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Chapter 3: Overview of the Diseases of the Periodontium

• The chapter focuses on the diseases affecting the periodontium.
• Periodontium encompasses the structures that support the teeth.
• Key states of the periodontium include health, gingivitis, and periodontitis.
• Gingivitis is confined to the gingiva (gum tissue).
• Periodontitis affects all structures of the periodontium, including the gingiva, periodontal ligament, alveolar bone, and cementum.
• Health:
  • Clinically: Pink, firm gingiva, no bleeding.
  • Histologically: Sulcus coronal to CEJ (cemento-enamel junction), intact supragingival fibers, intact alveolar bone, intact periodontal ligament.

Three Basic States of the Periodontium

• Gingivitis:
  • Clinically: Red, swollen gingiva, bleeding likely.
  • Histologically: Gingivial pocket, supragingival fiber destruction, alveolar bone intact, periodontal ligament intact, junctional epithelium (JE) at CEJ.
• Periodontitis:
  • Clinically: Pink or purplish, swollen/fibrotic gingiva, bleeding.
  • Histologically: Periodontal pocket, JE on cementum, supragingival fiber destruction, alveolar bone destruction, periodontal ligament destruction.

Characteristics of Periodontitis

• Characterized by:
  • Apical migration of junctional epithelium.
  • Loss of connective tissue attachment.
  • Loss of alveolar bone.
  • Intermittent tissue destruction at varying rates throughout the mouth.

Clinical Picture of Gingivitis

• Gingival tissue is red or reddish-blue (cyanotic).
• Gingival margin is swollen (edematous).
• Interdental papillae is bulbous and swollen.
• Bleeding upon gentle probing is common.
• Probing depths greater than 3mm.
• No apical migration of the junctional epithelium.

Microscopic Picture of Gingivitis

• Hemidesmosomes still attach to enamel.
• Epithelial ridges form and extend from junctional epithelium into adjacent connective tissue.
• Reversible damage to gingival fibers.
• No infection in the alveolar bone or periodontal ligament fibers and cementum.

Microscopic Picture of Periodontitis

• Apical migration of junctional epithelium.
• Coronal-most portion of junctional epithelium detaches from tooth surface.
• Extracellular matrix of gingiva and collagen fibers are destroyed.
• Junctional epithelium and sulcular epithelium extend into connective tissue.
• Small ulcerations of pocket epithelium expose underlying inflamed connective tissue.

Gingival Connective Tissue

• Widespread destruction of collagen and supragingival fiber bundles, allowing junctional epithelium migration.
• Pathologic tooth migration is possible.
• Destruction of alveolar bone, ligament fiber bundles.
• Cementum exposed to plaque biofilm.
• Inflamed pulp, pulpal necrosis, vascular congestion, and dentin demineralization are possible.

Bone Defects in Periodontitis

• Infrabony defect: Base of defect extends apical to residual alveolar crest.
  • Two types:
    • Intrabony defect: Bone resorption unevenly and obliquely, primarily affects one tooth.
    • Osseous Crater: Interdental bone loss, affecting two adjacent teeth.
• One-Wall Intrabony Defect: Half of the interdental septum is lost. Other half remains attached to tooth.
• Two-Wall and Three-Wall Intrabony Defects: Diagrams depicting these defects that are formed when vertical bone loss occurs.
• Proximal Bone Contour: Bone contour from facial to lingual dips apically, forms osseous crater that affects two adjacent root surfaces, producing interdental areas difficult to clean.

Bone Loss in Furcation Areas

• Furcation involvement occurs when periodontal infection invades the area between and around roots.
• Results in alveolar bone loss between roots.
• Can be hidden by gingival tissue.

Attachment Loss in Periodontal Pockets

• Destruction of fibers and bone supporting teeth.
• Spreads apically and laterally.
• Pockets on different root surfaces can exhibit varying depths.

Disease Sites

• Areas of tissue destruction.
• Inactive disease site: Junctional epithelium attachment level stable over time.
• Active disease site: Shows continued apical migration of junctional epithelium; assess with periodontal probe and record in chart.

Periodontal Pockets

• Areas of tissue destruction left by disease processes.
• Much like a demolished home after a hurricane.
• Not necessarily indicative of active disease.
• Most pockets in adult patients are inactive disease sites.

Gingival Sulcus

• In health, average sulcus is 1 to 3 mm deep.
• Junctional epithelium is coronal to CEJ.
• Attaches along the entire length to the tooth.

Gingival Pockets or Pseudopockets (False Pockets)

• Deepening of gingival sulcus due to swelling.
• Causes of increased probing depth:
  • Detachment of the coronal portion of junctional epithelium.
  • Increased tissue size due to swelling.

Periodontal Pockets

• Pathological deepening of gingival sulcus.
• Occurs as a result of:
  • Apical migration of junctional epithelium.
  • Destruction of periodontal ligament fibers.
  • Destruction of alveolar bone.

Suprabony Pocket

• Occurs with horizontal bone loss.
• Pocket base is coronal to alveolar crest.
• Junctional epithelium is located coronal to the crest of alveolar bone.

Infrabony Pocket

• Occurs with vertical bone loss.
• Types: Intrabony defect, osseous defect.
• Junctional epithelium is apical to the crest of alveolar bone.

Theories of Disease Progression

• Pattern of disease progression may vary from one individual to another, one site to another in a person's mouth, or one type of periodontal disease to another.

Continuous Progression Theory (Historical View of Disease Progression, Prior to 1980)

• Periodontal disease progresses throughout the entire mouth at a slow, constant rate.
• Untreated gingivitis cases progress to periodontitis.
  • All cases of periodontitis progress slowly at a steady rate.
• Research in the early 1980s indicates periodontal disease does not progress at a constant rate and doesn't affect all areas of the mouth simultaneously.

Intermittent Progression Theory (Current View)

• Characterized by periods of disease activity and inactivity (remissions).
• Tissue destruction is sporadic and occurs at different rates.
• Most untreated gingivitis does not progress to periodontitis.
• Different forms may progress at different rates.
• Susceptibility to periodontitis varies greatly by individual.

Epidemiology of the Diseases of the Periodontium

• Study of health and disease within a total population to understand behavioral, environmental, and genetic risk factors.
• Epidemiologists work to determine the occurrence, identify risk factors, and provide current information about treatment and prevention.
• Questions epidemiologists ask when researching periodontal disease: Why does one part of the population have less periodontal disease than another? How prevalent is periodontal disease in the population? What genetic factors might increase risk for periodontal disease? What lifestyle behaviors increase risk for periodontal disease? What is the cause of periodontal disease?.

Disease Incidence and Prevalence

• Incidence: Number of new cases in a population over a specific period.
• Prevalence: Number of all cases identified in a specific population at a given point in time.

Variables Associated with Prevalence of Disease (Page 76)

• Gender.
• Race/ethnicity.
• Education and socioeconomic status.
• Age.
• Behavior.
• Access to dental care.

What the Research Shows

• Periodontal disease is one of the most widespread diseases in adult Americans.
• Most individuals with the disease are unaware of its presence.
• Findings are based on data collected as part of the CDC's 2009-2010 NHANES.

Public Health Surveillance of Periodontal Disease

• AAP and CDC describe periodontal disease as a public health concern.
• Working toward improved disease surveillance.
• CDC's Division of Oral Health and the Association of State and Territorial Dental Directors collaborate to monitor the burden of oral disease and track state data.