PERIODONTOLOGY

 Periodontics is a branch of dentistry that aims at diagnosis, treatment and prevention of the
tooth and its supporting structures (periodontium)

 Periodontology is the scientific study of healthy and diseased periodontium and its related
contributing factors

 Calculus is not a causative factor in periodontal disease but rather, a plaque retentive factor

 Periodontal disease can be treated by either surgical or non- surgical methods can be used
- non-surgical management is the first intervention for periodontal disease
- root planing is a form of non-surgical management that can be done

PERIODONTAL
THERAPY

SURGICAL NON-SURGICAL
THERAPY THERAPY

Curretage Gingivectomy Scaling

Abscess drainage Flap surgery Root planing
GTR procedure Implant Splinting
Aesthetic surgeries Occlusal therapy
Local Drug delivery

GTR procedure = Guided Tissue Regeneration

 Root planing is the removal of necrotic cementum from the root with a hand instrument. It is
basically debriding the cementum

 Difference between scaling and root planing

− scaling removes toxins and buildup from your the gingiva whereas root planing helps
prevent this buildup from coming back
− root planing is used to smooth the root surfaces of teeth, allowing the gingival tissue
to more firmly attach to the roots
 SCALING AND ROOT PLANING
− also known as conventional periodontal therapy, non-surgical periodontal therapy or
deep cleaning

− it is a procedure involving removal of dental plaque and calculus (scaling or

debridement) and then smoothing, or planing, of the (exposed) surfaces of the roots,
removing cementum or dentine that is impregnated with calculus, toxins, or
microorganisms, the etiologic agents that cause inflammation

− it is a part of non-surgical periodontal therapy

− this helps to establish a periodontium that is in remission of periodontal disease
− periodontal scalers and periodontal curettes are some of the tools involved

− scaling and root planing is done under local anaesthesia

 Occlusal discrepancies on its own can cause periodontal disease

 Occlusal disharmony can worsen existing periodontal disease

 Chlorhexidine mouthwash - Kamaclox, Fosydyl

 How to use articuating paper to check high spots in occlusion

- pin-point imprint = no high spots (normal)
- heavy imprint = high spots

 High spots transmits “jiggling forces” to the opposite tooth in the oposite arch eventually
destroying the periodontal ligament leading to mobility of the tooth

 Jiggling type trauma

• jiggling forces are intermittent type of forces subjected to tooth or teeth in more than
one direction, such as in case of premature contacts (crowns/high fillings)
• in conjunction with “jiggling-type trauma” no clearcut pressure and tension zones can
be identified but rather there is a combination of pressure and tension on both sides
of the jiggled tooth
 Periodontitis and diabetes have a bidirectional relationship
 ─ diabetes is associated with an increased prevalence and severity of periodontitis
(especially if the glycemic control is poor)

─ severe periodontitis is associated with compromised glycemic control

─ because of this, Casanova et al argue that the dental team has an important role to
play in the management of people with diabetes

─ in an emerging role for dental professionals, diabetes screening tools could be used to
identify patients at high risk of diabetes, to enable them to seek further investigation
and assessment from medical healthcare providers

CONTRIBUTING FACTORS OF PERIODONTAL DISEASE

Systemic factors Local factors
− pregnancy − high restorations
− smoking − defective restorations
− stress (cortisol) − ledges
− diabetes − overhangs
− drugs (antihypertensives, antiseizures) − introduction of foreign bodies (dentures) -
due to poor finishing and polishing
− poor oral hygiene

PERIODONTAL DISEASES
• Gingival diseases
• Chronic periodontitis
• Aggressive periodontitis
• Periodontitis as a manifestation of systemic diseases
• Necrotizing periodontal diseases
• Abscesses of the periodontium
• Periodontitis associated with endodontic lesions
• Developmental or acquired deformities and conditions

