Pretest 2003 with answers/explanations

DAPE 761 – Advanced Periodontics Name: ______Dr. Dwight E. McLeod October 24, 2003

PRETEST

1. is a surgical procedure that is performed to eliminate periodontal pockets and includes eshaping of the gingiva. is a surgical procedure that includes reshaping of the gingiva to create physiologic contours with the sole purpose of recontouring the gingiva in the absence of pockets.

A. Both statements are true.* B. Both statements are false. C. The first statement is true and the second statement is false. D. The first statement is false and the second statement is true.

Gingivectomy means excision of the gingiva. By removing the pocket wall, gingivectomy provides visibility and accessibility for complete removal and thorough smoothing of the roots, creating a favorable environment for gingival healing and restoration of a physiologic gingival contour. Gingivoplasty is similar to gingivectomy, but its purpose is different. Gingivectomy is performed to eliminate periodontal pockets and includes reshaping as part of the technique. Gingivoplasty is a reshaping of the gingival to create physiologic gingival contours, with the sole purpose of recontouring the gingiva in the absence of pockets.

2. Indications for the gingivectomy procedure include:

A. Elimination of suprabony pockets. B. Elimination of gingival enlargements. C. Elimination of suprabony periodontal abscesses. D. A and B E. All of the above*

The gingivectomy procedure may be performed for (1) elimination of suprabony pockets, regardless of their depth, if the pocket wall is fibrous and firm, (2) elimination of , and (3) elimination of suprabony periodontal abscesses.

3. Contraindications for the gingivectomy procedure include:

A. The need for osseous surgery or evaluating the bony topography. B. Conditions in which the base of the pocket is apical to the . C. Esthetics considerations. D. A and B E. All of the above*

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Contraindications for the gingivectomy includes (1) the need for bone surgery or examination of the bone shape and morphology, (2) situations in which the bottom of the pocket is apical to the mucogingival junction, and (3) esthetic considerations, particularly in the anterior maxilla.

4. Which one of the following instruments cannot be used for a gingivoplasty procedure?

A. Periodontal knife B. Scalpel C. Rotary coarse diamonds D. Electrodes E. None of the above*

The gingivectomy technique may be performed by means of scalpels (also periodontal knives – Orban/Kirkland), electrodes (electrosurgery), laser beams, or chemicals (no longer used). The gingivoplasty technique may be done with a periodontal knife, scalpel, rotary coarse diamond stones, or electrodes (electrosurgery).

5. The purpose of using a membrane to treat an infrabony defect during guided tissue regeneration procedure is to prevent:

A. A blood clot from forming in the periodontal defect. B. Apical migration of epithelial cells and formation of a long .* C. Osteoblast and periodontal ligament cells from migrating coronally. D. A and C E. A, B, C

Guided tissue regeneration procedures attempt to regenerate lost periodontal structures through differential tissue responses. Barrier techniques (resorbable or nonresorbable membranes) such as expanded polytetrafluroethylene, polyglactin, polylactic acid, and collagen are employed in the hope of excluding epithelium (sulcular, gingival and junctional) and the gingival connective tissue (corium) from the root surface in the belief that they interfere with regeneration. Excluding the epithelium and the gingival connective tissue from the root surface during the postsurgical healing phase not only prevents epithelial migration into wound but also favors repopulation of the area by cells from the periodontal ligament and bone.

6. A is a localized accumulation of pus within the gingival wall of a periodontal pocket. A periodontal abscess may be acute or chronic.

A. Both statements are true.* B. Both statements are false. C. The first statement is true and the second statement is false. D. The first statement is false and the second statement is true.

A periodontal abscess is a localized accumulation of purulent inflammation (pus) in the gingival wall of a periodontal pocket. It is also known as a lateral or parietal abscess. A periodontal abscess may form due to several reasons. The reasons are (1) Extension of infection from a periodontal pocket deeply into the supporting periodontal tissues and localization of the suppurative inflammatory process along the lateral aspect of the root; (2) Lateral extension of inflammation from the inner surface of a periodontal pocket into the connective tissue of the pocket wall (Localization of the abscess results when drainage into the pocket space is impaired); (3) In a pocket that Pretest 2003 with answers/explanations describes a tortuous course around the root, a periodontal abscess may form in the cul-de-sac, the deep end of which is shut off from the surface; (4) Incomplete removal of calculus during treatment of a periodontal pocket (In this instance the gingival wall shrinks, occluding the pocket orifice, and a periodontal abscess occurs in the sealed-off portion of the pocket.); and (5) A periodontal abscess may occur in the absence of after trauma to the tooth or perforation of the lateral wall of the root in endodontic therapy.

