lecture 01еn periodontium _v08

© V.Nicolaiciuc * Lecture_01ЕN_Periodontium _V08 1

Lecture №1

PERIODONTIUM. GENERAL NOTION. ANATOMIC AND PHYSIOLOGIC PECULIARITIES OF PERIODONTAL TISSUES. CLASSIFICATION OF PERIODONTAL DISEASES.

Periodontal disease is widely distributed among the population of the earth. Early manifestations of periodontal disease of inflammatory nature are recorded in age from 10 to 20 years,

80% of children suffer from gingivitis. Severe destructive changes in the periodontium, involving in the process of bone most frequently detected in

patients older than 40 years.Epidemiological research indicate a high prevalence of inflammatory periodontal changes from 80-100%.

At the same time dominated the inflammatory form - gingivitis, periodontitis. About 90% of cases of catarrhal gingivitis. Periodontoz is about 4-5% of all periodontal diseases.

Periodontal disease is an adverse effect on the function of digestion, psycho-emotional environment, reduce the resistance of the organism, leading to sensibilization of the organism.

Periodontium - a complex of tissues surrounding the tooth, having a genetic and functional similarity: Periodont Alveolar bone The gingiva with the periosteum Tooth tissue

Fig. Tissues of Periodontium

Gingiva is an integral part of periodontium. Gingiva can be divided into two part:

free gingival; The attached gingival.


Fig. The Gingival Tissues

Fig. Gingival Tissue of the Palate

On the palate, the lingual gingiva is directly continuous with the keratinized masticatory mucosa of the gingiva.

Fig. Boundaries of the GingivaThere are: Alveolar; Marginal gingiva;


The marginal gingiva is located in the cervical area of the tooth, its boundary is the level of alveolar bone. A separate part of it is the interdentally papilla. It is free.

Alveolar gingiva is a part of gingiva cover the alveolar bone. It is attached.On the border of marginal (free) and attached (alveolar) gingiva is gingival sulcus.Gingiva consist of: In fact mucosa EpitheliumGingiva has no submucosal layer and connected to periosteum of the alveolar process of the jaw. The epithelium of the gingiva - multilayer flat. It consists of a basal layer, and a similar spike layer. In 50% of the epithelium keratinizing, forming a granular layer. It contains keratohyalin grains. If there is no keratinizing epithelium - this layer is absent.

In 40% of cases (normal) observed in the parakeratosis epithelium - superficial cell layer of compacted spike layer from the mechanical impact.

Fig. The components of orthokeratinized stratified squamous epithelium. The changes in the keratinocytes associated with differentiation as they move towards the surface are represented. The non-

keratinocyte or clear cell population, comprising Langerhans cells, melanocytes, lymphocytes, and Merkel cells, is also shown. These appearances are characteristic of masticatory mucosa, such as the attached gingiva or hard palate. In non-keratinized stratified squamous epithelia, typical of the lining

mucosa (e.g. alveolar mucosa, buccal mucosa), the changes seen as cells move towards the surface are less marked. The granular cell and keratinized layers are replaced by the intermediate and surface layers

and the keratinocyte nuclei are retained throughout the full thickness of the epithelium.

The epithelium of the gingiva has a high mitotic activity of cells (contains a large amount of RNA).

Fig. The regions of the gingival epithelium


Fig. The apical portion of the junctional epithelium. The basement membrane separates the junctional epithelium from the gingival connective tissue and then, at its most apical extent, near the amelo-

cemental junction, it is reflected upwards on to the enamel surface. The epithelial cells, which themselves secrete important components of the basement membrane, are attached to it by hemi-desmosomes.

Fig. The coronal portion of the junctional epithelium. Attachment to the tooth surface occurs in the same way as in the apical portion. Keratinocytes are shed from the junctional epithelium into the bottom of the gingival crevice and migrating neutrophils are also seen in this region, even in states of perfect gingival health. The keratinocyte population of the junctional epithelium is sustained by cell division in the lower part of the junctional epithelium, and there is a continuous movement of cells upwards into the gingival sulcus. The cells in the junctional epithelium are orientated parallel to the tooth surface and have large

intercellular spaces.

Fig. The fibre types present in the gingiva, which together form a Arm fibrous cuff around the neck of the tooth. On Figs shows the fibres seen on the buccal aspect (lingual and palatal aspects are essentially

similar).

Fig. This Fig shows the gingival fibers in the inter dental area.

This indicates a high level of metabolic and regenerative processes in the gingiva.In normal epithelial cells do not contain glycogen.


When it accumulates in inflammatory cells similar spike layer of gingiva (disturbed keratinization of the epithelium). Between the epithelial cells are glikozamino-glycans-cementing substance have protective effect when

influents bacteria and toxins.

Fig. Healthy Periodontium

In the area of free (marginal) gingiva are anatomical formations: Clinical gingival sulcus (gingival toothgap, gingival crevice); Circular ligament of teeth; Tops of the walls of the alveoli and inter-root septum.

Clinical gingival sulcus ( slit) - located between healthy gingiva and the tooth surface (it is deeper anatomical sulcus).

Fig. Gingival Sulcus. A periodontal probe inserted into the Gingival Sulcus, space between the free gingiva and the tooth.

