Introduction to Periodontal Diseases

• The presentation provides an introduction to periodontal diseases.
• It was prepared by Ronald George, D.D.S., Assistant Professor at Midwestern University, College of Dental Medicine Illinois in 2009

Objectives

• Identify components of a healthy periodontium.
• Recognize the signs of gingivitis.
• Recognize the signs of periodontitis.
• Recall the 2018 Classification of Periodontal and Peri-Implant Diseases and Conditions.
• Describe Peri-Implant Mucositis.
• Describe Peri-Implantitis.

Periodontics

• A specialty of dentistry that includes prevention, diagnosis, and treatment of diseases of supporting and surrounding tissues of the teeth or their substitutes.
• It also encompasses the replacement of lost teeth and supporting structures by regeneration, tissue engineering, implantation of natural and/or synthetic devices and materials.
• Involves the maintenance of the health, function, and esthetics of tissues and structures

Historical Background

• Periodontal disease was common in ancient Egyptians.
• Hippocrates (460-377BC) discussed the etiology of periodontal disease, believing inflammation of gums could be caused by accumulations of calculus.
• Albucasis (936-1013) had a clear understanding of the major etiologic role of calculus deposits and described techniques of scaling teeth with instruments he developed.
• Serefeddin Sabuncuoglu (1385-1468) initiated drug and surgical treatment of the gums.
• Bartholomeus Eustachius (1520-1574) wrote the first original book about the teeth, Libellus de Dentibus, which included a description of periodontal tissues.
• Girolamo Cardano (1501-1576) was the first to differentiate among the types of periodontal disease.
• Anton Van Leeuwenhoek (1632-1723) developed the microscope describing oral bacterial flora, and performed antiplaque experiments using strong vinegar.
• Pierre Fauchard is regarded as the father of the dental profession.
• In 1728 his book, The Surgeon Dentist, covered all aspects of dental practice.
• Leonard Koecker (1785-1850) wrote a paper in 1821 mentioning the careful removal of tartar and the need for oral hygiene by the patient.
• Levi Spear Parmly (1790-1859) is considered the father of oral hygiene and the inventor of dental floss.
• In the mid-19th century, John W. Riggs (1811-1885) was expert on periodontal disease.
  • Periodontitis was known as "Riggs' disease.”
  • Riggs seems to have been the first individual to limit his practice to periodontics and can therefore be considered the first specialist in this field.
• In the second half of the 19th century, anesthesia was discovered, germ theory of disease was established, asepsis in surgery, and the discovery of radiographs.
• Adolph Witzel (1847-1906) was the first to identify bacteria as the cause of periodontal disease.
• J. Leon Williams (1852-1932) described a gelatinous accumulation of bacteria adherent to the enamel surface in relation to caries.
• In 1899, G.V. Black (1836-1915) coined the term “gelatinous microbic plaque."
• In the first third of the 20th century, Bernhard Gottlieb (1885-1950), and Balint J. Orban (1899-1960) developed the basic histopathic concepts on which modern periodontics was built.
• During this time, Oskar Weski (1879-1952) and Robert Neumann (1882-1958) refined the surgical approach to periodontal therapy.
• Isadore Hirschfield (1882-1965) championed the nonsurgical approach.
• Alfred Fones (1869-1938) opened the first school for dental hygienists in 1913.
• Per-Ingvar Branemark developed a technique in the 1950s for titanium screw shaped intraosseous implants.
• Jens Waerhaug (1907-1980), researched and opened a new era in the understanding of the periodontium and management of periodontal problems.
• Conferences have summarized the existing knowledge of periodontology with the latest in 2017.
• The American Academy of Periodontology was founded in 1914 by Grace Rogers Spalding (1881-1953) and Gillette Hayden (1880-1929) and has become the leader in organized periodontics.
• In 1995 the AAP mandated that all postgraduate periodontal programs increase to a 3-year curriculum.

Periodontium

• Supporting structures of the teeth necessary to maintain teeth in function.
• These tissues make up the periodontium: Gingiva, Cementum, Periodontal ligament (PDL,) and Alveolar bone
• All components function as a single unit.
• Pathologic changes in one component may have ramifications for maintenance, repair, or regeneration of another component.
• Gingiva is oral tissue (oral mucosa) that is covered by keratinized tissue containing keratin.
• Alveolar mucosa is nonkeratinized mucous membrane apical to the attached gingiva.
• Gingiva includes gingival margin, free gingiva and attached gingiva.
• The compact layer of bone called the alveolar bone proper is also called bundle bone and radiographically the lamina dura