7. Symptoms of an acute periodontal abscess may include:

A. Throbbing and radiating pain. B. Tenderness of the gingiva upon palpation. C. Increased . D. A,C E. A,B, C*

The most common complaints are pain or discomfort (throbbing or radiating pain), and/or the appearance of an area of swelling that is tender to touch, chewing, or toothbrushing. Lymphadenitis may be present, and less frequently, systemic effects such as fever, leukocytosis, and malaise. The area of the swelling may be confined to one tooth, or it may involve multiple teeth. The gingival is elevated, edematous and red, with a smooth shiny surface. Periodontal probing depths are exaggerated in areas of abscess formation and bleeding/exudates upon probing is common. The tooth may display increased mobility but rarely is the tooth hypersensitive to percussion unless the interfurcal zone or apex of the tooth is involved. The vitality of teeth with periodontal abscesses, as determined using either thermal or electrical tests, is normal unless a tooth have been previously treated endodontically or is simultaneously affected by a pulpal lesion (a so-called combine lesion)

8. A gingival abscess may be differentiated from a periodontal abscess based upon:

A. The location of the abscess. B. The duration and severity of the pain. C. The history of the abscess. D. A, C* E. A, B, C

The principal differences between the periodontal abscess and the gingival abscess are the location and history. The gingival abscess is confined to the marginal gingival, and it often occurs in previously disease-free areas. It is usually an acute inflammatory response to forcing of foreign material into the gingival. The periodontal abscess involves the supporting periodontal structures and generally occurs in the course of chronic destructive periodontitis.

9. The treatment of an acute periodontal abscess may include:

A. Incision and drainage of the abscess. B. Endodontic therapy. C. Gingival flap surgery. D. A, C E. A, B, C*

The appropriate therapy for a periodontal abscess is determined by the stage of the abscess formation, the location and extent of the abscess, the extent and configuration of the attachment loss on the affected tooth, and the role of Pretest 2003 with answers/explanations the tooth in the overall periodontal plan. Therapy is directed at the resolution of pain and the drainage and of the abscess. Many localized periodontal abscesses can be evacuated and thoroughly debrided through the . In this case good plaque control and warm oral rinses should be adequate in resolving the abscess. Most patients require mild or no postoperative medication for discomfort. Antibiotic therapy is usually not indicated. Larger abscesses may require incision and drainage plus debridement of the root of the affected tooth. In the case of a combined periodontal-periapical lesion, a flap procedure can be utilized. The mucoperiosteal flap provides excellent access for visualization and instrumentation of the affected area.

10. Which abscess is most likely associated with a sinus or fistula?

A. Gingival abscess B. Acute periodontal abscess C. Chronic periodontal abscess* D. None of the above

A draining sinus on the lateral aspects of the root suggests periodontal rather than apical involvement; a sinus from a periapical lesion is most likely to be located further apically. However, sinus location is not conclusive. The chronic periodontal abscess usually presents a sinus that opens onto the gingival mucosa somewhere along the length of the root. There may be a history of intermittent exudation. The orifice of the sinus may appear as a difficult-to-detect pinpoint opening, which, when probed, reveals a sinus deep in the . The sinus may be covered by a small, pink, beadlike mass of granulation tissue. The chronic periodontal abscess is usually asymptomatic. However, a patient may report episodes of dull, gnawing pain, slight elevation of the tooth and a desire to bite down and grind the tooth. The chronic periodontal abscess often undergoes acute exacerbations, with all the associated symptoms. Microscopically, an abscess is a localized accumulation of viable and nonviable PMNs within the periodontal pocket wall. The PMNs liberate enzymes that digest the cells and other tissue structures, forming the liquid product known as pus, which constitutes the center of the abscess. An acute inflammatory reaction surrounds the purulent area, and the overlying epithelium exhibits intracellular and extracellular edema and invasion of leukocytes. The localized acute abscess becomes a chronic abscess when its purulent content drains through a fistula into the outer gingival surface or into the periodontal pocket and the infection causing the abscess is not resolved.