 Periodontitis as a manifestation of systemic diseases

─ at least 16 systemic diseases have been linked to periodontitis

─ these systemic diseases are associated with periodontal disease because they
generally contribute to either a decreased host resistance to infections or dysfunction
in the connective tissue of the gums, increasing patient susceptibility to inflammation-
induced destruction
─ some of the associated diseases are
 i. diabetes mellitus
ii. leukemia
iii. acquired neutropenia
iv. genetic disorders (Down syndrome, Ehlers-Danlos syndrome, etc)

 Periodontitis associated with endodontic lesions

Combined periodontic-endodontic lesions take the form of abscesses and can originate from
either or both of two distinct locations and may be informally subclassified as follows:

1. Endo-Perio: infection from the pulp tissue within a tooth may spread into the
bone immediately surrounding the tip, or apex, or the tooth root, forming a
periapical abscess. This infection may then proliferate coronally to communicate
with the margin of the alveolar bone and the oral cavity by spreading through
the periodontal ligament

2. Perio-Endo: infection from a periodontal pocket may proliferate via accessory

canals into the root canal of the affected tooth, leading to pulpal inflammation.
Accessory canals may not be big enough to allow bacterial penetration,
periodontal disease must reach the apex to induce an endodontic lesion

Treatment includes conventional endodontic therapy followed by conventional periodontal therapy. If

the lesion is deemed too severe for treatment, the involved tooth may require extraction

AGGRESSIVE vs CHRONIC PERIODONTITIS

The amount of plaque present in periodontitis

should be consistent with destruction. However,
sometimes this is not the case. This can be seen in
aggressive periodontitis with virulent bacteria

Horizontal bone loss = Chronic periodontitis

Vertically bone loss =Aggressive periodontitis

Clinical determinants/findings of diagnosis of periodontal

disease
- age
- amount of plaque deposition/microbial deposit
- sex (pregnancy induced gingivitis)
Pregnancy gingivitis
 it is caused by a rise in the hormone progesterone which can contribute to an increase in
the flow of blood to gingival tissues making them sensitive, swollen and more likely to
bleed when upon brushing and flossing

 these hormonal changes can make it easier for certain gingivitis-causing bacteria to grow
and can make gingival tissues more tender

 while pregnancy gingivitis can occur anytime between the second and eighth month, it’s
usually most severe during the second trimester

 occasionally a red lump or “overgrowth” develops on the gingiva– usually near the upper
front teeth. These are called pregnancy tumors and they are not cancerous or contagious.
Most of these lumps disappear after the baby is born

 Between 60% and 70% of women experience pregnancy gingivitis

Basic Periodontal Disease Proprioception of periodontium

- gingivitis - periodontal ligament
- periodontitis - pulp
- occlusal trauma - muscles
- manifestationof systemic disease - tendons

Physiology and Embryology of the periodntium ???

Gingivitis does not always progress to periodontitis. It depends on:

─ general/systemic factors
─ local factors
─ irritant factors - plaque biofilms
─ contributing factors
─ virulence of bacteria
 PERIODONTAL DISEASE: GINGIVITIS vs PERIODONTITIS
 Periodontal disease is an inflammatory disease that affects the soft and hard structures that
support the teeth

 In its early stage, called gingivitis, the gums become swollen and red due to inflammation, which
is the body’s natural response to the presence of harmful bacteria

 In the more serious form of periodontal disease called periodontitis, the gums pull away from
the tooth and supporting gum tissues are destroyed. Bone can be lost, and the teeth may loosen
or eventually fall out

 Chronic periodontitis, the most advanced form of the disease, progresses relatively slowly in
most people and is typically more evident in adulthood

 Although inflammation as a result of a bacterial infection is behind all forms of periodontal

disease, a variety of factors can influence the severity of the disease. Important risk factors
include: - inherited or genetic susceptibility
- smoking
- lack of adequate home care
- age
- diet
- health history
- medications

