Periodontology

Dr Musab Arabeyat

Definitions

Periodontics: That branch of

dentistry that deals with the diagnosis

and treatment of disease and

conditions of supporting and

surrounding tissues of the teeth or

their implanted substitutes

Periodontology: The scientific

study of the periodontium in health

and disease

Periodontist: Dental practitioner

who by virtue of special knowledge

and training in the field limits his

practice or activities to

periodontics.

Periodontitis: Inflammation of the

supporting tissue of the teeth

Periodontium The tissues that invest and

support the teeth including

the:

Gingiva / Alveolar Mucosa

Periodontal Ligament

Alveolar Bone

Cementum

Gingiva The fibrous investing tissues, covered by

keratinized epithelium, which

immediately surrounds a tooth and is

contiguous with a periodontal ligament

and with the mucosal tissues of the

mouth

Gingiva

Marginal / Free Gingiva

Attached Gingiva

Interdental Gingiva

1)Mucogingival junction.

2)Interdental gingiva.

3)Free gingival groove

4)Attached gingiva.

5)Alveolar mucosa

6) Marginal gingiva.

Gingival sulcus (crevice):Shallow

fissure (space) between the

marginal gingiva and the enamel

or cementum. The clinical

normal gingival sulcus in human

is 2 to 3 mm, can be determined

clinically with a periodontal

probe (probing depth).

Gingival Fluid: The gingival (crevicular) fluid is continually secreted from the gingival connective tissues into the sulcus through the sulcular epithelial wall. This fluid helps to mechanically clean the sulcus and in addition, possess anti-microbial properties and antibodies that enhance the resistance of the gingiva to gingivitis.

Gingival components

Gingival Epithelium

-Oral epithelium (OE)

- Sulcular epithelium (SE)

-Junctional epithelium (JE)

Gingival connective tissue

Histology:Gingival tissues are

made up of fibrous connective

tissue covered by stratified

squamous epithelium.

1:Enamel.

2:gingival margin.

3:gingival sulcus.

4:free gingival groove.

5:lveolar bone.

6:CEJ

7Cementum

8:PDL

Between 2 and 4 is free gingiva

Gingival Collagen Fibers Functions

1. Bracing the marginal gingiva against

the tooth

2. Providing rigidity to withstand the

forces of mastication.

3. To unite the free marginal gingiva

with the cementum of the root and

adjacent attached gingiva

Oral mucosa 1. Masticatory mucosa: Is a tissue that is firmly attached to the

underlying bone and covered with parakeratinized or keratinized epithelium. The gingiva and the tissue covering the hard palate are examples.

2. Lining mucosa: Loosely attached to their underlying

structures and covered with non-keratinized epithelium. Lips, cheeks, floor of the mouth.

3. Specialized mucosa: Covers the dorsal surface of the tongue.

Periodontal ligament (PDL):the CT that surrounds and attaches roots of teeth to the alveolar bone. Average width of PDL is 0.18 mm, widest in coronal aspect narrower in the apex, and narrowest in the middle.

It consists of bundles of collagen fibers arranged into a network referred as principle fibers.

Consist of bundles of fibers, according to their directions: 1)Alveolar crest group 2)Horizontal group 3)Oblique group. 4)Apical fibers.

Roles of PDL:

–Mechanical functions

–Formative function

–Nutritive function

–Sensory function

Cementum: is calcified tissue that covers the root of the tooth

and provides a means of attachments for the periodontal ligament fibers to the tooth

It consists of calcified collagen fibers and interfibriller ground substance.

It is made up of 45% to 50% inorganic material and 50% to 55% organic matter and water

Cemento Enamel Junction:

The area where cementum and enamel meet (cervical area).

Three different relationship:

60-50% cementum overlaps enamel

30% edge to edge

5%-10% cementum fail to meet enamel resulting in exposed dentine

Alveolar bone: are the parts of the maxilla and mandible

providing the housing for the roots of the teeth.

Alveolar bone:

1-alveolar bone proper

(lamina dura in radiographs)

2-trabecular bone

3-compact bone

Periodontium Vascular Supply

Branches of Superior and inferior alveolar arteries

1. Supraperiosteal arteries

2. Interdental arteries

3. Periodontal ligament arterioles

Etiology of Periodontal Diseases

Bacterial Plaque (Primary Factor)

Secondary/Predisposing Factors

Bacterial Plaque: Bacterial aggregation on the teeth or other solid oral structures.

