1998 Board Questions and Answers

DAPE 761 – Advanced Dr. Dwight E. McLeod November 12, 2004

1998 BOARD QUESTIONS AND ANSWERS (ASSIGNMENT #3)

These questions and answers were provided for your convenience to allow you to study for the National Board Part II. The explanations were included to give you a clear understanding of why each choice was selected. Should you encounter any doubts or problems in your interpretation of the explanation, it is your responsibility to consult your textbook, journal articles or handouts for further clarification. I will also be available to assist you if needed. I hope that the explanations below will not only help you to understand each question better but will help to broaden your knowledge in Periodontics as you prepare for the examination. Good Luck!

1. When would you prescribe an antibiotic in conjunction with periodontal ?

a. Severe b. Localized * c. Advanced d.

Antibiotic therapy is not generally recommended for patients with a diagnosis of chronic periodontitis, unless there are some unique systemic problems or compromised conditions. Patients with chronic periodontitis and severe gingival inflammation usually respond well to elimination of the local factors (nonsurgically and/or surgically) and compliance with and supportive periodontal care. Patients with the more aggressive forms of periodontitis (Localized Aggressive Periodontitis and Generalized Aggressive Periodontitis) are generally treated with antibiotics. There is usually a specific microbe that is associated with the disease process, which may have the potential to invade the host’s connective tissues. The microbe, Actinobacillus actinomycetemcomitans, is associated with LAP. The antibiotic is usually an effective adjunctive treatment. Tetracycline/doxycycline is effective against the microbe that is associated with LAP. Other antibiotic alone or in combination may be used such as amoxicillin and metronidazole.

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2. Polly Pontic is a 50 - year - old female patient who presented with a Class III furcation lesion, on tooth # 3 that communicates with the facial and distopalatal furcations. The distal root showed bone loss approaching the apex of the root. The tooth exhibits no significant mobility and the other remaining roots showed minimal bone loss. The patient showed strong interest in saving the tooth. Which would be the best definitive treatment option?

a. Vital root amputation of the distal root* b. Osseous surgery c. Guided tissue regeneration d. Periodontal scaling and root planing

In this case a vital root amputation of the distal root would be the choice of treatment since the palatal and mesiobuccal root have good bone support. Usually the patient does not experience any pulpal discomfort after a vital root amputation. The root canal therapy and the restorative treatment can be done at a later date.

3. Which one (s) of the following antimicrobial agents has (have) been shown to have a substantivity of 12 hours?

a. The essential oils in Listerine b. The digluconate in Peridex c. The in Colgate Total toothpaste d. B and C* e. All of the above

Chlorhexidine (0.12%) has been shown to have a 12 hour substantivity. When prescribed the instructive is usually to rinse twice daily. Triclosan (0.30%) that is an antimicrobial agent that is found in Total Toothpaste and it also has a substantivity of 12 hours. This is made possible by the 2% copolymer which enhances the substantivity of the Triclosan. The essential oils are said to have a substantitivy of approximately 4 to 6 hrs.

4. In performing a incision in a person with drug induced gingival hyperplasia, the tip of the scalpel is held in what direction relative to the base of the pocket?

a. At right angle to the base of the pocket b. Coronal to the base of the pocket c. Apical to the base of the pocket* d. None of the above

The gingivectomy incision is made slightly apical to the base of the psuedopocket. The starting point is from the external surface of the gingiva toward the tooth. The blade is angled at a 45 degree such that a bevel is created. Thus the term external bevel or bevel incision.

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5. What is the type of incision that is used in the gingivectomy procedure?

a. Bevel incision b. Inverse bevel incision c. Intrasulcular incision d. External bevel incision e. A and D*

See explanation for question number 4

6. Of the instruments listed below, which one is the most reliable for detecting furcation involvement?

a. EXD 11/12 explorer b. 17/18 curette c. d. Nabers furcation probe*

The Nabers furcation probe is very similar to the CH3 explorer except that it has millimeter gradations which makes it much easier to measure the extent of horizontal furcal penetration. This would be very appropriate for use with the Hamp’s furcation classification.

