• Plaque Biofilm:
  • Quorum sensing: bacterial communication
  • Co-aggregation: Gram-negative adherence
• Microbial Shift (Health → Disease):
  • Facultative → Obligate anaerobes
  • Fermenting → Proteolytic
  • Cocci → Rods
  • Non-motile → Motile
• Immunoglobulins:
  • Saliva: IgA
  • GCF: IgG
• Interleukins & MMPs:
  • IL-1β: Most potent bone-destructive cytokine
  • MMP-8 & MMP-1: Collagenases
  • MMP-2 & MMP-9: Gelatinases
  • Activated by neutrophil proteases (e.g., cathepsin G)

• Scaling in 2 appointments within 24 hours
• Tongue brushing with 1% chlorhexidine gel
• 0.2% chlorhexidine rinse
• 1% chlorhexidine pocket irrigation

Oral Hygiene Tools

Toothbrush Bristle Diameter:

• Soft: 0.007" (0.2 mm)
• Medium: 0.012" (0.3 mm)
• Hard: 0.014" (0.4 mm)

Brushing Techniques:

• Roll: Modified Stillman
• Circular: Fones
• Vertical: Leonard
• Horizontal: Scrub

Scaling Instruments

• Gracey curettes: Only outer cutting edge
• Universal curettes: Both edges cutting
• Langer curettes: Gracey shank + Universal blade
• Best grasp: Modified pen grasp (tripod effect)
• Scaling angle: 45 – 90°

Ultrasonic Scaling

• Vibration frequency: 18,000 – 50,000 cycles/sec

Stroke Types

• Exploratory: Light feeling (with probes)
• Scaling: Short powerful pull
• Root planing: Moderate to light pull

Automated Probing Systems

Automated probing systems have become increasingly important in periodontal assessments, providing enhanced accuracy and efficiency in measuring pocket depths and clinical attachment levels. This lecture will focus on the Florida Probe System, the Foster-Miller Probe, and the Toronto Automated Probe, discussing their features, advantages, and limitations.

1. Florida Probe System

• Overview: The Florida Probe System is an automated probing system designed to facilitate accurate periodontal assessments. It consists of several components:

  • Probe Handpiece: The instrument used to measure pocket depths.
  • Digital Readout: Displays measurements in real-time.
  • Foot Switch: Allows for hands-free operation.
  • Computer Interface: Connects the probe to a computer for data management.

• Specifications:

  • Probe Diameter: The end of the probe is 0.4 mm in diameter, allowing for precise measurements in periodontal pockets.

• Advantages:

  • Constant Probing Force: The system applies a consistent force during probing, reducing variability in measurements.
  • Precise Electronic Measurement: Provides accurate and reproducible measurements of pocket depths.
  • Computer Storage of Data: Enables easy storage, retrieval, and analysis of patient data, facilitating better record-keeping and tracking of periodontal health over time.

• Disadvantages:

  • Lack of Tactile Sensitivity: The automated nature of the probe means that clinicians do not receive tactile feedback, which can be important for assessing tissue health.
  • Fixed Force Setting: The use of a fixed force setting throughout the mouth may not account for variations in tissue condition, potentially leading to inaccurate measurements or patient discomfort.

2. Foster-Miller Probe

• Overview: The Foster-Miller Probe is another automated probing system that offers unique features for periodontal assessment.

• Capabilities:

  • Pocket Depth Measurement: This probe can measure pocket depths effectively.
  • Detection of the Cemento-Enamel Junction (CEJ): It is capable of coupling pocket depth measurements with the detection of the CEJ, providing valuable information about clinical attachment levels.

3. Toronto Automated Probe

• Overview: The Toronto Automated Probe is designed to enhance the accuracy of probing in periodontal assessments.

• Specifications:

  • Probing Mechanism: The sulcus is probed with a 0.5 mm nickel titanium wire that is extended under air pressure, allowing for gentle probing.
  • Angular Control: The system controls angular discrepancies using a mercury tilt sensor, which limits angulation within ±30 degrees. This feature helps maintain consistent probing angles.