It consists of:

Bacteria

Organic : protein, polysaccharide …..

Inorganic: calcium, phosphorus ……

Secondary/Predisposing Factors

Dental Calculus: Mineralized dental plaque attached and covering the enamel and/or root surface

The pathological diseases affecting the periodontium

Gingivitis

Periodontitis

Gingivitis: Inflammation of the gingiva.

It is the most common type of gingival disease

Periodontitis

Inflammation of the supporting tissues of the teeth.

Usually a progressively destructive changes leading to loss of bone and periodontal ligament.

An extension of inflammation from gingiva to adjacent bone and ligament.

Periodontal Therapy

Eliminate gingival inflammation

Oral hygiene -Scaling and root planing -Local or systemic antimicrobials -Systemic collagenase inhibitor

Restore normal tissue contours-Tooth surfaces assessable to daily oral hygiene

Regenerate periodontal attachment-Bone graft, guided tissue generation

Scaling: Instrumention of the crown and root surfaces of the teeth to remove plaque, calculus and stains from these surfaces.

Root Planing: A treatment procedure designed to remove cementum or surface dentin that is rough, impregnated with calculus or contaminated with toxins or microorganisms

AAP Classification of Periodontal Diseases and Conditions (1999)

Gingival Diseases Dental plaque-induced gingival diseases Non-plaque induced gingival lesions

Chronic Periodontitis (Slight: 1-2mm CAL; moderate: 3-4mm CAL; severe: >5mm CAL) Localized Generalized (>30% of sites are involved)

Aggressive Periodontitis (Slight: 1-2mm CAL; moderate: 3-4mm CAL; severe: >5mm CAL) Localized Generalized (>30% of sites are involved)

AAP Classification of Periodontal Diseases and Conditions (1999) Periodontitis as a Manifestation of Systemic Diseases

Associated with hematological disorders Associated with genetic disorders Not otherwise specified

Necrotizing Periodontal Diseases Necrotizing ulcerative gingivitis Necrotizing ulcerative periodontitis

Abscesses of the Periodontium Gingival abscess Periodontal abscess Pericoronal abscess

AAP Classification of Periodontal Diseases and Conditions (1999) Periodontitis Associated with Endodontic Lesions

Combined periodontic-endodontic lesions

Developmental or Acquired Deformities and Conditions

Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases periodontitis

Mucogingical deformities and conditions around teeth

Mucogingival deformities and conditions on edentulous ridges

Occlusal trauma

Acute periodontal conditions Abscesses of the Periodontium

Necrotizing Periodontal Diseases

Gingival Diseases of Viral Origin-Herpesvirus

Recurrent Aphthous Stomatitis

Allergic Reactions

Abscesses of the Periodontium Gingival Abscess

Periodontal Abscess

Pericoronal Abscess

Gingival Abscess

A localized purulent infection that involves the marginal gingiva or interdental papilla

Gingival Abscess

Gingival Abscess Etiology

Acute inflammatory response to foreign substances forced into the gingiva

Clinical Features

Localized swelling of marginal gingiva or papilla

A red, smooth, shiny surface

May be painful and appear pointed

Purulent exudate may be present

No previous periodontal disease

Gingival Abscess Treatment

Elimination of foreign object

Drainage through sulcus with probe or light scaling

Follow-up after 24-48 hours

Periodontal Abscess

A localized purulent infection within the tissues adjacent to the periodontal pocket that may lead to the destruction of periodontal ligament and alveolar bone

Periodontal Abscess

Periodontal Abscess Usually pre-existing chronic periodontitis present!!!