TRUE vs PSEUDO POCKETING

 Pseudopocket
− pocket develops because of gingival enlargement
− causes of gingival enlargement can be gingival hyperplasia, edema, drug-induced, or
hormones (pregnancy gingivitis)
− no loss of supporting periodontal tissues
− no loss of connective tissue attachment
− no apical migration of junctional epithelium
− gingival margin migrates coronally
− base of pocket is coronal to alveolar bone crest (suprabony; supracrestal;
supraalveolar)

 True Periodontal Pocket

− pocket develops because of migration of connective tissue attachment
− apical migration of junctional epithelium (base of pocket)
− actual loss of supporting periodontal tissues. Actual loss of connective tissue
attachment
− base of pocket can be coronal to alveolar bone crest (horizontal bone loss), or apical
to alveolar bone crest (infrabony; subcrestal; intraalveolar; angular bone loss)

Radiographs for periodontal disease

1. Orthopantomogram (OPG)
2. Bitewing
3. Periapical
OPG helps assess bone loss (horizontal/vertical)

Plaque disclosing agents and Periodontal Probes

- refer to assignment
 * = furcation involvement, Periodontal Pocket Depth > 7mm

TREATMENT PLANNING
1. General therapy
2. Emergency therapy
3. Non-surgical therapy
4. Prosthetic therapy
5. Maintenance therapy

BIOLOGIC WIDTH
 Biologic width is defined as the dimension of the soft tissue, which is attached to the portion of
the tooth coronal to the crest of the alveolar bone
 The biologic width is commonly stated to be 2.04 mm, which represents the sum of epithelial
and connective tissue measurements
 Hence, encroachment of the biologic width frequently leads to gingival inflammation, clinical loss
of attachment and bone loss
 CLINICAL ATTACHMENT LEVEL (CAL)
 CAL does not stand for "calibrated attachment level" or "clinical attachment loss" !!!

 The greater the loss of clinical attachment, the larger the CAL measurement

 Loss of clinical attachment level is associated with true periodontal pockets, but not necessarily
with pseudopockets

 There are three possible scenarios, and calculating CAL is different for each
1. Gingival margin is right at CEJ:
☛ CAL = pocket depth

2. Tooth has recession, and gingival margin is below/apical to the CEJ:

☛ CAL = (pocket depth) PLUS (gingival margin level from CEJ)

3. Gingival margin is above/coronal to CEJ:

☛ CAL = (pocket depth) MINUS (gingival margin level)

CAL is frequently measured and charted incorrectly. For dental practice management software to
automatically calculate CAL correctly, then dental personnel must properly enter pocket depths AND
gingival margin level, including using + and - correctly
 CAL = Periodontal Pocket Depth + Amount of Gingival Recession
Amount of Gingival Recession = CEJ to Gingival Margin

 Root cementum is characterized by continuous deposition throughout life. Some can be found
on small portions of the crown

 Loss of scalloped margin/knife edge margin is indicative of periodontal disease

 There is a small amount of gingival crevicular fluid on healthy gums

 The periodontal ligament

− joins root cementum to alveolar bone
− its width is approximately 0.25mm
− the PDL ranges in width from 0.15 to 0.38mm
− its thinnest part located in the middle third of the root
− the width progressively decreases with age
− the PDL is a part of the periodontium that provides for the attachment of the teeth to
the surrounding alveolar bone by way of the cementum

 Plaque builds up supragingivally and proceeds subgingivally

− supragingival plaque is the responsibility of the patient
− if oral hygiene is poor, the supragingival plaque builds up and progresses sungingivally
− at this stage scaling and polishing is done by the dentist

 Spirochetes are the implicated etiologic agents of ANUG (gram negative organisms)

 Streptococus sp - Streptococcus intermidius, Streptococcus angionosus, Streptococcus anginosus

 Porphyromonas gingivalis (obligate anaerobe)

− chronic and aggressive periodontitis

 Aggregatibacter actinomycetemcomitans (Aa)

− aggressive periodontitis

 Prevotella intermedia
− localized aggressive periodontitis
− chronic periodontitis
− necrotizing periodontal diseases