Periodontal Disease Progression

Disease Progression

• Disease progression, known as pathogenesis, happens during development of a disease or abnormal conditions
• Periodontology studies these events in periodontal disease development

Periodontal Disease vs Periodontitis

• Periodontal disease should not be confused with periodontitis
• Gingivitis and periodontitis are basic periodontal disease categories
• Periodontal disease arises when pathogenic bacteria, inflammatory responses, and immune responses are imbalanced and may be affected by risk factors
• Periodontitis involves apical migration of JE, loss of CT and alveolar bone, and is irreversible
  • Tissue destruction isn't continuous, happening in intermittent bursts

Gingivitis to Periodontitis

• Gingivitis must precede periodontitis but doesn't always progress to it
• Progression needing a decrease in beneficial bacteria, critical pathogenic bacteria mass, a favorable disease environment, and host response

Theories of Periodontal Disease Progression

• Continuous Disease Progression Theory (Historical Perspective) suggests periodontal disease progresses throughout the mouth slowly and constantly throughout life
• Intermittent Progression Theory (Current View) posits periodontal disease progresses in short bursts of exacerbation(active attachment loss), followed by remission with no progressive attachment loss

States of the Periodontium

• The basic states: health, gingivitis, periodontitis
• Health: no BOP, erythema, edema, patient symptoms, attachment loss, or bone loss; JE at CEJ
• Gingivitis: occurs 4-14 days after biofilm accumulation, and causes gingival enlargement
  • There is no apical migration of the JE, and has reversible tissue damage
  • Hemidesmosomes attach to enamel coronal to or at CEJ
  • Bleeding is a sign of disease can be present
• Periodontitis involves apical migration of JE, loss of CT and alveolar bone, resulting in irreversible tissue damage
  • Bleeding is a sign of disease and can be present

Periodontal Disease, Gingivitis, and Periodontitis Described

• Periodontal disease is an overarching term with gingivitis and periodontitis as categories
• Gingivitis: inflammation of gingiva without involvement of periodontal ligament, cementum, or alveolar bone
  • It's initiated by plaque biofilm and reversible with plaque removal, with clinical signs
  • There is no attachment loss, and the JE remains at CEJ
  • Gingival pockets may be present and supragingival fibers damaged, but there is no destruction of PDL or alveolar bone
• Periodontitis: A bacterial infection destroying periodontium parts that leads to irreversible destruction and apical migration of the JE

Gingivitis vs Periodontitis Microscopic Differences

• Gingivitis has JE hemidesmosomes attached to enamel at or coronal to CEJ, extends epithelial ridges (rete pegs) into CT
• Periodontitis has apical migration of JE extending epithelial ridges into CT, thickening of SE extending ridges into CT
  • Periodontal ligament fibers and alveolar bone are destroyed

Alveolar Bone Loss Progression in Periodontitis

• In healthy conditions and with gingivitis, alveolar bone crest is ~2 mm apical to CEJ
• In periodontitis it is located >2 mm apical to the CEJ
• Bone destruction eventually leads to tooth mobility or loss due to insufficient bone support

Attachment Loss

• Attachment loss occurs with the destruction of fibers and alveolar bone
• Bony defects called osseous defects are a deviation from the normal form or contour of bone

Horizontal vs Vertical Bone Loss

• Suprabony/infrabony pockets differ in the base of pocket-to-alveolar crest relationship, and bone destruction type
• Horizontal bone loss (HBL) occurs with suprabony pockets, having even bone loss
  • Inflammation in spreads from gingival connective tissue along blood vessel sheaths into alveolar bone, then PDL
• Vertical bone loss (VBL) occurs with infrabony pockets, having uneven bone loss
  • Inflammation spreads directly from gingival connective tissue into PDL, then alveolar bone

Gingival vs Periodontal Pockets

• Gingival pockets (pseudopockets): gingival enlargement, coronal migration of gingival margin but the JE remains at the CEJ with damaged supragingival fibers
  • There is no destruction of PDL or alveolar bone, and probing depths are >3 mm due to gingival swelling
• Periodontal pockets: apical migration of JE only caused by gingival CT fiber destruction
  • Periodontal ligament fibers and alveolar bone are destroyed
  • The pockets do not necessarily indicate active disease

Periodontal Health: Definition

• Periodontal health is a state that allows normal function and avoids consequences due to current or past disease, and has no BOP, erythema, edema, patient symptoms, attachment loss, and bone loss.