7. Osseous surgery is a procedure used:

a. to treat shallow interdental craters.* b. to regenerate mandibular class II furcations. c. to treat three wall infrabony defects. d. None of the above

Shallow interdental craters are not graftable lesions and therefore, they are usually eliminated by osseous surgery to achieve a positive bony architecture.

8. Which of the following tissue(s) listed below is (are) included in a partial thickness flap?

a. Periosteum, connective tissue, and epithelium b. Bone, connective tissue, periosteum, and epithelium c. Connective tissue and epithelium* d. , periosteum, connective tissue and epithelium

A full thickness flap is comprised of epithelium on the outer side, connective tissue in the middle and the periosteum on the internal aspect of the flap. When a partial thickness flap is done, the connective tissue is sectioned and thus some connective tissue remained on alveolar bone along with the periosteum. The partial-thickness flap that is reflected is composed of epithelium on the outer side and connective tissue on the inner side. The periosteum is left attached to the alveolar bone

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9. You have been instructed by Dr. Roller to perform limited periodontal surgery on tooth # 19. Upon examining the patient you noticed that on the lingual the tooth probed 7 - 2 - 8 mm and on the facial the tooth probed 6 – 3 – 7 mm. What type of periodontal surgery would you perform?

a. Modified Widman or Gingival Flap b. Osseous surgery including apically positioned flap* c. Connective tissue graft d. Gingival curettage

Gingival curettage is a procedure that is no longer recognized as a specific ADA code. However, each time that you do periodontal scaling and root planing you are inadvertently doing curettage of the soft tissue wall of the periodontal pocket. In other words, you are removing the inflamed epithelial lining and possible some inflamed connective tissue.

The Modified Widman procedure is not intended to treat infrabony defects or areas of osseous irregularities secondary to . The main purpose of this surgery is to gain access for root instrumentation. The flap is generally not reflected beyond the .

The connective tissue graft is used for treating or augmentation of edentulous ridges but not for treating a periodontal pocket.

The objective of osseous surgery is to access the underlying bone for recontouring purposes. This also provides the operator to access the root surfaces for instrumentation. The goal of osseous surgery is to reestablish a more ideal osseous architecture. In the above questions, the periodontal probing depths indicated areas of bony irregularities or infrabony defects.

10. Which inflammatory cell infiltrate predominates the exudate in the acute ?

a. Plasma cells b. Lymphocytes c. Eosinophils d. Polymorphonuclear leukocytes*

In stage I Gingivitis (Initial Lesion) occurs at days 2-4 and the predominant cell is the PMN. In stage II Gingivitis (Early Lesion) occurs at days 4-7 and the predominant cell is the Lymphocyte. In stage III Gingivitis (Established Lesion) occurs at days 14-21 and the predominant cell is the Plasma Cell.

Exudate (Pus) is a fluid product of inflammation, consisting of a liquid containing leukocytes and the debris of dead cells and tissue elements liquefied by the proteolytic and histolytic enzymes (e.g. leukoprotease) that are elaborated by polymorphonuclear leukocytes.

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11. Which bacterial species predominates the lesions in Localized aggressive periodontitis?

a. Actinomyces viscosus b. Actinobacillus actinomycetemcomitans* c. Actinobacillus migrans d. Actinomyces juvenilli

Actinobacillus actinomycetemcomitans (Aa) has been shown by numerous studies to be the predominant bacteria isolated from persons with Localized Juvenile Periodontitis. This bacterial species is the most studied bacteria and is generally used to support the Specific Plaque Hypothesis that not all the bacteria in are pathogenic, only specific bacteria in dental plaque cause periodontitis.