• Limitations:

  • Reproducible Positioning: The probe requires reproducible positioning of the patient’s head, which can be challenging in some clinical settings.
  • Limited Access: The design may not easily accommodate measurements of second or third molars, potentially limiting its use in comprehensive periodontal assessments.

Plaque Formation

Dental plaque is a biofilm that forms on the surfaces of teeth and is a key factor in the development of dental caries and periodontal disease. The process of plaque formation can be divided into three major phases:

1. Formation of Pellicle on the Tooth Surface

• Definition: The pellicle is a thin, acellular film that forms on the tooth surface shortly after cleaning.
• Composition: It is primarily composed of salivary glycoproteins and other proteins that are adsorbed onto the enamel surface.
• Function:
  • The pellicle serves as a protective barrier for the tooth surface.
  • It provides a substrate for bacterial adhesion, facilitating the subsequent stages of plaque formation.

2. Initial Adhesion & Attachment of Bacteria

• Mechanism:
  • Bacteria in the oral cavity begin to adhere to the pellicle-coated tooth surface.
  • This initial adhesion is mediated by specific interactions between bacterial adhesins (surface proteins) and the components of the pellicle.
• Key Bacterial Species:
  • Primary colonizers, such as Streptococcus sanguis and Actinomyces viscosus, are among the first to attach.
• Importance:
  • Successful adhesion is crucial for the establishment of plaque, as it allows for the accumulation of additional bacteria.

3. Colonization & Plaque Maturation

• Colonization:
  • Once initial bacteria have adhered, they proliferate and create a more complex community.
  • Secondary colonizers, including gram-negative anaerobic bacteria, begin to join the biofilm.
• Plaque Maturation:
  • As the plaque matures, it develops a three-dimensional structure, with different bacterial species occupying specific niches within the biofilm.
  • The matrix of extracellular polysaccharides and salivary glycoproteins becomes more pronounced, providing structural integrity to the plaque.
• Coaggregation:
  • Different bacterial species can adhere to one another through coaggregation, enhancing the complexity of the plaque community.

Composition of Plaque

• Matrix Composition:
  • Plaque is primarily composed of bacteria embedded in a matrix of salivary glycoproteins and extracellular polysaccharides.
• Implications for Removal:
  • The dense and cohesive nature of this matrix makes it difficult to remove plaque through simple rinsing or the use of sprays.
  • Effective plaque removal typically requires mechanical means, such as brushing and flossing, to disrupt the biofilm structure.

ANUG (Acute Necrotizing Ulcerative Gingivitis)

• Signs: Punched – out crater depressions of interdental papilla
• Symptoms: Metallic foul taste, pasty saliva
• Treatment: 3 visits (2nd visit: 1 – 2 days after 1st; 3rd visit: 5 days after 2nd)

NUG/NUP

• No pocket formation (destroys junctional epithelium)

Primary Herpetic Gingivostomatitis

• Cellular change: Ballooning degeneration → Tzanck cells
• Treatment:
  • Within 3 days: Acyclovir 15 mg/kg × 5 times × 7 days
  • After 3 days: Supportive care with NSAIDs

Leukemic Gingivitis

• Most common in acute monocytic leukemia

Lead Intoxication

• Steel gray linear pigmentation (Burton's line)

🗣 Speech & Language

😵‍💫 Headache & Migraine

• Pain-sensitive meningeal layer: Dura
• Ophthalmoplegic migraine: III nerve palsy
• Telcagepant: New anti-migraine drug

🧠 Stroke & Hemorrhage

• Stroke in young women (India): Cortical vein thrombosis
• Commonest CVA cause: Embolism
• ICH most commonly due to: Intracerebral hemorrhage (trauma)
• Infarction site → hemiplegia: MCA territory
• Thrombolytic for stroke: Tissue plasminogen activator (tPA)
• Carotid stenosis management: Aspirin reduces TIA risk

🧠 Cranial Nerves

• Trigeminal nerve disorder: Tic Douloureux
• UMN VII palsy: Contralateral lower face paresis
• Ramsay – Hunt syndrome: Herpes virus
• Griesinger’s sign: Sigmoid sinus thrombosis

🧠 Parkinsonism

• Cause: Wilson disease (Copper accumulation)
• Lazabemide: MAO-B inhibitor