11. Identify the findings that are commonly associated with a gingival cyst.

1. Painless 2. May cause expansion and erosion of alveolar bone 3. Commonly found in the mandibular canine and premolar areas 4. Develops from epithelium

A. 1, 2, 3, 4* B. 1, 2, 3 C. 1, 2, D. 1

The gingival cyst is usually painless, but with expansion, it may cause erosion of the surface of the alveolar bone. The cyst frequently occurs in the mandibular canine and premolar area. The cyst develops from odontogenic epithelium or from surface or traumatically implanted in the area. Removal is followed by uneventful healing. Microscopically, a cyst is lined by a thin, flattened epithelium with or without localized areas of thickening. Pretest 2003 with answers/explanations

12. Identify the common findings that are associated with a periodontal cyst.

1. Commonly found in the mandibular canine and premolar areas 2. Arises within the alveolar bone lateral to the root 3. Usually asymptomatic 4. Is developmental in origin.

A. 1, 2, 3, 4* B. 1, 2, 3 C. 1, 2, D. 1

A periodontal cyst is an uncommon lesion that produces localized destruction of the periodontal tissues along a lateral root surface, most often in the mandibular canine-premolar area. The lateral periodontal cyst arises within the alveolar bone adjacent to the root and is developmental in origin. The periodontal cyst is usually asymptomatic, but it may present as a swelling. Radiographically, an interproximal periodontal cyst appears on the side of the root as a radiolucent area bordered by a radiopaque line. Its radiographic appearance cannot be differentiated from that of a periodontal abscess.

13. Which one of the following is routinely not done during a periodontal maintenance procedure?

A. Polishing B. Oral cancer screening C. Restorative evaluation D. Updating the medical history E. None of the above*

During a typical maintenance visit the following procedures should be done: update of medical history; head, neck and intraoral examination; /charting; radiographs as necessary; evaluation of plaque control, restorative/caries evaluation; treatment as indicated (scaling, localized root planing as indicated, adjunctive treatment as necessary, and polishing), patient education and OHI as necessary (may include smoke cessation and nutrition counseling)

14. Which one of the following periodontal conditions is considered an aggressive form of periodontitis?

A. Necrotizing ulcerative periodontitis* B. Severe drug induced C. Acute necrotizing ulcerative gingivitis D. A, C E. None of the above

Of the answers listed above, necrotizing ulcerative periodontitis would be the right choice. NUP is an extension of NUG into the periodontal structures, leading to attachment and bone loss. NUP may include combinations of the following signs and symptoms: necrosis and ulceration of the coronal portion of the interdental papillae and/or ; painful, bright-red marginal gingival that bleeds on even slight manipulation; mouth malodor; and systemic manifestations including fever, malaise, and lymphadenopathy. In addition, increased levels of stress, Pretest 2003 with answers/explanations heavy smoking, and poor nutrition have been shown to be contributing factors to NUP. Two types of NUP have been described. Non-Aids and Aids associated NUP.

15. Moderate clinical attachment loss is defined as:

A. Clinical attachment loss of 1 or 2 mm. B. Clinical attachment loss of 3 or 4 mm.* C. Clinical attachment loss of 5 or 6 mm. D. Clinical attachment loss of 7 or 8 mm.

Chronic periodontitis may be subclassified into localized and generalized forms and characterized as slight, moderate, or severe based on the common features and the following specific features. Localized form; < 30% of sites involved Generalized form: > 30% of sites involved Slight: 1 or 2 mm of clinical attachment loss Moderate: 3 or 4 mm of clinical attachment loss Severe: ≥ 5mm of clinical attachment loss

16. Plaque induced gingivitis may occur on a periodontium with no attachment loss. Plaque induced gingivitis may also occur on a periodontium with attachment loss that is stable.

A. Both statements are true.* B. Both statements are false. C. The first statement is true and the second statement is false. D. The first statement is false and the second statement is true.

Plaque-induced gingivitis may occur on periodontium with no attachment loss or on a periodontium with previous attachment loss that is stable and not progressing. This implies that gingivitis may be the diagnosis for inflamed gingival tissues associated with a tooth with no previous attachment loss or with a tooth that has previously undergone attachment loss (reduced periodontal support) but is not currently losing attachment or bone even though gingival inflammation is present. For the diagnosis to be made, longitudinal records of periodontal status, including clinical attachment levels, should be available.

17. Which of the following characteristics are common to persons with ?

A. Prevalent in adult but can occur in children B. Slow to moderate rate of progression with possible periods of rapid progression C. Amounts of destruction consistent with local factors D. A, C E. A, B, C. *

The following characteristics are common to patients with chronic periodontitis: (1) Prevalent in adults but can occur in children, (2) Amount of destruction consistent with local factors, (3) Subgingival calculus frequently found, (4) Slow to moderate rate of progression with possible periods of rapid progression, and (5) Possibly modified by or associated with the following: systemic diseases such as diabetes mellitus and HIV infections. Cigarette smoking and emotional stress may be local predisposing factors.