12. Tunneling procedure is a surgical procedure that is best reserved for:

a. Maxillary molars b. Mandibular molars* c. Maxillary first premolars d. None of the above

This procedure surgically converts a Class III into Class IV furcation defect. Tunneling procedure is best suited for mandibular molars and usually provides access for the patient to clean the furcation area. A proxy brush or interdental brush would be the recommended dental aid. Recurrent caries are common in the furcal area if plaque control is not ideal and therefore some clinicians recommend using a daily application of fluoride gel or varnish. A tunneling procedure is not typically done on maxillary molars because of the anatomy. The presence of three roots will obstruct the complete passage of the interdental brush. A root amputation would be the treatment of choice for maxillary molars.

13. Allergic gingivitis is most commonly associated with the use of which of the following agents?

a. Cinnamon flavored chewing gum* b. Listerine mouth rinse c. Total - toothpaste d. Hydrogen peroxide

Cinnamon flavored chewing gum has been reported to cause allergic gingivitis. This is due to one of the chemicals in the ingredients. The other agents may cause adverse effects but probably not a true allergic response. Adverse effects may include burning, mucosal sloughing or hyperkeratosis.

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14. Which one of the following teeth listed below would be least likely to be treated with a connective tissue graft?

a. Mandibular premolar b. Maxillary Canine c. Maxillary second molar* d. Mandibular central

The mandibular premolar, maxillary canine and mandibular centrals are teeth that are often subjected to gingival recession thus resulting in a mucogingival defect and/or need for gingival augmentation/root coverage procedures. Also, these teeth are located in the smile zone and would be of esthetic concern. Therefore, a connective tissue graft would be indicated in the case of gingival recession. The maxillary second molar is further back in the arch and less subjected to gingival abrasion. Its position in the arch may also make it difficult to place a connective tissue graft.

15. When would you prescribe an antibiotic for a person who has acute necrotizing ulcerative gingivitis?

a. When the patient is febrile and has lymphadenopathy* b. When there are severe amounts of and inflammation c. When there is cratering of the interdental papilla d. When there are bleeding and foul breath

Generally, an antibiotic is not prescribed for patients who have ANUG without associated fever and lymphadenopathy. In a case where the patient does not have systemic symptoms, the ANUG is treated through very gentle (not s/rp). Scaling and root planing is contraindicated at this time because of the possibility of extending the infection into deeper tissues, causing a bacteremia, and damaging the fragile gingival tissues which could lead to further clinical loss of attachment. A mouth rinse such as chlorhexidine is prescribed and the patient is seen back within days for follow-up care and eventually definite periodontal treatment. If an antibiotic were to be prescribed, the antibiotic of choice would be penicillin.

16. When would you perform a ?

a. When there is 3 mm of keratinized tissue and a probing depth of 7 mm. b. When there is 6 mm of keratinized tissue with 3 mm attached. c. When there is 4 mm of attached tissue and a probing depth of 1 mm. d. When there is 1 mm of keratinized tissue and a probing depth of 3 mm.*

No information is Answer E, indicates that there is a mucogingival problem or defect because the probe is now probing beyond the mucogingival junction. Most clinicians recommend doing a free gingival graft when there is only 1 mm of keratinized tissue remaining. Lang and Loe recommended that at least 2 mm of keratinized tissue – 1 mm attached and 1 mm unattached is necessary to maintain gingival health. A free gingival graft is one of the treatments of choice when there is a diagnosis of a mucogingival defect. The main purpose of the free gingival graft is to increase the band of keratinized tissues. Even though a free gingival graft can be used to obtain root coverage (The Miller Thick Free Gingival Graft), it is most often used to augment or increase the zone of keratinized gingiva ( i.e., preprosthetic or orthodontic treatment) and not obtain root coverage. The Miller Thick Free Gingival Graft has almost been exclusively replaced by the Connective Tissue Graft in root coverage procedures. The goal of the connective tissue graft is to

6 1998 Board Questions and Answers obtain root coverage with an inadvertent increase in the width of keratinized gingiva. Sometimes the increased keratinized tissue is not readily appreciated because it is covered with mucosal tissue from the coronal positioning of the flap. A secondary surgical procedure can be performed to remove the nonkeratinized mucousal tissue and expose the keratinized tissue. In choices B and C, no treatment is indicated. In choice A, a periodontal pocket is present and treatment is indicated which could include conservative therapy such as scaling and root planing, and possible local drug delivery therapy, or surgical therapy such as a gingival flap procedure or more sophisticated procedure depending upon the findings at the time of flap reflection. A free gingival graft is not used to treat a periodontal pocket and in choice A, a periodontal pocket is present.

