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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
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