Factors associated with abscess development

Occlusion of pocket orifice (by healing of marginal gingiva

following supragingival scaling)

Furcation involvement

Systemic antibiotic therapy (allowing overgrowth of resistant

bacteria)

Diabetes Mellitus

Periodontal Abscess Clinical Features

Smooth, shiny swelling of the gingiva

Painful, tender to palpation

Purulent exudate

Increased probing depth

Mobile and/or percussion sensitive

Tooth usually vital

Periodontal Vs. Periapical Abscess Periodontal Abscess

Vital tooth

No caries

Pocket

Lateral radiolucency

Mobility

Percussion sensitivity variable

Sinus tract opens via keratinized gingiva

Periapical Abscess

Non-vital tooth

Caries

No pocket

Apical radiolucency

No or minimal mobility

Percussion sensitivity

Sinus tract opens via alveolar mucosa

Periodontal Abscess Treatment

Anesthesia

Establish drainage

Via sulcus is the preferred method

Surgical access for debridement

Incision and drainage

Extraction

Periodontal Abscess Other Treatment Considerations:

Limited occlusal adjustment

Antimicrobials

Culture and sensitivity

A periodontal evaluation following resolution of

acute symptoms is essential!!!

Periodontal Abscess Antibiotics (if indicated due to fever, malaise,

lymphadenopathy, or inability to obtain drainage)

Without penicillin allergy Penicillin

With penicillin allergy Azithromycin

Clindamycin

Alter therapy if indicated by culture/sensitivity

Pericoronal Abscess

A localized purulent infection within the tissue surrounding the crown of a partially erupted tooth.

Most common adjacent to mandibular third molars in young adults; usually caused by impaction of debris under the soft tissue flap

Pericoronal Abscess

Pericoronal Abscess Clinical Features

Operculum (soft tissue flap)

Localized red, swollen tissue

Area painful to touch

Tissue trauma from opposing tooth common

Purulent exudate, trismus, lymphadenopathy, fever, and malaise may be present

Pericoronal Abscess Treatment Options

Debride/irrigate under pericoronal flap

Tissue recontouring (removing tissue flap)

Extraction of involved and/or opposing tooth

Antimicrobials (local and/or systemic as needed)

Culture and sensitivity

Follow-up

Necrotizing Periodontal Diseases

Necrotizing Ulcerative Gingivitis (NUG)

Necrotizing Ulcerative Periodontitis (NUP)

Necrotizing Ulcerative Gingivitis

An infection characterized by gingival necrosis presenting as “punched-out” papillae, with gingival bleeding and pain

Necrotizing Ulcerative Gingivitis

Necrotizing Ulcerative Gingivitis Historical terminology

Vincent’s disease

Trench mouth

Acute necrotizing ulcerative gingivitis (ANUG)…this terminology changed in 2000

Necrotizing Ulcerative Gingivitis Necrosis limited to gingival tissues

Estimated prevalence 0.6% in general population

Young adults (mean age 23 years)

More common in Caucasians

Bacterial flora

Spirochetes (Treponema sp.)

Prevotella intermedia

Fusiform bacteria

Necrotizing Ulcerative Gingivitis Clinical Features

Gingival necrosis, especially tips of papillae

Gingival bleeding

Pain

Fetid breath

Pseudomembrane formation

Necrotizing Ulcerative Gingivitis Predisposing Factors

Emotional stress

Poor oral hygiene

Cigarette smoking

Poor nutrition

Immunosuppression

***Necrotizing Periodontal diseases are common in

immunocompromised patients, especially those who

are HIV (+) or have AIDS

Necrotizing Ulcerative Periodontitis

An infection characterized by necrosis of gingival tissues, periodontal ligament, and alveolar bone

Necrotizing Ulcerative Periodontitis

Necrotizing Ulcerative Periodontitis

Clinical Features

Clinical appearance of NUG

Severe deep aching pain

Very rapid rate of bone destruction

Deep pocket formation not evident

Necrotizing Periodontal Diseases Treatment

Local debridement

Oral hygiene instructions

Oral rinses

Pain control

Antibiotics

Modify predisposing factors

Proper follow-up

Necrotizing Periodontal Diseases Treatment

Local debridement

Most cases adequately treated by debridement and sc/rp

Anesthetics as needed

Consider avoiding ultrasonic instrumentation due to risk of HIV transmission

Oral hygiene instructions

Necrotizing Periodontal Diseases Treatment

Oral rinses – (frequent, at least until pain subsides allowing effective OH)

Chlorhexidine gluconate 0.12%; 1/2 oz 2 x daily

Hydrogen peroxide/water

Povidone iodine

Pain control

Necrotizing Periodontal Diseases Treatment

Antibiotics (systemic or severe involvement) Metronidazole

Avoid broad spectrum antibiotics in AIDS patients

Modify predisposing factors

Follow-up Frequent until resolution of symptoms

Comprehensive periodontal evaluation following acute phase!!!!