17. The best indicator to determine the predictability for success of a periodontal root coverage surgical procedure is:

a. the amount of root exposed b. the height of the interdental bone* c. the depth of the vestibule d. the thickness of the adjacent gingiva

The height of the interdental bone is the primary and most important criterion that determines the success of a root coverage surgical procedure. Miller has classified gingival recession according to the extent of the gingival recession in relationship to the mucogingival junction and secondly, according to the height of the interproximal bone. Class I: Recession that does not reach the mucogingival junction with no interproximal bone loss. Complete root coverage is expected.

Class II: Recession that extends past the mucogingival junction with no interproximal bone loss. One hundred percent root coverage can be anticipated.

Class III: Recession that has loss of interproximal tissue will negate the chances for complete root coverage.

Class IV: Severe gingival recession and soft and hard tissue loss (Advanced Periodontitis) to the extent that no root coverage should be expected. In this case, a root coverage procedure would not be attempted.

18. Which procedure will result in the best color match after healing?

a. Free gingival graft b. Connective tissue graft c. Lateral pedicle graft* d. A and C

The above choices are listed in order from the least to the best color match. One of the disadvantages of the free gingival graft is its color match. In most cases the donor site is the palate, which is usually pinker in color. The difference in color of the tissues from the palate is usually more obvious than the adjacent tissues at the recipient site. The color match is usually not very good. The connective tissue graft offers a better color match than the free gingival graft because it is “sandwiched” by the flap from the recipient site which will maintain most of its surface characteristics. However, some subtle color differences may be observed.

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The lateral pedicle graft offers the best color match since the donor site is the adjacent tissue, which is surgically moved from one tooth to another. Upon healing, there is no noticeable color change.

19. What is the term used to describe the condition where there is only one wall of bone remaining in a periodontal defect?

a. Osseous crater b. Hemiseptal defect* c. Trough d. Moat defect

A hemiseptal defect is the same as a one-wall defect – meaning there is only one wall of bone remaining. In this case, the treatment during osseous surgery would resection (ostectomy) of the wall of remaining bone. In terms of predictability for bone regrowth, a one wall or hemiseptal defect is the least predictable. A three - wall infrabony defect offers the best chances for bone regrowth followed by a two-wall infrabony defect.

A moat defect is sometimes described as a circumfrential defect or trough. This is one of the older terms. A trough defect is similar to a moat defect.

An osseous crater is a concavity in the crest of the interdental bone that is confined within the facial and lingual walls.

20. When would you perform guided tissue regeneration?

a. # 19 that has a Class II furcation with a vertical component and no recession.* b. # 19 that has 5 mm recession, Class II furcation and a vertical component. c. # 19 that has a Class II defect with a horizontal component and no recession. d. # 19 that has 5 mm recession, Class II furcation and a horizontal component.

The potential for success of guided tissue regeneration is best in mandibular molars with Class I – II furcation defects. The predictability increases when there is a deep and narrow vertical component within the furcation – think of it as a three – wall infrabony defect within the furcation area. It is also important that the buccal or lingual crestal bone heights remain high and not significantly lower than the furcation entrance.

Non-resorbable and resorbable membranes can be used. Resorbable membranes are usually made from collagen. Non-resorbable membranes are usually made from materials such as extended- polytetrafluorethylenes (ePTFE - Gortex). The non-resorbable membrane requires a second surgical procedure for removal at 6 to 8 weeks after placement.