Gingival Health

• Characteristics of Gingival Health: 3 C's
  • Color is coral pink or pink with melanin pigmentation.
  • Contour has papillae fill gingival embrasure and are knife edged.
  • Scallops are parabolic.
  • Consistency is firm and resilient.
  • A surface texture is stippled (orange peel) and matte (dull).
  • There is no bleeding or suppuration.
  • Absence of mucogingival defect.
  • Sulcus depths are 1-3mm.
• Free Gingiva is part of the gingiva that surrounds the tooth and is not directly attached to the tooth surface or alveolar bone.
  • Forms a collar of tissue with a space between it and the tooth called the gingival sulcus.
  • The depth of the sulcus can be measured with a periodontal probe (1-3mm).
• The probing depth in health is the distance from the gingival margin to the base of the sulcus ranging from 1 to 3mm in depth.
• Junctional epithelium is the tissue that forms the base of the sulcus by attaching to the enamel of the crown near the cementoenamel junction (CEJ).
• Interproximal (crestal) bone approximates the cementoenamel junction (1-2mm apical to the CEJ of adjacent teeth) radiographically.

Gingivitis

• Inflammation of the gingiva, altering the gingival tissues.
• Results from a response to harmful metabolic products of bacterial colonies within dental plaque in close proximity to gingival tissues.
• Plaque induced gingivitis is the most common form.
• Increase in inflammatory cells, tissue fluids, redness, and loss of the epithelium's integrity can be seen.
• Characteristics include:
  • Redness (color).
  • Rolled swollen margins (contour).
  • Loss of (consistency)/resiliency.
  • Smooth and shiny surface texture.
  • Loss of stippling
  • Bleeding upon probing.
  • Spontaneous bleeding.
  • Suppuration.
• Bleeding upon probing is a hallmark.
• Gingivitis is reversible through removal of plaque.

Pericoronitis

• Inflammatory involvement of the pericoronal flap (operculum) and adjacent structures.
• Etiology due to a partially erupted or impacted tooth mostly the mandibular third molar, usually partially erupted wisdom teeth, subjected to aggravating factors.
• Clinical Symptoms
  • Pain.
  • Foul taste.
  • Inability to close the mouth.
  • Trismus.
  • Swelling at the region of the angle of the mandible.
  • Fever, lymphadenopathy and malaise
• Aggravating Factors
  • Traumatic occlusion.
  • A foreign body trapped underneath the tissue flap (e.g., popcorn husk, or nut fragment).
• Clinical Signs
  • Red, swollen, suppurating lesion in gingival flap (operculum). Possible overlying crown of partially erupted or impacted tooth,
• Potential Complications
  • Pericoronal abscess.
  • Peritonsillar abscess.
  • Cellulitis.

Periodontitis

• Untreated gingivitis may progress to periodontitis
• Plaque and dental calculus contribute to disease development and progression.
• Inflammation of periodontal tissues resulting in clinical attachment loss, alveolar bone loss, and periodontal pocketing (≥ 4mm pocket depth).
• Inflammatory breakdown extends from the gingiva to periodontal ligament and bone when the junctional epithelium migrates apically due to broken down connective tissue attachment.
• Progression of disease causes breakdown of bone and adjacent periodontal ligament.
• In periodontal pockets the sulcus base is apical to the alveolar crest.
• Smoking and diabetes increase the odds of periodontal disease progression.
• Periodontal disease may be a risk factor for several systemic diseases including cardiovascular disease.
• A periodontal pocket is used when to describe loss of attatchment

Systemic Diseases

• Diabetes
• Pre-term Low Birth Weight Babies
• Cerebrovascular Stroke
• Respiratory Diseases
• Cardiovascular Diseases
• Periodontitis is irreversible and requires treatment for life.
  • Nonsurgical - Scaling & Root Planing.
  • Surgical.
  • Maintenance.
• Unlike gingivitis, person remains a periodontitis patient for life, even following successful therapy, requiring long-term maintenance.

Gingival Recession

• Loss of gingival tissue with underlying bone loss.
• Gingival margin apical to the CEJ with exposure of the root surface.
• Papillae may be blunted or rounded.
• Possible Causes
  • Periodontitis.
  • Lack of attached gingiva.
  • Poorly aligned teeth.
  • Abnormal tooth and root prominence.
  • Thin periodontal tissues,
  • Aggressive tooth brushing.
  • Poor restorations.

Histopathology of Periodontal Disease

• The stages of periodontal disease are when plaque is left undisturbed.
• Health: Supragingival plaque consists of gram-positive microbes, no rete pegs, predominant PMN immune cell, with normal fibroblasts, collagen fibers.
• Gingivitis/Early Lesion: In early phases, supragingival plaque contains G(+) microbes with proliferation in collagen depleted areas; rete pegs formation, T cells, macrophages, altered fibroblasts with some collagen fibers destroyed.
• Chronic Gingivitis/Established Lesion: Subgingival plaque contains G(+) and G(-)microbes, which leads to apical proliferation and conversion into pocket epithelium, plasma cell predominant immune cell, damaged fibroblasts, destroyed collagen fibers with some repair areas (fibrosis).
• Advanced Lesion/Transition To Periodontitis: The area is predominated by G(-) anaerobes and plasma immune cells leading to the severe damage of the fibroblasts, periodontal ligament fibers, alveolar bone and osteoclastic resorption.