Gingival Diseases of Viral Origin

Acute manifestations of viral infections of the oral mucosa, characterized by redness and multiple vesicles that easily rupture to form painful ulcers affecting the gingiva.

Primary Herpetic Gingivostomatitis

Classic initial infection of herpes simplex type 1

Mainly in young children

90% of primary oral infections are asymptomatic

Primary Herpetic Gingivostomatitis

Primary Herpetic Gingivostomatitis

Clinical Features

Painful severe gingivitis with ulcerations, edema, and stomatitis

Vesicles rupture, coalesce and form ulcers

Fever and lymphadenopathy are classic features

Lesions usually resolve in 7-14 days

Primary Herpetic Gingivostomatitis

Treatment

Bed rest

Fluids – forced

Nutrition

Antipyretics

Acetaminophen, not ASA due to risk of Reye’s Syndrome

Primary Herpetic Gingivostomatitis

Treatment

Pain relief

Viscous lidocaine

Benadryl elixir

50% Benadryl elixir/50% Maalox

Antiviral medications

Immunocompromised patients

Recurrent Oral Herpes “Fever blisters” or “cold sores”

Oral lesions usually herpes simplex virus type 1

Recurrent infections in 20-40% of those with primary infection

Herpes labialis common

Recurrent infections less severe than primary

Recurrent Oral Herpes

Recurrent Oral Herpes Clinical Features

Prodromal syndrome

Lesions start as vesicles, rupture and leave ulcers

A cluster of small painful ulcers on attached gingiva or lip is characteristic

Can cause post-operative pain following dental treatment

Recurrent Oral Herpes Virus reactivation

Fever

Systemic infection

Ultraviolet radiation

Stress

Immune system changes

Trauma

Unidentified causes

Recurrent Oral Herpes

Treatment

Palliative

Antiviral medications

Consider for treatment of immunocompromised patients, but not for periodic recurrence in healthy patients

Recurrent Aphthous Stomatitis “Canker sores”

Etiology unknown

Prevalence 10 to 20% of general population

Usually begins in childhood

Outbreaks sporadic, decreasing with age

Recurrent Aphthous Stomatitis Clinical features

Affects mobile mucosa

Most common oral ulcerative condition

Three forms

Minor

Major

Herpetiform

Recurrent Aphthous Stomatitis Clinical features

Minor Aphthae

Most common

Small, shallow ulcerations with slightly raised erythematous borders

Central area covered by yellow-white pseudomembrane

Heals without scarring in 10 –14 days

Minor Apthae

Recurrent Aphthous Stomatitis Clinical features

Major Aphthae

Usually larger than 0.5cm in diameter

May persist for months

Frequently heal with scarring

Major Aphthae

Recurrent Aphthous Stomatitis Clinical features

Herpetiform Aphthae

Small, discrete crops of multiple ulcerations

Lesions similar to herpetic stomatitis but no vesicles

Heal within 7 – 10 days without scaring

Recurrent Aphthous Stomatitis Predisposing Factors

Trauma

Stress

Food hypersensitivity

Previous viral infection

Nutritional deficiencies

Recurrent Aphthous Stomatitis Treatment - Palliative

Pain relief - topical anesthetic rinses

Adequate fluids and nutrition

Corticosteroids

Oral rinses (Chlorhexidine has been anecdotally reported to shorten the course of apthous stomatitis)

Topical “band aids”

Chemical or Laser ablation of lesions

Allergic Reactions

Intraoral occurrence uncommon

Higher concentrations of allergen required for allergic reaction to occur in the oral mucosa than in skin and other surfaces

Allergic Reactions Examples

Dental restorative materials

Mercury, nickel, gold, zinc, chromium, and acrylics

Toothpastes and mouthwashes

Flavor additives (cinnamon) or preservatives

Foods

Peanuts, red peppers, etc.

Allergic Reactions Clinical Features – Variable

Resemble oral lichen planus or leukoplakia

Ulcerated lesions

Fiery red edematous gingivitis

Treatment

Comprehensive history and interview

Lesions resolve after elimination of offending agent

Allergic Reaction

Good luck