Introduction To Periodontology

Definitions
• Periodontics: The branch of dentistry that deals
with the diagnosis and treatment of the disease
and conditions of the supporting and
surrounding tissues of the teeth or their
implanted substitutes
• Periodontology: The scientific study of
periodontium in health and disease
• A professional who practices this specialty field
of dentistry is known as a Periodontist.
What do you mean by Periodontium?
 Periodontium
• The tissues which surround the teeth, and
provide the support necessary for normal
function form the periodontium
• (Greek peri- “around”; odont-, “tooth”)
 Periodontium
• It includes:
– Gingiva
– 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
• Gingival sulcus (crevice):Shallow fissure
(space) between the marginal gingiva and the
enamel or cementum.
Periodontal Ligament
 Cementum

• A calcified avascular mesenchymal tissue that

forms the outer layer of the anatomic root

• It attaches the periodontal ligament fibers

(PDLF) to the root

• It contributes to the process of repair after

damage to the root surface.
Relationships of the enamel and CEJ

A, butt joint;  B,exposed dentin; C,cementum overlap

30% 10% 60%
 Alveolar Bone

Definition:
The parts of the maxilla and the mandible that
form and support the sockets of the teeth
 Classification Of 1999
I. Gingival Diseases
A. Dental plaque-induced gingival diseases
1. Gingivitis associated with dental plaque only
a. Without other local contributing factors
b. With local contributing factors
2. Gingival diseases by systemic factors
a. Associated with endocrine system
1) Puberty-associated gingivitis
2) Menstrual cycle-associated gingivitis
3) Pregnancy associated
a) Gingivitis
b) Pyogenic granuloma
4) Diabetes mellitus-associated gingivitis
b. Associated with blood dyscrasias
1) Leukemia-associated gingivitis
2) other
3. Gingival diseases modified by medications
a. Drug-influenced gingival diseases
1) Drug-influenced gingival enlargements
2) Drug-influenced gingivitis
a) Oral contraceptive-associated gingivitis
b) other
4. Gingival diseases modified by malnutrition
a. Ascorbic acid-deficiency gingivitis
b. other
 Classification Of 1999
I. Gingival Diseases
B. Non-plaque-induced gingival lesions
1. Gingival diseases of specific bacterial origin
a. Neisseria gonorrhea-associated lesions
b. Treponema pallidum-associated lesions
c. Streptococcal species-associated lesions
d. other
2. Gingival diseases of viral origin
a. Herpes infections
1) Primary herpetic gingivostomatitis
2) Recurrent oral herpes
3) Varicella-zoster infections
b. Other
3. Gingival diseases of fungal origin
a. Candida-species origin
1) Generalized gingival candidosis
b. Linear gingival erythema
c. Histoplasmosis
d. other

