivarius; may lead to the destruction of the amorphous ground substance

chondroitin sulfatase

produced by diphtheroids; may lead to the destruction of the amorphous ground substance

Antibodies or immunoglobulins are:

produced by plasma cells in response to oral bacteria or their by products.

What are the most numerous Antibodies or immunoglobulins? What do they do?

IgG; which act to neutralize bacterial toxins by enhancing phagocytosis.

The most likely source of of bacteria found in diseased periodontal tissue is __.

subgingival plaque

The likelihood that bacterial endotoxins play a major role in gingival inflammation is evidence by:

1. The reduction in inflammation by the removal of plaque
2. A reduction of the inflammatory state with antibiotic treatment

what is the predominant periodontal disease?


Which of the following clinical signs is characteristic of NUG?

"punched-out" papillae

Essential components of NUG:

-interdental gingival necrosis- described as "punch-out" papillae
-Variable features: fetid oris (offensive odor), lymphadenopathy, fever, malaise

What are the predominant organisms associated with NUG?

P. intermedia
Fusobacterium species
spirochetal microorganisms

NUG is usually associated with predisposing factors such as:

host factors
immunosuppression (HIV)

treatment of NUG or NUP:

-hydrogen peroxide (chlorhexidine)
-antiobiotic therapy: (Pen. V)

For treatment of Acute herpetic gingivostomatitis , which medication should be prescribed?

-If diagnosed within 3 days of onset, acyclovir suspension should be prescribed, 15 mg/kg fives times daily for 7 days
-All patients, including those presenting more than 3 days after onset, may recieve palliative care, including plaque removal, systemic NSAIDs, and topical anesthetics
-Patients should be informed that herpetic gingivostomatitis is contagious at certain stages; such as when vesicles are present

In a healthy sulcus, which bacteria are most abundant?

Streptococcus and Actinomyces species
-gram positive cocci and filamentous bacteria

Normal inhabitants of the oral cavity: gram-positive:


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