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18. Which of the following characteristics are common to persons with ?

A. Amounts of microbial plaque inconsistent with disease severity B. Familial aggregation of diseased individuals C. Otherwise clinically healthy individuals D. A, C E. A, B, C*

The following characteristics are common to patients with aggressive periodontitis: (1) Otherwise clinically healthy patients, (2) Rapid attachment loss and bone destruction, (3) Amounts of microbial deposits inconsistent with disease severity, and (4) Familial aggregation of diseased individuals.

19. Periodontal is indicated when a periodontal pocket is present. Scaling is not a procedure that is used to treat gingivitis.

A. Both statements are true. B. Both statements are false. C. The first statement is true and the second statement is false.* D. The first statement is false and the second statement is true.

Scaling is the process by which plaque and calculus are removed from both supragingival and subgingival tooth surface. Root planing is the process by which residual embedded calculus and portions of are removed from the roots to produce a smooth, hard, clean surface. Scaling alone is sufficient to completely remove plaque and calculus form enamel, leaving a smooth clean surface.

20. Periostat is a broad spectrum

A. Macrolide. B. Cephalosporin. C. Quinolone. D. None of the above*

Periostat is a low dose (20 mg) doxcycycline that is used as an adjunct to scaling and root planing to promote attachent level gain and to reduce pocket depth in patients with chronic periodontitis. The low dose has no antibacterial effect (subinhibitory against bacteria).

21. Periostat is an effective because of its ability to

A. Inhibit bacterial replication. B. Destroy bacterial cell wall. C. Slow the production destructive host enzymes.* D. None of the above

Pretest 2003 with answers/explanations

Loss of periodontal attachment and bone involves destruction of connective tissue. The chemicals that are responsible for connective tissue remodeling is a group of enzymes, MMPs (Matrix Metalloproteinases) and they include collagenases and gelatinases. The MMPs that have been studied most extensively in periodontitis are those produced mainly by connective tissue cells: fibroblasts (MMP-1), monocytes (MMP-1), and polymorphonuclear leukocytes (MMP-1). Tetracycline directly blocks the action of MMPs.

22. A higher prevalence and severity of gingivitis and gingival enlargement is found in the circumpubertal period. This form of gingivitis is termed acute necrotizing ulcerative gingivitis.

A. Both statements are true. B. Both statements are false. C. The first statement is true and the second statement is false.* D. The first statement is false and the second statement is true.

Puberty is often accompanied by an exaggerated response of the gingival to local irritants. Pronounced inflammation, bluish red discoloration, edema, and enlargement result form local factors that would ordinarily elicit a comparatively mild gingival response. Although the prevalence and severity of gingivitis is increased in puberty, gingivitis is not a universal occurrence during this period; with good , it can be prevented.

23. Pregnancy does not cause gingivitis. Pregnancy accentuates the gingival response to plaque.

A. Both statements are true.* B. Both statements are false. C. The first statement is true and the second statement is false. D. The first statement is false and the second statement is true.

Pregnancy gingivitis is an acute inflammation of the gingival tissues that is associated with pregnancy. This condition is accompanied by increase in steroid hormones in the crevicular fluid and dramatic increase in P. intermedia, which use the steroids as growth factors. Pregnancy itself does not cause gingivitis. Gingivitis in pregnancy is caused by bacterial plaque, just as it is in non-pregnant individuals. Pregnancy accentuates the gingival response to plaque and modifies the resultant clinical picture. No notable changes occur in the gingiva during pregnancy in the absence of local factor.

24. Which cell in the gingival crevicular fluid produces the most collagenase?

A. Epithelial cells B. Fibroblasts C. Bacterial cells D. PMNs* E. Mast cells

PMNs have been shown to be the first line of host defense to combat acute bacterial infection. A characteristic morphologic feature of all stages of gingivitis and periodontitis is the accumulation of PMNs in the gingival connective tissue, junctional epithelium, and gingival crevice or periodontal pocket. PMNs are associated with the production of an abundance of destructive enzymes such as collagenase.