4. Gingival lesions of genetic origin

a. Hereditary gingival fibromatosis
b. Other
 Classification Of 1999
I. Gingival Diseases
B. Non-plaque-induced gingival lesions
5. Gingival manifestations of systemic conditions
a. Mucocutaneous disorders
1) Lichen planus
2) Pemphigoid
3) Pemphigus vulgaris
4) Erythema multiforme
5) Lupus erythematosus
6) Drug-induced
7) Other
b. Allergic reactions
1) Dental restorative materials
a) mercury
b) Nickel
c) Acrylic
d) Other
2) Reactions attributable to
a) Toothpastes/dentrifices
b) Mouthrinses/mouthwashes
c) Chewing gum additives
d) Foods and additives
3) Other
6. Traumatic lesions(factitious, iatrogenic, accidental)
a. Chemical injury
b. Physical injury
c. Thermal injury
7. Foreign body reactions
8. Not otherwise specified (NOS)
 Classification Of 1999
II. Chronic Periodontitis
A. Localized
B. Generalized
III. Aggressive Periodontitis
A. Localized
B. Generalized
IV. Periodontitis as a Manifestation of Systemic Diseases
A. Associated with Hematological disorders
1) Acquired neutropenia
2) Leukemias
3) Other
B. Associated with genetic disorders
1) Familial and cyclic neutropenia
2) Down syndrome
3) Leukocyte adhesion deficiency syndrome
4) Papillon-Lefévre syndrome
5) Chediak-Higashi syndrome
6) Histiocytosis syndromes
7) Glycogen storage disease
8) Infantile genetic agranulocytosis
9) Cohen syndrome
10) Ehlers-Danlos syndrome(type IV and VIII)
11) Hypophosphatasia
12) Other
C. Not otherwise specified (NOS)
 Classification Of 1999
V. Necrotizing Periodontal Diseases
A. Necrotizing ulcerative gingivitis (NUG)
B. Necrotizing ulcerative periodontitis (NUP)
VI. Abscesses of the Periodontium
A. Gingival Abscess
B. Periodontal abscess
C. Pericoronal abscess
VII. Periodontitis Associated With Endodontic Lesions
A. Combined periodontic-endodontic lesions
VIII. Development or Acquired Deformities and Conditions
A. Localized tooth-related factors that modify or predispose to plaque-
induced gingival diseases/periodontitis
1. Tooth anatomic factors
2. Dental restorations/appliances
3. Root fractures
4. Cervical root resorption and cemental tears
 Classification Of 1999
VIII.Development or Acquired Deformities and Conditions
B. Mucogingival deformities and conditions around teeth
1. Gingival /soft tissue recession
a. Facial or lingual surfaces
b. Interproximal (papillary)
2. Lack of keratinized gingiva
3. Decreased vestibular depth
4. Aberrant frenum/muscle position
5. Gingival excess
a. Pseudopocket
b. Inconsistent gingival margin
c. Excessive gingival display
d. Gingival enlargement
6. Abnormal color
C. Mucogingival deformities and conditions on edentulous ridges
1. Vertical and /or horizontal ridge deficiency
2. Lack of gingiva/keratinized tissue
3. Gingival/soft tissue enlargement
4. Aberrant frenum/muscle position
5. Decreased vestibular depth
6. Abnormal color
D. Occlusal trauma
1. Primary occlusal trauma
2. Secondary occlusal trauma
Gingivitis with local contributing Factors
Puberty associated gingivitis
Pregnancy related Gingivitis & Pregnancy Epulis
Scurvy
Leukemia Associated Gingivitis
Dilantin
Cyclosporin hyperplasia
Cyclosporin/nifedipine hyperplasia
Acute Necrotizing Ulcerative Gingivitis
Gingival fibromatosis
Allergic Gingivostomatitis
Chronic Periodontitis
Localized Aggressive Periodontitis
Lateral Periodontal Abscess
Papillon-Lefevr`e Syndrome
Primary Herpetic Gingivostomatitis
HIV-Associated Gingivitis
Lichen Planus
Lupus Erythematosus
Candidiasis
Linear Gingival Erythema
Thank You
 Epidemiology
• The term epidemiology is of Hellenic origin; it consists of the
preposition “epi”, which means “among” or “against”, and the
noun “demos” which means “people”

• Epidemiology is defined as “the study of the distribution of

disease or a physiological condition in human populations and
of the factors that influence this distribution” (Lilienfeld 1978)

• A more inclusive description by Frost (1941) emphasizes that

“epidemiology is essentially an inductive science, concerned
not merely with describing the distribution of disease, but
equally or more with fitting it into a consistent philosophy”
• Based on the above definitions, epidemiological research in
periodontology must

(1) Fulfill the task of providing data on the prevalence of

periodontal diseases in different populations, i.e. the frequency
of their occurrence, as well as on the severity of such
conditions, i.e. the level of occurring pathologic changes;
(2) Elucidate aspects related to the etiology and the determinants
of development of these diseases (causative and risk factors);
and
(3) Provide documentation concerning the effectiveness of
preventive and therapeutic measures aimed against these
diseases on a population basis
 Scales of Measurement
• Non-parametric (categorical)
– Nominal (giving names)
– Ordinal (ranking)

• Parametric (numerical)
– Interval (arbitrary zero point)
– Ratio (natural zero point)
 Measuring Oral Hygiene (plaque)
• Use disclosing agent or not
• Use probe or not

• Dichotomous—present or absent
• Ordinal—by thickness at gingival margin
• Ordinal—by tooth area covered by plaque
• Ratio—by weight (wet or dry)
 Silness & Löe Plaque Index (PI)