21. What is the likely cause(s) of a periodontal abscess developing post periodontal scaling and root planing?

a. Gingival shrinkage causing occlusion of the orifice of the sulcus. b. Calculus removed during s/root planing becomes embedded in soft tissue. c. The presence of a deep tortuous pocket d. A and B e. A,B,C*

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All three conditions can result in an acute abscess forming in a periodontal pocket after nonsurgical therapy. In all three situations, residual accretions (bacterial plaque and/or calculus) remained trapped deep within the pocket, which can act as a “seed” for an acute infection.

22. Mary Molar presented to your office for an initial examination. Upon examining the patient you got a PSR reading of 4 in all quadrants. What type(s) of radiographs would you recommend that your dental assistant take?

a. Panorex radiographs b. Panorex and bitewing radiographs c. Cephalometric and bitewing radiographs d. Full mouth series radiographs*

The American Academy of Periodontology recommends a full mouth series of radiographs including periapicals and bitewings (preferably vertical bitewings) to aid in the diagnosis of periodontal diseases. This of course would be in addition to a comprehensive . A panorex radiograph, though useful to determine pathology of the maxilla and mandible, third molar impactions, and bone for implant placement, does not provide enough diagnostic details. A cephalometric radiograph is more routinely used for orthodontics and orthognathic procedures.

23. The type of healing that takes place after a gingivectomy procedure on a person with drug induced gingival hyperplasia can be best described as:

a. Primary intention b. Secondary intention* c. Tertiary intention d. None of the above

Healing by Primary intention may be obtained sometimes during procedures such as the Modified Widman Flap procedure where the clinician may obtain close approximation of the buccal and lingual interdental tissues for suturing. In case of a conventional gingivectomy, there is no flap to suture, therefore the “raw” tissue margins remain which will granulate over a period of 2 – 4 weeks. In this case, this type of healing is termed “secondary intention”.

Definitions: Healing by first intention, primary adhesion; primary union; healing by fibrous adhesion, without suppuration or granulation tissue formation. Healing by second intention, secondary adhesion; secondary union; delayed closure of two granulating surfaces. Healing by third intention, the slow filling of a wound cavity or ulcer by granulations, with subsequent cicatrization.

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24. Which one of the periodontopathogens listed below is most commonly associated with adult periodontitis? a. * b. Actinobacillus actinomycetemcomitans c. d. Streptococcus intermedius

Porhyromonas gingivalis is the primary bacteria most consistently isolated from persons with chronic periodontitis and is the most extensively studied for its association with adult periodontitis. As mentioned previously, Aa is associated with LAG. Capnocytophaga is found within the periodontal pockets of patients with Diabetes. It is found in some cases of LAG. Their implication in the disease process is somewhat inconclusive and controversial. Streptococcus intermedius (also another bacterium Peptostreptococcus micros) is one of the few Gram- positive bacterium that is primarily investigational that may be associated with Chronic periodontitis.

25. Which statement describes the initiation of periodontal disease?

a. Coronal proliferation of the . b. Coronal proliferation of the gingival epithelium. c. Loss of alveolar crestal density. d. Apical migration of the junctional epithelium.*

The apical migration of the junctional epithelium below the CEJ is the initiation of periodontal disease – early, mild or slight periodontitis. Loss of alveolar crestal density is sometimes seen in cases with traumatic occlusion; however, trauma from occlusion does not cause clinical loss of attachment or initiation of periodontal disease but it may affect the pattern or density of the underlying alveolar bone.

26. Which of the following procedure(s) listed below has (have) a double blood supply?

a. The Modified ENAP b. The free gingival graft c. The subepithelial connective tissue graft* d. A and C e. All of the above

The subepthelial connective tissue graft receives blood from the connective tissue bed on which it is placed and also from the partial thickness flap that is placed over its outer surface. This improves the prognosis or the success of the graft. The conventional free gingival graft receives blood supply/nutrients from its periosteal tissue bed. The ENAP procedure is not viewed in terms of blood supply since the flap remains intact and there is no tissue that is being grafted.