Pretest 2003 with answers/explanations

25. A material that is derived from a nonhuman species such as bovine bone is classified as:

A. Isograft. B. Xenograft.* C. Allograft. D. Alloplast. E. None of the above

Autogenous graft: Graft tissue obtained from self (Free gingiva graft, autogenous bone graft ). Allograft: Graft tissue obtained from same species (DFDB – demineralized freeze dried bone). Xenograft: Graft tissue obtained from a different species (Bioss – Bovine bone). Isograft: Graft tissue obtained from a twin. Allopast: Inert material used as a filler in infrabony defects such as Perioglas or HA.

26. The gingival col is

A. Covered by nonkeratinized gingiva. B. Present in the healthy dentition when there is a contact between two posterior teeth. C. Covered by keratinzed gingiva. D. A, B* E. A, C

The interdental gingival occupies the gingival embrasure, which is the interproximal space beneath the area of contact. The interdental gingival can be pyramidal or have a “col” shape. In the former, the tip of one papilla is located immediately beneath the contact point: and the latter presents a valleylike depression that connects a facial and lingual papilla and conforms to the shape of the interproximal contact. The col is covered with nonkeratinized stratified squamous epithelium.

27. During the periodontal examination of a patient, the vertical insertion of the probe may detect interdental craters. An oblique positioning of the probe will reach the depths of interdental craters.

A. Both statements are true. B. Both statements are false. C. The first statement is true and the second statement is false. D. The first statement is false and the second statement is true.*

Walking the probe explores the entire pocket. Vertical insertion of the probe may not detect interdental crater; oblique positioning of the probe will reach the depth of a crater. The probe should be inserted parallel to the long axis of the tooth and walked circumferentially around each surface of each tooth to detect the areas of deepest penetration. To detect an interdental crater, the probe should be placed obliquely from both the facial and lingual surfaces so as to explore the deepest point of the pocket located beneath the contact point.

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28. What important factor determines whether an intrasulcular or extrasulcular incision should be made on the facial gingiva of tooth # 5 during a crownlengthening surgery?

A. The sulcus depth B. The bony topography C. The width of keratinzed gingival* D. The amount of tooth structure to be exposed. E. None of the above

The width of the remaining keratinized gingival is the most important factor. If a large width of keratinized tissue is present, an extrasulcular or inverse bevel incision can be made. If there is a minimal width of keratinized tissue present, an intrasulcular incision would be indicated. Care must be taken not to create a mucogingival defect or to make an existing mucogingival defect worse by performing an extrasulcular or inverse bevel incision.

29. Which factor(s) determine(s) the predictability of gaining 100% root coverage during a connective tissue graft surgery?

A. The classification of the mucogingival defect B. The thickness of the donor graft C. The height of the interdental bone in the recipient site. D. A, B E. A, C*

Miller’s Classification of

Class I. Marginal tissue recession that has not extended to the mucogingival junction. There is no loss of interdental bone or soft tissue. Class II. Marginal tissue recession that extends to or beyond the mucogingival junction. There is no loss of interdental bone or soft tissue. Class III. Marginal tissue recession that extends to or beyond the mucogingival junction. There is loss of interdental bone, and the junctional soft tissue is apical to the cementoenamel junction but remains coronal to the apical extent of the marginal tissue recession. Class IV. Marginal tissue recession that extends beyond the mucogingival junction. There is loss of interdental bone and soft tissue to a level corresponding to the apical extent of the marginal tissue recession.

30. Which one of the following tissues listed below are included in a full thickness flap?

A. Periosteum, connective tissue, and epithelium* B. Bone, connective tissue, periosteum, and epithelium C. Cementum, periosteum, connective tissue, and epithelium D. Connective tissue and epithelium E. None of the above

A full thickness gingival flap includes the periosteum, connective tissue and the overlying gingival epithelium. The connective tissue is also known as the lamina propria and it consists of two layers, a papillary layer and a reticular layer toward the epithelial side and a reticular layer toward the connective tissue side.

Pretest 2003 with answers/explanations

31. may lead to all of the following except

A. Mobility. B. Widening of PDL space. C. Clinical loss of attachment.* D. Flaring of teeth.

Trauma from occlusion does not lead to clinical loss of attachment.

32. Which one of the following surgical procedures is the treatment of choice for obtaining root coverage when there is abundant keratinized gingiva mesial or distal to the recipient tooth?

A. B. Lateral pedicle graft* C. Connective tissue graft D. Coronally positioned flap

The lateral pedicle graft or laterally positioned flap can be used to cover isolated, denuded roots that have adequate or lateral donor tissue as well as vestibular depth.