• Developed in early 1960s

• No disclosing
• Use a probe to detect the plaque if no plaque
is seen
• 3 buccal and 1 lingual surfaces scored (disto-
buccal, mid buccal, mesio-buccal)
• All teeth (or selected teeth)
 Silness & Löe Plaque Index (PI)

No plaque
0

Looks clean but possible to remove plaque from gingival

1 margin with a probe

2 Visible plaque along gingival margin

3 Abundant amount of plaque along gingival margin

 Visible Plaque Index (VPI)
• no disclosing
• No probe is used
• 4 surfaces scored
– Disto-buccal, midbuccal, mesio-buccal, lingual)
• All teeth (selected teeth)
• Code=1 when plaque is visible
• Code=0 when plaque is not visible
 Visible Plaque Index (VPI)
• Score for an individual calculated as the
number of tooth surfaces visible plaque as
percentage of the total number of surfaces
examined

• Measurement is a ratio scale

 Quigley and Hein Index
• Disclosing agent used
• Visual inspection, no probe
• Scoring on facial surfaces of teeth

• Designed to be more sensitive for detecting

change in plaque level than other indices
• Commonly used in clinical trials of
toothbrushing and toothpaste
 Quigley and Hein Index
0 No Plaque

1 Flecks of plaque present

2 Plaque along gingival margin (˂1/3)

3 Gingival 1/3 covered by plaque

4 2/3 of surface covered by plaque

5 Whole surface (˃2/3) covered by plaque

 Measuring calculus level
• Use probe or not

• Dichotomous—present or absent
• Ratio—by the height of calculus from gingival
margin
 Volpe-Manhold Index (V-M I)

• Developed in the 1960s

• Measure the level of supragingival calculus on
the lingual surfaces of 6 mandibular anterior
teeth

• Commonly used in clinical trials

 Volpe-Manhold Index (V-M I)

• Graduated probe
• 1 vertical line
• 2 diagonal lines
• Total calculus score = sum of 3 measurements
for each surfaces
 Volpe-Manhold Index (V-M I)
• Measure on a ratio scale
• Can use mean score

• Only reflect the calculus level in the lingual

surface of lower anterior teeth, not the whole
mouth
 Measuring periodontal condition

• Gingival condition only or periodontium

• Use probe or not
• Use special measures- x-ray or GCF
• Dichotomous—present or absent
• Ordinal—by stages of inflammation
• Ratio—measure pocket depth
• Whole dentition or partial examination (index teeth)
 Measuring gingival condition

• Signs of gingivitis
– Redness (normal is pink)
– Edema
– Bleeding on probing (BOP)
 Löe & Silness Gingival Index (GI)

0 Healthy gingivae

1 Mild inflammation—slight change in colour, slight

edema, no bleeding on probing
2 Moderate inflammation—redness, edema, bleeding on
probing
3 Severe inflammation—marked redness and edema,
tendency to bleed spontaneously
 Gingival Bleeding Index
• Periodontal probe is used
• Assess bleeding on probing only

• 4 surfaces scored (disto-buccal, mid-buccal,

mesio-buccal, lingual)
• All teeth (or selected teeth)
• Code = 1 bleeding after probing is visible
• Code = 0 no bleeding after probing
 Gingival Bleeding Index (GBI)
• Score for an individual calculated as the
number of gingival sites with bleeding after
probing as a percentage of the total number
of sites probed

• Commonly used together with the VPI

• Measurement is a ratio scale

 Loss of Periodontal Support
• Periodontal Disease Index (PDI), developed by
Ramfjord (1959)
• It measures loss of attachment instead of
pocket depth and is, therefore, an irreversible
index.
• Periodontal health (scores 0–6)
• Gingival health (scores 0–3)
• Various levels of attachment loss (scores 4–6)
Community Periodontal Index (CPI)

Recommended for use by WHO and FDI

 Background of CPI
• The community periodontal index of treatment
need (CPITN) was developed by the oral health
unit of WHO in 1981, for population surveys
• It is designed to assess periodontal treatment
need rather than periodontal status
• However, concepts of the nature amd
treatment of periodontal diseases has changed
greatly during 1980’s
 Background of CPI (continued)
• CPITN was devised as an index to assess
treatment needs, based upon a hierarchical
relationship (an ordinal scale)
• However, the need for recording periodontal
status in survey is very great. This resulted in a
gradual shifting away from the original focus of
CPITN
• The name Community Periodontal Index (CPI) is
currently being used
 Indicators used in CPI
• Gingival bleeding
• Presence of calculus
• Depth of periodontal pockets