Intact vs Reduced Periodontium

• Periodontal health can occur on an intact or reduced periodontium
• An intact periodontium has no loss of periodontal tissue while a reduced periodontium has pre-existing loss of tissue, but no current bone loss

Gingival Disease Subdivisions

• The AAP's major gingival disease subdivisions are plaque-induced gingivitis (biofilm) and non-plaque induced gingival diseases

Non-Plaque Induced Gingival Diseases Causes

• Non-plaque induced gingival diseases stem from genetics, infections, inflammation, reactive processes, neoplasms, endocrine, metabolic, traumatic lesions, and gingival pigmentation

Plaque-Induced vs Non-Plaque Induced Gingival Diseases Etiology

• Dental plaque-induced gingival diseases are initiated by plaque biofilm while non-plaque induced are not caused by plaque biofilm
  • Non-plaque induced are not resolved after plaque removal and have other etiologies

Plaque-Induced Gingivitis Clinical Signs

• Clinical signs include redness, tenderness, swollen margins, bleeding upon probing, increased crevicular fluid, reversibility damage, no attachment loss, and no radiographic changes to bone height or character
• Color and contour changes in the gingiva can occur
• The position of the gingival margin can be displaced but inflammation can be localized or generalized inflammation distribution can be papillary, marginal, or diffuse

Systemic Factors and Gingival Inflammation

• Systemic conditions can modify the host response;
  • For Example fluctuations in sex hormones (puberty, menstrual cycle, pregnancy) cause bright red, soft gingival with a local pyogenic granuloma
  • Hyperglycemia exaggerates gingival inflammatory response, and reduction leads to needing less insulin
  • Blood dyscrasias such as leukemia can cause enlarged, spongy tissues with oral changes and ascorbic acid deficiency (vitamin C) can lead to scurvy

Clinical and Radiographic Features of Periodontitis

• Clinical features may include swelling, redness, gingival bleeding, periodontal pockets, pus, bad breath, tooth mobility, attachment loss, and absence of pain
• Clinical appearance is not always reliable to indicate severity
• Radiographic features include bone loss and possible furcation involvement (detected with a Nabers probe)

Periodontitis Progression

• Untreated periodontitis usually advances slowly; rapid destruction is limited
• Tissue destruction doesn't evenly affect all teeth and can be site-specific

Periodontitis: Recurrent and Refractory

• Recurrent periodontitis: return of previously arrested destructive periodontitis often with noncompliant care
• Refractory periodontitis: continued attachment loss despite continuous care

Clinical Attachment Level (CAL)

• Clinical Attachment Level (CAL) is a measurement of periodontal support around the tooth, from the CEJ to base of sulcus or pocket (JE)
• It is a more accurate measurement than probing depth due to gingival margin changes and distinguishes gingivitis from periodontitis

Periodontitis: Severity, Complexity, and Staging

• Staging indicates the severity/extent of disease at presentation
• Staging classifies extent based on current tissue damage; assessment of complexity relates to pocket depths, bone loss, furcation, tooth mobility, and rehabilitation

Determining Periodontitis: Grading of a Patient

• Grading estimates periodontitis progression
• Considers radiographic bone loss (RBL) or CAL over time, % bone loss/age
• Risk factor analysis considers smoking and diabetes

Recurrent & Refractory Descriptors Pertaining to Periodontitis

• Recurrent includes return of destructive periodontitis that had been previously arrested that indicates somebody with prior disease is always at risk for recurrence
• Refractory exhibits continued attachment loss, despite care & maintenance but ideology is unknown

Acute Necrotizing Diseases Clinical Presentation

• Acute bacterial infections of the periodontium with tissue necrosis are acute
• Distinguishing features include necrosis, ulceration, pseudomembrane, and punched-out papillae

Necrotizing Diseases: NUG

• For necrotizing ulcerative gingivitis (NUG):
  • Manifests as infection that is limited to gingival tissues
  • Characterized by oral pain, punched out cratered papillae, tissue necrosis, gray white pseudomembrane formation, lymphadenopathy and extreme bad breath
  • Connected to smoking, poor nutrition, recent stress and impaired host response

NUP

• For necrotizing ulcerative periodontitis (NUP):
  • They are similar characterisitcs to NUG, but they aaffect deeper structures of the periodontium like bone
  • Those can be accompanied by the formation of bone sequestrum

Features that Define Periodontal NUP

• Features include necrosis, pseudomembrane, and punched out papillae but affects deeper portion and can be accompanied by bone sequestrum
• Complex treatment often requires referral to a periodontitis and potential medical consultation as well

Types of Periodontium Abscesses including Gingival Abscesses

• Gingival abscess: Is a painful swelling at the free gingival margin that presents as a smooth surface
• Periodontal abscess: often occurring in deep pockets and furcation sites and may be sensitive to percussion
• Periconal abscess: Infection within the tissue surrounding crown of partially erupted tooth and symptoms may include exudate, lymphadenopathy, trismus

Possible Causes of of the Three Types of Periodontium Abscesses

• Gingival abscess typically caused by a foreign body being lodged in the gingival sulcus
• Periodontal abscess can be caused by a foreign trapped in a deep pocket can can be caused by incomplete calculus removal
• Pericoronal Abscess is due to an infection surrounding the partially erupted tooth

Treatment for the Abscess Types Listed

• Gingival Abscess Treatment starts by etiologic agent removal and post operative instructions as well
• Periodontal abscess treatment starts with drainage of the abscess, adjusments, and antibiotic use if needed