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27. Mrs. Dentition presented to your office complaining that “my bite is off because I have discomfort whenever I chew”. Your examination revealed a PSR reading of 4 in all quadrants. You confirmed that the tooth she is complaining of is in traumatic occlusion. Based upon your assessment, you would classify the as:

a. primary occlusal traumatism b. secondary occlusal traumatism* c. Tertiary bruxism d. Excessive mobility

Definition: Primary Occlusal Traumatism: Excessive force on a healthy – i.e., a high restoration, loss of posterior support with occlusion on healthy anterior teeth. Definition: Secondary Occlusal Traumatism: Normal occlusal forces on a diseased or Weakened periodontium. This is what the above patient has a weakened periodontium.

28. The anterior flaring of teeth that occurs in the presence of advanced periodontitis and especially when there is lost of posterior support is best described as:

a. pathological migration of teeth.* b. a normal aging process. c. a psychological phenomenon. d. none of the above

The above condition is know as pathological migration and is usually seen in moderate or advanced chronic periodontitis, especially when there is secondary occlusal traumatism.

29. is best defined as:

a. the sum of probing depth and bone loss b. the sum of probing depth and gingival coronal height c. the sum of probing depth, bone loss and gingival recession d. the sum of probing depth and gingival recession*

Clinical attachment loss is defined as the sum of the periodontal probing depths plus the amount of gingival recession, i.e., a 6 mm probing depth plus gingival recession of 5 mm from the CEJ to the = 11 mm of clinical attachment loss. In the case of a psuedopocket where one may get a probing depth of 9 mm, there is no loss of attachment because the junctional epithelium is still attached to the CEJ. The increase in probing depth is due to the increase in coronal height of the marginal gingiva.

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30. When would you most likely consider antibiotic therapy as an adjunctive treatment for a person with a diagnosis of periodontal disease?

a. a person with a diagnosis of chronic periodontitis b. a person with a diagnosis of generalized aggressive periodontitis* c. a person with a diagnosis of severe gingival hyperplasia d. a person with a diagnosis of progressive gingival recession e. a person with a diagnosis of severe gingival recession

Antibiotic therapy is not generally recommended for patients with a diagnosis of chronic periodontitis, unless there are some unique systemic problems or compromised conditions. Patients with chronic periodontitis and severe gingival inflammation usually respond well to elimination of the local factors (nonsurgically and/or surgically) and compliance with oral hygiene and supportive periodontal care. Patients with the more aggressive forms of periodontitis (LAG and GAP) are generally treated with antibiotics. There is usually a specific microbe that is associated with the disease process, which may have the potential to invade the host’s connective tissues. The microbe, Actinobacillus actinomycetemcomitans, is associated with LAG. The antibiotic is usually an effective adjunctive treatment. Tetracycline/doxycycline are effective against the microbe that is associated with Localized Juvenile Periodontitis. Other antibiotic alone or in combination may be used such as amoxicillin and metronidazole. In patients with GAP, Porhpyromonas gingivalis, and spirochetes are major subgingival components of the microbial make-up.

31. Which brushing technique is most effective for removing plaque below the gingival margins?

a. Sulcular method* b. Horizontal method c. Roll method d. none of the above

Sulcular brushing is most effective against flushing or disturbing the accumulation of bacterial plaque below the gingival margins. Horizontal method is not recommended because of its adverse effect of abrading the gingival tissues. The roll method is not recommended because it is not effective against disturbing the growth of subgingival plaque.

32. is the most prevalent type of gingivitis in childhood. a. Linear gingival erythema b. Eruption gingivitis c. Acute herpetic gingival stomatitis d. Chronic marginal gingivitis*

Chronic marginal gingivitis is the most prevalent form of gingivitis in children and is plaque related. Linear gingival erythema is found in patients with AIDS and is a diffused

12 1998 Board Questions and Answers erythema involving the marginal and attached gingiva. Acute herpetic gingival stomatitis is the most common acute gingival infection in childhood. Eruption gingivitis is most common during the mixed dentition stage.

