Periodontology as a part of Preventive Dentistry Periodontology as a part of Preventive Dentistry. Periodontal definition. Anatomical and physiological characteristics of periodontal tissues. Department of Therapeutic Dentistry TSMU 4th year of study

Periodontology or periodontics is the specialty of dentistry that studies supporting structures of teeth, diseases and conditions that affect them. The supporting tissues are known as the periodontium which includes: 1.gingiva (gums) 2.alveolar bone 3.cementum 4.periodontal ligament Professional who practices this specialty field of Dentistry is known as a periodontist

The major elements of the periodontium

Fig.1. Schematic illustration of the different epithelia at the dentogingival junction.

Junctional epithelium JE forms a specialised attachment to the tooth via: a hemidesmosomal layer within the JE cells; a hasal lamina produced by the epithelial cells The most apical part of the JE lies at the cement-enamel junction in health

Standard periapical radiograph of the tooth and alveolar bone support.

Classification of Periodontal Diseases Necrotizing Periodontal Diseases Abscesses of the Periodontium Periodontitis Associated with Endodontic Lesions Developmental or Acquired Deformities and Conditions Gingival Diseases Chronic Periodontitis Aggressive Periodontitis Periodontitis as a Manifestation of Systemic Diseases

CLASSIFICATION OF PERIODONTAL DISEASES (based on the American Academy of Periodontology Classification, 1999)

CLASSIFICATION OF PERIODONTAL DISEASES

CLASSIFICATION OF PERIODONTAL DISEASES

Periodontal lesions associated with endodontic lesions

Concepts Gingivitis: Periodontitis: Inflammation that is confined to the gingival tissues. Periodontitis: Inflammation of the supporting structures of the tooth. O’Leary TJ et al. 1988.

GINGIVITIS Gingivitis is plaque-induced inflammation of the gingivae, recognised by erythema and edema, bleeding on brushing or probing, and perhaps detachment of the gingivae from the teeth. Gingivitis may be exacerbated by various factors. The hormonal changes associated with pregnancy produce an increase in inflammatory signs, resulting in increased bleeding that may bring it to the attention of the patient. Sometimes an individual papilla may swell sufficiently to become a pregnancy epulis. The severity of pregnancy gingivitis reduces after parturition and reverts to the previous low level of inflammation.

Gingival recession

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

Gingivitis Is caused by nonspecific bacterial plaque (dental). Löe H et al. 1988 Microbial colonization: Streptococcal sp Gram + rods As plaque matures, its ecology becomes more complex: Specific proliferate (environment becomes suitable). Hardie & Bowden 1976 Facultative. Anaerobes (environment changes). Grant et al. 1988

Gingival Abscess

NECROTISING ULCERATIVE GINGIVITIS (NUG) AND PERIODONTITIS (NUP) Necrotising ulcerative gingivitis is a painful ulceration of the tips of the interdental papillae with grey necrotic tissue visible on the surface of the ulcers. This may cause loss of papillae. There is a characteristic halitosis and submandibular lymph nodes may be tender and palpable. NUG is common among smokers and patients with poor oral hygiene. NUP is diagnosed in the presence of attachment loss.

NECROTISING ULCERATIVE GINGIVITIS (NUG) AND PERIODONTITIS (NUP) Acute necrotizing ulcerative periodontitis in a 16 year-old female with AIDS. There is marginal ulceration of the gingiva (short arrows), gingival recession with loss of attachment, and crater-like interdental defects (“punched-out papillae”; large arrows).

GINGIVAL HYPERPLASIA Hyperplasia is thickening of the gingivae due to proliferation of cells within the tissue. It can be induced b y irritation by plaque and calculus, repeated friction or trauma, and by some medications, no tably calcium c hannel bloc kers used in t he treatment of hypertension, ciclosporin (used as an anti-rejection agent for organ transplant patients) and phenytoin, used to control epilepsy. Mouth breathing can also lead to gingivitis and gingival overgrowth. Localised gingival fibrous hyperplasia. The lesion has caused displacement of the adjacent teeth

Gingivitis with hyperplasia

Oral microbes Dual and paradoxical roles. Protection against pathogens. Causation of chronic disease. Periodontal disease. Caries.

Chronic Periodontitis Localized Generalized

Chronic Periodontitis Is thought to result from the activity of mixed cultures of predominantly anaerobic gram-negative bacteria. Marsh PD 1986 The association of specific microbial species with localized forms of disease has greatly strengthened the belief that the periodontal diseases are opportunistic infections. Van Palenstein Helderman WH 1981; Slots J & Listgarten MA 1988

CHRONIC PERIODONTITIS For most patients, gingivitis does not progress beyond the gingival margins. However 10-15% of people are susceptible to a more destructive process. Susceptibility is thought to be partly genetically determined, which explains why periodontitis can affect members of the same family. In chronic periodontitis, plaque left near the gingival margins causes gingivitis, which becomes periodontitis as it destroys the junctional epithelium and forms a periodontal pocket, harbouring plaque inaccessible to the toothbrush and floss. This process usually progresses slowly and is related to the amount of dental plaque and calculus deposits

Site-specificity Site-specific microbes cause localized periodontal lesions. Fundamental conflict: Oral microbes can cause deep pockets. Bacteria are unable to create an environment conductive to their proliferation. All bacteria are able to flourish only when their required conditions already exist.

1) Localized lesions are either created by site-specific bacteria; or Two possible explanations for the presence of specific bacteria in severe periodontal defects 1) Localized lesions are either created by site-specific bacteria; or 2) Populated by the oral bacteria selected by the conditions of a deep pocket that has been established by a different pathologic process.

AGGRESSIVE PERIODONTITIS Approximately 1/1000 of susceptible patients suffer more rapid attachment loss, a small per centage losing more than half of the bone support by the age of 35. This is known as aggressive periodontitis, which may be localised to some of the teeth, or generalised, involving all the teeth. Aggressive periodontitis is diagnosed from its rapid rate of progress or severe disease in individuals usually under 35 years. It is characterised by vertical bone defects on radiographs. There may be very little plaque or calculus present in some of these patients.

Periodontitis The assumption that untreated gingivitis generally progresses to periodontitis is unproven. Ivanyi L, Newman HN, 1986 In fact, periodontitis is an unusual consequence of gingivitis. Cutress et al. 1982; Baelum et al. 1986; Lembarti et al. 1988; Gaengler et al. 1988 The role of bacteria in the progression of gingivitis to horizontal or angular alveolar bone loss is not established. Kornam KS 1986

Aggressive Periodontitis Localized Generalized

Aggressive Periodontitis With no evidence of: Intratissue bacterial multiplication; Disease transmission between persons; or Spread from diseased to healthy sites in affected patients. Aggressive periodontitis cannot be considered to be infectious. There is no definitive evidence that it is a specific infection initiated by Aa. A. actinomycetemcomitans

PERIODONTAL ABSCESS An acute infection in a periodontal pocket is a common occurrence. It is important to distinguish between a periapical and periodontal abscess and this may be difficult if both conditions are present at the same time. Abscesses can be acute or chronic and asymptomatic if freely draining. If there is no endodontic component, the tooth will be vital.

Periodontal Abscess

Exam of dental patients