16-May-18

Periodontology

Basic Terminology &

Special Cases

Healthy Gum

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Definition
 Periodontology is the field of
dentistry that deals with the
treatment of diseases of the tissues
around the teeth, commonly called
the periodontium. The periodontium
serves as an attachment apparatus
and is composed of three major
tissues.

The Gingiva
Gingiva – fibrous,
epithelial tissue
surrounding a tooth,
which may be divided
into four types:

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Attached
 Attached Gingiva –
that portion which is
firm, dense, stippled,
and bound to the
underlying periosteum,
tooth, and bone.

keratinized
Keratinized Gingiva –
Hard tissue, also called masticatory
mucosa. The area where the gingiva
and mucous membrane unite, which
is indicated by the color changes
from pink gingiva to red mucosa, is
called the mucogingival border.

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Marginal
Marginal Gingiva –
 That portion which is unattached
to underlying tissues and helps
to form the sides of the gingival
crevice. Also called the free
marginal gingiva, forming the
gingival sulcus, approximately 1
to 3 mm. in depth.

Papillary
 Papillary Gingiva
 Part of the marginal gingiva that
occupies the interproximal
spaces. Normally this tissue is
triangular and fills the tooth
embrasure area, and is also
called interdental papilla.

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The Gingiva – Light

 In light-skinned
individuals the gingiva
(G) can be readily
distinguished from the
adjacent dark red
alveolar mucosa (AM)
by its lighter pink
color. Its apical
border, that separates
it from the adjacent
alveolar mucosa, is
the mucogingival
junction (MGJ).

The Gingiva – Dark

 In dark-skinned
persons the gingiva
may contain melanin
pigment to a greater
extent than the
adjacent alveolar
mucosa. The melanin
pigment is
synthesized in
specialized cells, the
melanocytes, located
in the basal layer of
the epithelium.

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The Gingiva – Lingual Aspect

 Lingual aspect of
the mandible
showing the tightly
adhering gingiva (G)
and the adjacent
non-keratinized
alveolar mucosa
(AM) that lines part
of the alveolar
process and floor of
the mouth (F).

Sulcus – Groove – Margin

 The most coronal
portion of the gingiva is
the gingival margin.
 The gingival sulcus is
the shallow groove
between the marginal
gingiva and the tooth.
 The gingival groove is an
indentation that parallels
the oral or vestibular
surface of the gingival
margin.

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Periodontal ligaments
bundles of
fibers that
support and
retain the
tooth in the
socket.

Types of Periodontal Ligament

 There are a variety of ligaments in
the periodontium, of which there are
five principal types:
 Alveolar crest fibers – found at the
cementoenamel junction, they help
to retain the tooth in its socket and to
provide protection for the deeper
fibers.

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Horizontal Fibers
Connect the
alveolar bone
to the upper
part of the root
and assist with
the control of
the lateral
movement.

Oblique Fibers
 attach the
alveolar socket
to the majority
of the root
cementum and
assist in the
resistance of the
axial forces.

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Apical Fiber Bundles

 Run from the apex
of the tooth to the
alveolar bone.
These fibers help
to prevent tipping
and dislocation, as
well as protect the
nerve and blood
supply to the
tooth.

Interradicular Fiber Bundles

 Present in
multirooted teeth,
extending apically
from the tooth
furcation. These
bundles help the
tooth resist tip-
ping, turning, and
dislocation.

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Alveolar Bone Process

Alveolar Bone
 Compact bone that forms tooth
socket. It is supported by the
stronger bone tissue of the mandible
and maxilla and accepts periodontal
fiber attachment. The alveolar
process makes up the cribriform (=
sieve-like) plate to form and line the
tooth socket. This outline is called
lamina dura and is easily viewed on
radiographs.

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Incisive Papilla
Palatal rugae
(RR), the
ridges
behind the
anterior
teeth, on
either side of
the incisive
papilla (IP).

Etiology of Periodontal Diseases

 The major contributing factors are
plaque (= plate or buildup ), an
adhering film, or pellicle which
harbors an assortment of bacterial
pathogens, and calculus, a hard,
substance formed from calcium and
phosphorus salt deposits during
plaque formation.

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Supra… & Sub…

 These irritants are classified as
either supragingival (found on the
tooth crowns) or subgingival (found
on root surfaces below the gingival
margin). When this collection of
pellicle and/or plaque with pathogens
extends into periodontal pockets, it
causes irritation and disease.

Attachment Loss

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So Visible?

Thin Pellicle

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Calculus – Sub & Supra

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Detrimental Plaque

Signs & Symptoms

 Redness – gingiva appears inflamed.
 Hyperplasia (= excessive tissue
cells) - gingiva looks irritated.
Hyperplastic gum tissue may be
caused by drug reactions, allergies,
and hormonal changes, as well as by
local irritants and disease.
 Hypertrophy (= increase in size) –
gingiva seems swollen.