Clinical Situations that May Result in Pericoronal Abscess and How to Trat

• Pericoronal abscess results in localized infection surrounding the crown and often comes with the mandibular third molar and treatment should include oral rinses, removal, and antibiotics if needed

Primary Herpetic Gingivostomatitis

• The symptoms include fever, nausea, and malaise, vesicles then break to create yellow ulcers and red halo, risk of dehydration so infection is still considered dangerous

Types of Abscesses Radiographic Appearances

• Gingival abscess features painful edema at gingival margin or papillae
• Periodontal abscess localized within tissues exhibits exudate, maybe painful to probing but also radiographically show bone loss
• Pericoronal abscess features localized infection in crown may or may not have radiographic finding so

Hygienist Treatment and Role of and How

• The role can be the removal of etiologic agent for abscesses, in addition gentle removal of the pseudomembrane can be considered, but not to forget NUP referral is needed

Risk Factors

• A risk factor is any characteristic or exposure associated with the increased likelihood of developing disease or injury
• Examples: systemic risks like smoking, diabetes, genetic susceptibility and local risks like tooth crowding causing xerostomia

Non Modifiable Factors of Patients

• Non modifiable factors are those that can be easily changed such as plaque accumulation of diabetes
• Non modifiable, genetic susceptibility, age, history of periodontitis

Biologic Equilibrium and Homeostasis

• Biologic equilibrium is the state in balance, periodontal health example balance between host and oral microflim

Factors That Disturb Balance in Health

• The balance between health and disruption of potential
• Local risk
• Systemic risk
• Accumulation of bacteria Genetic Factors

PRAs and Dental Treatment Assessment

• PRA is the procedure to assess risk and can classify between the two groups
• Asses the factors need to identify patients and control
• help patients understand

Gram Positive vs Gram Negative

• Gram positive - Single cell membrane and they hold color dye and hold color
• Gram negative - Double cell membrane and they hold no dye

What Is A Bio Film?

• Extracellular slime layer that adheres rapidly to a surfaces

Steps Bioflim Formation

• Attaches to pellicle or the tooth surface
• Permanent connection where attracts microbes
• Self productive where bacterial secrete poly matrix
• Micro colonies where bloom occurs and channels
• And dispersion where surfaces are colonized

Timeline

• Form with in a week
• Form with in 3-12 weeks

How Do They Protect?

Blocking a physical Matrix acts on the cell

• Mutual protections from environmental and cell surface and defense
• hibernation some species have enzymes to degrade effects

Symbiosis vs Dysbiosis

• Mutual human in the oral
• Micro Imbalance
• If this continue relationships trigger response

How Do Routes of Transmission Occur?

• Direct or direct contact
• Vertical sharing salvia between and care givers mainly with children through parents

Horizontal and health associate

• horizontal with the same generation
• Health Gram pos

Supra plaque on change with gingival

• Supra begins change
• Deep sulcus
• Bacteria extension
• Progression of periodontitis
• A nature bioflim is not a single bacteria
• Microorganisms

Early Collonizer with Early and intermediate

• Early = positive
• Intermediate = negative
• Lead colonize -Gram Array are negative

Timeline With Bacterial Formation

• 6 - 12 then produce initial cell array

Three Attatch With Most Virgin and Bacteria

• Densely with Tooth Attatched Bio flim
• Epithelial
• Loose Attached Bflim -Free loath -Research

Role three bacteria periodontitis

• Accumulation triggers host
• Nonspeftifc bacteria triggers response
• Local triggers responses

How Does Bio flim Survive With Against?

• Bio flim resist antibotics and mechanism of survival

How Is Periodontal Assessed and Document?

• List all assessments for components that'll then be evaluated
• Evaluate and the tissue for general localized areas
• Probing depths with a periodic probe with specific areas
• Checking wall gently
• Exudate apply finger pressure to check for yellow
• Margin determine the cell.

Differentate and how ?

• Is measurement Fixed point And helps
• Clinical dependence with position with ginval

Importance Disease Classifcation System and What Are They?

Classification system helps health

• Accurately
• Form Diagnosis
• Predicts
• Connect Starting conver

List and Explain Risk Factors

• Factors teeth/gingival dryness Can modify system Smoking Med Hlv/Leukimia

Explain Severity and complexity in role Staging Periodintitis and and what is it?

The extent with the ammount that occur

• Clinical attachment, Radiolohraphs

List Criteria Used to Determine

. Grades can estimate that the primary rate by assessing the progression

• Grade: Indirect with bone oss and it with the The patient with the Assess

• If a patient health then don't fill them They are only done with present

Then you decide

• Staging of
• Then grading. Determine the likelihood with radio.

Where It Begins

They is

Free groove, which the attach

What's

A v shape

• Inter dental what fills space Attach

• And the soft tissue

What it is?

• No health red or loss!
• Or firm!

Function of Each Tissue.

• Gingival: Provides for protetcrion
• What support that maintain tooth
• Surrounds And bone
• In the health

What is They form

• What is a PDL for the bone??