33. The drug Periostat, which is used for treating periodontitis is a form of:

a. Penicillin b. Doxycycline* c. Cephalosporin d. Erythromycin

Periostat is composed of 20 mg of doxycycline. The manufacturers claimed that this low dosage of doxycycline does not have any antibacterial effects and does not cause any bacterial resistance. The drug is given twice daily for up to 9 months. The drug may be repeated per professional judgment.

34. The efficacy of Periostat is attributed to its ability to:

a. act as a broad spectrum antimicrobial b. act as a narrow spectrum antimicrobial c. prevent the release of destructive host enzymes* d. all of the above e. None of the above

Periostat is effective in blocking the matrix metalloproteinases (destructive enzymes that are produced by the host during periodontal inflammation/periodontitis) that are produced by the host that may cause destruction of soft tissues, mainly collagen. This therapeutic approach is unique in that the drug targets the host and not the periodontopathogens.

35. Which elements are removed during periodontal scaling and root planing?

a. Plaque and calculus b. Diseased cementum and dentin c. Inflamed d. All of the above*

Typically, during periodontal scaling and root planing all of the above tissues are removed. The plaque and calculus are removed during scaling, the diseased dentin and cementum are removed during root planing, and the inflamed sulcular epithelium is, inadvertently removed.

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36. What is the most common reason for tooth loss among adult patients? a. Trauma b. Advanced periodontitis* c. Caries d. Iatrogenic factors

Among older adults, periodontitis is the major cause for tooth loss.

37. When would you perform a mesial wedge? a. When there is mesial drifting of a molar due to loss of a mesial tooth.* b. When there is an enlarged interdental papilla. c. When there is subgingival calculus present. d. When there is a periodontal pocket greater than 5 mm.

A mesial wedge is generally performed on a tooth in which the tooth mesial to it is missing. The mesial wedge is indicated for similar reasons such as you would a distal wedge. The reasons may be for of the mesial aspect of that tooth, for pocket reduction, and etc. Choices B, C, D will be discussed in class.

38. Which inflammatory cell predominates in established (stage III) gingivitis? a. Eosinophils b. Plasma Cells* c. Macrophage d. Merkel cells e. None of the above

In stage I Gingivitis (Initial Lesion) occurs at days 2 – 4 and the predominant cell is the PMN. In stage II Gingivitis (Early Lesion) occurs at days 4-7 and the predominant cell is the Lymphocyte. In stage III Gingivitis (Established Lesion) occurs at days 14-21 and the predominant cell is the Plasma Cell.

39. What is the main cause of periodontal disease in furcation areas? a. Enamel pearls b. Bacterial plaque* c. Enamel projections d. Trauma from occlusion

Bacterial plaque is the primary etiology of periodontal disease. Enamel pearls and projections (are secondary etiological factors. i.e., overhanging restoration) may create unfavorable environments that make it difficult for plaque control which may aid in the spread of the periodontitis. Trauma from occlusion does not cause or initiate periodontitis but it may cause unfavorable changes in the underlying structures (bone and periodontal ligaments) that may lead to the spread of the disease.

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40. What is the predominant microflora in the periodontal abscess?

a. Primarily Gram negative anaerobic bacteria* b. Primarily Gram positive aerobic bacteria c. Yeast and protozoans d. Mixed flora

The predominant flora is an acute periodontal abscess is the Gram negative anaerobic bacteria.

41. In the sequencing of periodontal and orthodontic therapy, when would you most likely perform pocket reduction surgery?

a. Before the orthodontic therapy is completed b. After the orthodontic therapy has been completed* c. During the orthodontic therapy d. None of the above

In most cases, it is best to do periodontal surgery after orthodontic therapy because some times orthodontic movement can create bony changes or alterations in the periodontium that may eliminate a bony defect thus precluding the need for periodontal surgery. Periodontal surgery is referring to pocket reduction surgery and not mucogingival surgery such as root coverage or gingival augmentation. Mucogingival surgeries are usually done prior to orthodontic therapy.