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Signs & Symptoms (Cont.)

 Loss of stippling (= spotting), tone, or
tissue attachment – puffy gums become
loose.
 Pocket formation – gingiva is unattached
and the root may be observed.
 Alveolar bone loss with exudate (=
passing out of pus) – foul odor is present.
 Mobility - the tooth seems loose and
moves under pressure.
 Eventual loss of tooth from lack of
support or from extraction.

Classification of Diseases of
the Periodontium

There are five basic

classifications of
gingival diseases.

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Gingivitis
Gingivitis –
 inflammation of the
gingiva, may be plaque
and irritant associated.

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ANUG
ANUG –
acute necrotizing
ulcerative gingivitis,
formerly known as
"trench mouth."

Desquamative Gingivitis
Desquamative (= shedding or
scaling off) gingivitis –
painful, red
sloughing of the
gingival epithelium.

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Induced gingivitis
 Induced gingivitis –
 inflammation of the gingiva
caused by external or somatic (=
pertaining to the body) forces,
such as pregnancy, drug
reactions, hormones, and
disease (HIV or acute leukemia).

Periodontitis
 Inflammation of gingival and supporting
tissues, which can be further divided into
various types. Adult, prepubertal, and
juvenile periodontitis can appear in mild,
moderate, and severe forms. Rapid and
progressive periodontitis occurs with
rapid onset and severe bone loss, while
systemic periodontitis results from
systemic diseases, such as HIV or drug
therapy.

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Refractory & ANUP

 refractory = (resistant to treatment) –
periodontitis that does not respond
to treatment or medication.
 ANUP (acute necrotizing ulcerative
periodontitis) – massive tissue
destroying disease which is an
extension of ANUG.

The Periodontal Probe

 The most common instrument used for
measurement of the gingival pocket index
records is the periodontal probe, a round or
a flat-bladed hand instrument marked in
millimeter increments. The probe is normally
inserted into six specific areas with the
deepest pocket marking measurement
recorded for that spot. The six areas are the
facial (F), mesiofacial (MF), distofacial (DF),
lingual (L), mesiolingual (ML), and
distolingual (DL).

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Probing the depth…

The Probe…

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Measuring Device

Marking…
 When connected by a continuous line,
measurement marks placed on a dental chart
give a visual indication of the gingival crest,
indicating the heights of the interdental
papilla and the depths of gingival pockets.
Dental radiographs are examined to
determine bone resorption and loss.
Palpation and tests for tooth mobility are
performed along with a thorough patient
health history.

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Taking Control…

If Not… Progression…

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Nonsurgical Treatment of
the Periodontium
 Prophylaxis – treatment consist of flaking,
scaling, or scraping off any hard deposits or
accumulated extrinsic (= outer) stains on the
tooth surfaces.
 Root planing – removal of all detectable
deposits and endotoxins (= absorbed
pathogens) on the accessible cementum.
 Gingival curettage – debridement of the soft
tissue wall of the gingival pocket and removal
of the inflamed granulated tissue.

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Nonsurgical Tx (Cont.)
 Polishing – buffing tooth surfaces with power
or hand tools and pumice polish. Selective
polishing concentrates teeth in specific areas
instead of entire dentition.
 Instructions – information on brushing,
flossing, and plaque control and home care.
 Antimicrobial therapy – includes prescription
mouthwashes (chlorhexidine digluconate),
over-the-counter mouthwashes, systemic
antibiotics such as tetracycline, penicillin,
clindamycin, erythromycin, and
metronidazole medicines, and treated fibers
to be placed locally.

Nonsurgical Tx (Cont.)
 Occlusal adjustment – selective
grinding of occlusal cusps to eliminate
premature contact.
 Tooth stabilization – splinting, wire
ligation, or bonding of teeth to lessen
tooth mobility.
 Occlusal guards – custom-formed
acrylic night guard to protect from tooth
grinding.

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Periodontal Surgery Techniques

A variety of specialized surgical treatments
are applied when there is extensive disease
of the periodontium.
 Mucogingival excision – used to correct
defects in shape, position, or amount of
gingiva around the tooth. This surgery
eliminates the pocket formation and
pericoronitis generally found on erupting third
molars.
 Gingivectomy – excision of gum tissue area.

Surgery Techniques (Cont.)

 Gingivoplasty – surgical contour of
gingival tissue.
 Periodontal flap surgery – a
loosened section of tissue is
separated from the adjacent tissues
to enable elimination of deposits
and contouring of alveolar bone.