Special designed probe is used CPI

 Assessment of periodontal treatment needs
• The dentition is divided into six sextants
• Only the most severe measure in the sextant is chosen to represent the
sextant
• Code 1: no pockets, calculus or overhangs of fillings but bleeding occurs
after gentle probing in one or several gingival units
• Code 2: no pockets exceeding 3 mm, but dental calculus and plaque-
retaining factors are detected subgingivally
• Code 3: 4–5 mm deep pockets
• Code 4: 6 mm deep or deeper
• The treatment needs are scores based on the most severe code in the
dentition as
– TN = gingival health,
– TN 1 = code 1 (need to improve oral hygiene)
– TN 2 = code 2+3 (need for scaling, removal of overhang and improved OH)
– TN 3 = code 4 (need complex treatment)
Six sextants in CPI measurements

18-14 13-23 24-28

48-44 43-33 34-38

A sextant should be examined only if there are two or

more teeth present which are not indicated for
extraction
 Index teeth in CPI

• For adults aged 20 years 17,16 11 26,27 or more:

47,46 31 36,37

• For subjects under the age

16 11 26
of 20 years:
46 31 36

• For children aged under 15 years, pockets should not be recorded, only
bleeding and calculus should be considered
 CPI probe
• A special light weight probe
– Ball tip 0.5 mm in diameter
– A black band between 3.5 and 5.5 mm
– Rings at 8.5 and 11.5 mm from the ball tip

11.5mm
3.0mm
8.5 mm
3.0mm
5.5 mm
2.0mm
5.5mm 3.5mm
3.5mm
0.5mm
 Examination and recording CPI
• After probing, record the highest score
0 Healthy
1 Bleeding observed after probing
2 Calculus detected during probing, but all of the black band on the probe
visible
3 Pocket 4-5mm (gingival margin within the black band on the probe)
4 Pocket 6 mm or more (black band on the probe not visible)
X Excluded sextant (less than 2 teeth present)
Background of measuring Loss of Attachment

• Loss of attachment first appeared in the 4th

edition of WHO oral health survey
• It was recommended to be recorded in each
sextant immediately after recording the CPI
score for the sextant
• LoA should not be recorded for children under
the age of 15 years
 Examination and recording LoA
• Use same sextants and index teeth as CPI
• Record the highest score in each sextant
0 0-3 mm (CEJ not visible and CPI score 0-3)
1 4-5 mm (CEJ within the black band)
2 6-8 mm (CEJ between the upper limit of the
black band and the 8.5mm ring)
 Examination and recording LoA
3 9-11 mm (CEJ between 8.5mm-11.5mm ring)
4 12mm or more (CEJ beyond the 11.5mm ring)
X Excluded sextant (less than two teeth
present)
9 Not recorded (CEJ neither visible nor
detectable)
 Measuring periodontal status
• CPI is not sensitive for measuring change in
periodontal status in clinical studies
• The followings are more commonly used
– Gingival recession (GR)
– Probing pocket depth (PPD)
– Clinical attachment level (CAL)
Recording Loss of attachment (LoA)
• LoA = PPD – GR (when GR˂0)
• LoA = PPD + GR (when GR˃0)
 Assessing boneloss
• Assessments of bone loss in intraoral radiographs are usually
performed by evaluating a multitude of qualitative and
quantitative features of the visualized interproximal bone,
e.g.

(1) presence of an intact lamina dura,

(2) the width of the periodontal ligament space
(3) the morphology of the bone crest (“even” or “angular”
appearance)
(4) the distance between the CEJ and the most coronal level at
which the periodontal ligament space is considered to
retain a normal width
 Assessing boneloss
• Radiographic data are usually presented as

(1) mean bone loss scores per subject (or group

of subjects)
(2) number or percentage of tooth surfaces per
subject (or group of subjects) exhibiting bone
loss exceeding certain thresholds