2018 Classification of Periodontal and Peri-Implant Diseases and Conditions

Includes:

• Periodontal Health, Gingival Diseases and Conditions.
• Periodontitis.
• Periodontal Manifestations of Systemic Diseases and Developmental and Acquired Conditions.
• Peri-Implant Diseases and Conditions.
• Periodontal health and gingival health includes:
  • Clinical gingival health on an intact periodontium.
  • Clinical gingival health on a reduced periodontium.
  • Stable periodontitis patient.
  • Non-periodontitis patient
• Gingivitis is dental biofilm induced and associated with dental biofilm alone.
• Gingival diseases are non-dental biofilm induced by genetic disorders, specific infections, inflammatory & immune conditions, neoplasms, endocrine & nutrition related, traumas.

Grading and Staging Periodontitis

• Severity, Complexity of Management and Extent are used to measure the stages. The stages include:
  • Stage I: Initial Periodontitis.
  • Stage II: Moderate Periodontitis.
  • Stage III: Severe Periodontitis with potential for tooth loss.
  • Stage IV: Severe Periodontitis with potential for loss of the dentition. Extent and distribution can also be measured: localized or general.
• Progression is associated with the Grades including grades for:
  • Grade A: Slow rate of progression.
  • Grade B: Moderate rate of progression.
  • Grade C: Rapid rate of progression.
• Necrotizing Periodontal Diseases
  • Necrotizing = causing necrosis: tissue death
  • Necrotizing Gingivitis.
  • Necrotizing Periodontitis.
  • Necrotizing Stomatitis (soft tissues of the oral cavity). - characterized by (punched-out), craterlike depressions. - loss of clinical attachment and alveolar bone
• Periodontal Abscesses and Endodontic-Periodontal Lesions
  • Periodontal Abscess results in a localized accumulation of pus located within the gingival wall leading to a common dental emergency requiring immediate attention.
  • Endodontic-Periodontal Lesions involve both the pulp and periodontal tissues.

Periodontal Manifestations of Systemic Diseases and Developmental and Acquired Conditions

Includes:

• Systemic Disorders.
• Mucogingival Deformities.
• Traumatic occlusal forces.
• Tooth and Prothesis Related Factors affecting periodontal supporting tissues.
• Factors can involve:
  • Gingival Phenotype.
  • Lack of gingiva.
  • Decreased vestibular depth.
  • Aberrant frenum/muscle position.
• Traumatic occlusal forces can involve:
  • Primary occlusal trauma.
  • Secondary occlusal trauma.
  • Orthodontic forces.
• Tooth and Prothesis Related Factors can include:
  • Localized tooth related factors.
  • Localized dental prostheses related factors.

Peri-Implant Diseases and Conditions

• Peri-implant Health: absence of visual signs of inflammation and bleeding on probing.
• Peri-implant Mucositis: bleeding on probing and visual signs of inflammation.
• Peri-implantitis: inflammation and progressive loss of bone.
• Peri-implant Soft and Hard Tissue Deficiencies: healing after tooth loss leads to diminished alveolar ridge.
• Peri-implant mucositis the presence of inflammation is confined to the mucosa surrounding a dental implant with no signs of loss of supporting bone.
  • Similar to gingivitis and reversible as a soft tissue change only.
  • Reported in up to 80% of patients with implants.
• Peri-implantitis is an inflammatory process around an implant which includes soft tissue inflammation and loss of supporting bone.
  • Similar to periodontitis but irreversible.
  • Diagnosis includes 1-1.5mm bone loss from baseline.
  • Pain is not typical feature.
  • Can progress quicker than periodontitis around natural teeth.
  • The implant body is usually titanium.

Dental Implants

• Endosseous dental implant composed of:
  • Implant body.
  • Implant abutment.
  • Prosthesis or superstructure.
• Implant abutment and prosthesis are exposed to the oral cavity.
• Osseointegration is a direct contact/connection between living bone tissue and an implant.
• Prevalence of peri-implantitis among patients is 11.2%-53%.

Parting Words

• Gingivitis is inflammation confined to the gingival tissues without loss of attachment/bone loss and it's reversible.
• Not all untreated gingivitis will progress to periodontitis, but all chronic periodontitis patients have experienced gingivitis.
• Periodontitis is inflammation of the periodontium with attachment/bone loss, so bone loss is irreversible.
• Periodontal diseases are multifactorial, so a comprehensive approach is necessary.

This presentation introduces periodontal diseases. It covers the components of a healthy periodontium, signs of gingivitis and periodontitis. The presentation also touches upon the 2018 classification of periodontal and peri-implant diseases and conditions.