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Types of Periodontal Flap…

 Envelope flap – no vertical incision with the mucoperiosteal
flap retracted from a horizontal incision line.
 Mucoperiosteal – mucosal tissue flap includes the
periosteum, reflected from the bone; also called full
thickness flap.
 Partial thickness flap – surgical flap including mucosa and
connective tissue but no periosteum.
 Pedicle flap – tissue flap with lateral incisions.
 Positioned flap – flap which is moved to a new position,
apically, laterally, or coronal.
 Repositioned flap – surgical flap replaced into its original
position.
 Sliding flap – pedicle flap resituated to a new position.

Surgery Techniques (Cont.)

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Surgery Techniques (Cont.)

Surgery Techniques (Cont.)

 Osseous surgery – involves tissue surgery with
alteration in the bony support of the teeth.
 Reentry – second-stage surgical procedure to
enhance or improve conditions from a previous
surgical procedure.
 Vestibuloplasty – surgical alteration of the
gingival mucous membrane in the vestibule of
the mouth, includes frenum reposition and
muscle attachment change.
 ENAP (excisional new attachment procedure) –
removal of chronically inflamed soft tissue to
permit formation of new tissue attachment.

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Surgery Techniques (Cont.)

 Guided tissue regeneration – placement of a semi-
permeable membrane (Gore-Tex) beneath the flap to
prevent ingrowth of epithelium between flap and defect. It
encourages the growth of new periodontal attachment.
 Bone Grafting. Some periodontal surgical techniques will
involve bone tissues. Bone grafts involve transplants to
restore bone lost due to periodontal disease.
 Allograft – human bone graft from a person other than
the patient.
 Autograft – bone graft from another site in the same
patient.
 Xenograft – graft taken from another species, such as
cow or pig bone

INSTRUMENTATION FOR PERIODONTICS

Periodontal treatment
requires specialized
instruments. The majority
used are hand instruments,
but ultrasonic, sonic, and
power-drive tools are also
part of the necessary setup.

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HAND INSTRUMENTS
 Hand instruments used in periodontal treatment
employ a push or pull method to accomplish a
desired outcome.
 Push instruments use a push stroke direction
with a blade-to-tooth angle of less than 45
degrees perpendicular to the instrument's shaft.
An example is the chisel.
 Pull instruments use a pull stroke direction with a
blade-to-tooth angle of between 45 and 90
degrees perpendicular to the instrument's shaft.
The most effective pull angle is approximately 75
degrees. Examples include scalers, curettes,
hoes, and files.

HAND INSTRUMENTS
 Explorer – instrument with a longer,
tapered, thin wire tip to determine calculus
formation, restoration overhangs, and any
root furcation involvement.

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Scaler
 Instrument with a sharpened blade to
remove supragingival calculus
deposits and stains. Scalers are
supplied in various shapes such as
sickle for universal use, straight for
anterior areas, and contra-angled for
posterior areas.

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Hoe
 Instrument with long shank and hoe-
like tip, used to remove heavy or
thick supra gingival calculus in
posterior areas.

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Chisel
 Instrument with longer shaft and chisel-
bladed tip, used to break off and
remove heavy calculus in the anterior
region.

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Curette
 Instrument with longer shaft and
neck to access tissue area to remove
subgingival deposits. A universal
curette has a cutting edge on each
side of the blade to enable use in all
areas. Other curettes are designed
for specific areas, such as the
Gracey curettes with a cutting edge
on one side of blade.

Curette

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Curette

Gracey Curette
 Gracey 5/6 is used on all surfaces of
anterior teeth and bicuspids;
 Gracey 7/8 is used for buccal and
lingual surfaces of posterior teeth;
 Gracey 11/12 is used for mesial
surfaces of posterior teeth;
 and the Gracey 13/14 is used for
distal surfaces of posterior teeth.

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Gracey Curette

Files
 Hand instrument with rasp blade, used to
smooth off rough and uneven tissues and
remove stubborn calculus deposits.

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Ultrasonic and sonic instrument tip

A selected tip is inserted into an

ultrasonic handle and the sonic forces
move the tip in rapid, short (0.001 in.)
waves at speed frequencies of 20,000 to
35,000 vibrations per second to break
apart and dislodge deposits from the tooth
surface. The tips or inserts are designed
for specific areas and designated uses.
Machine tips are cooled with a water spray
to lessen friction heat.

Polishing Instruments
 Instruments used to polish the tooth
surfaces include straight handpieces,
prophylaxis contra-angles, and rubber
cups, as well as polishing agents, such as
pumice, cleaners, and chemically
impregnated rubber points. Polishing is
completed using a power-driven
bicarbonate of soda spray unit or slow
handpiece rotary rubber cups with
pumice.

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Periodontal pocket marker

 Set of instruments similar to
tweezers with a sharp point on
one tip for insertion into the
depth of the pocket and then
compressed for making puncture
marks indicating pocket depth.
There is one marker for each
side of the pocket.

Knives

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