42. When would you recommend a free gingival graft to be done on a 12-year-old patient who is scheduled for orthodontic therapy?

a. If there is a localized area that has no recession but 4 mm of keratinized tissue b. If there is an over-all thin periodontium c. If the there is thick gingiva and very prominent root eminences d. If there is a labially positioned tooth with a gingival cleft* e. None of the above

A gingival cleft indicates recession that could be worsened by the orthodontic therapy. Please refer to question 41. In the case of choice B, one may do selective grafting when there is a thin periodontium in anticipation of preventing gingival recession on teeth that he or she thinks may be more susceptible to gingival recession during the orthodontic therapy. However, D is a more clear cut answer.

43. At what rate and distance does epithelial migration occur during wound healing?

a. 0.5 mm/day* b. 5.0 mm/day c. 2.5 mm/day d. 7.5 mm/day

Epithelium migrates at a rate of 0.5 mm per day.

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44. A commercial bone graft that has been obtained from another species for use in a periodontal defects is referred to as:

a. Allograft b. Xenograft* c. Isograft d. Autograft

The xenograft that is available for use in periodontal regenerative procedures is derived from bovines (cows). One such brand is Bioss. Isograft is tissue obtained from an identical twin. Allograft is tissue obtained from the same species and an autograft is tissue that is obtained from the same individual or “self”.

45. Which one of the following procedures has, as its primary objective, the reduction of existing inflammation?

a. Periodontal scaling and root planing* b. Splinting of mobile teeth c. Mucogingival surgery d. All of the above

The primary purpose of periodontal scaling and root planing is to remove the local factors that elicit gingival inflammation.

46. Which tissues comprise the biological width? a. Crestal bone and connective tissue b. Connective tissue and gingiva c. Connective tissue and junctional epithelium* d. Crestal bone and junctional epithelium

The tissues that comprise the biological width are the gingival connective tissue (1.07 mm) and the junctional epithelium (.97 mm). The operative word here is tissue. This should not be confused with the amount of root structures that should be exposed during a crown lengthening procedure. In this question, the sulcus depth was not considered because it is a space and not “tissue”.

47. Which immunoglobulin predominates in the gingival crevicular fluid? a. Ig G* b. Ig A c. Ig D d. Ig M

Ig G is the predominant Ig in the gingival crevicular fluid while Ig A is the predominant Ig in saliva.

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48. What is the most likely cause of gingival recession?

a. Mal-alignment b. abrasion* c. Orthodontic treatment d. Traumatic occlusion e. Caries

The most obvious cause is toothbrush abrasion.

49. Splinting is recommended for teeth with progressive mobility. In this circumstance, splinting will improve the prognosis.

a. Both statements are true.* b. Both statements are false. c. The first statement is false and the second statement is true d. The first statement is true and the second statement is false.

Splinting is usually recommended when there is progressive mobility that interferes with function and comfort. In this case, splinting a tooth may improve the prognosis and save it from being extracted. However, splinting will not improve the support or cause regrowth of the alveolar bone. It is just aimed at stabilizing the tooth for comfort and function.

50. You have performed crown lengthening on tooth # 30. How long should you wait before taking an impression of the supragingival margins that do not require gingival retraction?

a. 4 – 6 weeks depending on the rate of healing* b. 2 – 4 weeks if no osseous recontouring was performed c. 8 – 10 weeks if osseous recontouring was performed d. All of the above

At approximately 4 – 6 weeks following a crown-lengthening surgery, the , epthelial attachment, and adjacent connective tissue should be fully developed or healed.

51. Which one of the following agents listed below is made from chlorhexidine and is recommended by the manufacturer for local treatment of a periodontal pocket?

a. Periostat b. DMX c. Perio Chip* d. Atridox e. None of the above

PerioChip is made from chlorhexidine. The concentration is 2.5 mg.

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