Her depth of 1-2mm. It is lined with stratified squamous epithelium in the connective-over (not keratinization).

Communication between the epithelium and the enamel is physical - chemical nature, adhesion of cells is carried out by micro-molecular gingival fluid.


Fig. Periodontal Ligament (anchored of periodontal ligament fibers)

Epithelium of the sulcus and the connecting epithelium - protect the periodontal tissues by pathogens factors. Violation of the connective tissue due to enamel epithelium leads to the formation of periodontal pockets.

In the gingival sulcus is fluid the amount up to 0.06 mg.Gingival fluid is produce as result of permeability blood vessels in the area of the epithelial attachment.The composition of gingival fluid:

blood serum; variety of enzymes; protein fractions; trace elements (microelements).

The reaction of gingival fluid (PH) is neutral.

Gingival sulcus: Is a strategic area in her maintains initial symptoms of periodontal disease. Connective tissue epithelium is a barrier, protecting all of periodontal tissue (from all external influence) It is penetrates and goes through it, the movement on both sides of biologically active substances From the mouth of the dental plaque diffuse centripetally - toxins, enzymes, antigens, chemotacsis factors. There is a movement of dead epithelial cells in the gingival sulcus and replacing them with new ones (the

epithelium is updated) In the connection epithelium there is a movement of vascular cells, polymorph nuclear leukocytes (they

are in a healthy gingiva). At the time of microbial attack, they stay out of the deep layers of parodontium in connective tissue in

the periodontal, and through him to the gingival sulcus - one million in one minute - This is a protective barrier.

In the process of the life connecting epithelium is constantly being updated.

Gingival sulcus and the gingival fluid perform a barrier function for the underlying periodontal tissues. The integrity of the sulcus, and the connection epithelium protects the periodontal tissues of bacteria and their toxins and other irritants.

Inflammation of gingiva begin to from sulcular epithelium and the epithelial attachment. In this study the quantitative and qualitative changes in the gingival fluid is of great importance in the diagnosis of early pre-clinical manifestations of inflammation and can get information about periodontal changes.The mucous membrane of the gingiva is represented by: loose connective tissue (papillary layer under the epithelium); A dense connective tissue (in the deep parts of the gingiva).

The mucous membrane of the gingiva consists of: Basic (intercellular) substance fibrous structures cellular elements


There are blood and lymph vessels. Located neural elements. Intercellular substance is represented by glycosaminoglycans and glycoproteins.

The important role of regulation - vascular tissue permeability and the maintenance of barrier properties belongs to system of the hyaluronic acid – hyaluronidase.When the hyaluronidase is activity begin the depolymerization of hyaluronic acid and increases the permeability of ground substance and loss of protective function against bacteria, toxins and other agents.The cellular element of connective gingiva tissue - fibroblasts, even less mast and plasmatic cells.Fibroblasts - synthesize collagen and mukoproteidy containing hyaluronic acid and hondroetinsulfat.Mast cells - produce heparin and histamine.Lymphoid and plasma cells - produce antibodies (immune response)The basis of the mucous membrane of the gingiva - are bundles of collagen fibers.Elastic fibers - are found in the papillary part of the gingiva.Argyrophilic fibers - form under epithelial membrane.In the gingiva a lot of arterioles, capillaries, venules - support metabolism in tissues.Nerve endings - in the form of loops, tangles, Meissner corpuscles.

Periodontium - a tissue complex , located between the walls of the alveoli of a compact plate and cement of the root.The width of periodontal sulcus ranged from 0.15 to 0.35 mm.

The fibrous structure of periodontal: Collagen fibers Oxy-talanov fiber Elastic fibers argyrophilic fibers

The cellular composition of periodontium: Osteo-blasts Cementoblasts

They are responsible for building bone and cementRound ligament of the tooth form: Collagen fibers; Elastic fibers; Argyrophilic fibers.

Dento-gingiva fibers connecting adjacent sections of the gingiva with the neck of the tooth.Circular fibers surround the teeth and distribute pressure (chewing) on a large area.Interdentalis fibers connecting with buccal and lingual side of inter dental papillae and thus protect them from the variation in horizontal stress.Circular-tooth fibers coming from the circular ligament of the tooth to the tooth and keep it under loads acting at an angleCross over inter-circular ligaments - go from one circle to another ligament in the inter dental spaces around the teeth and form a figure eight-shaped plexus. They fix their teeth, and redistribute the pressure of chewing.Alveolar bone:60 - 70% of mineral salts and small amounts of water.30 - 40% of organic matter (the main component is collagen).

Bone tissue consists of: Compact; Spongy substance.

The compact substance is located on the oral and vestibular surfaces of the tooth root and is composed of bony plates, and osteons. Between the layers of compact substance is located spongy substance. It is formed by interwoven bone beams. Medullary cavity of bone are made of fat marrow. The compact substance is permeated by channels through which periodontal penetrate blood vessels and nerves.The functioning of the bone tissue occurs through the activity of cells: osteoblasts, osteocytes and osteoclasts. The normal process of bone formation and resorption are balanced. It depends on the activity of parathyroid hormone. Tirokalotsitonin and fluorine plays a role in the formation and bone resorption.


Activity of acid and alkaline phosphatase observed in the younger age in the periosteum, osteons and processes of odontoblasts.

On the x-ray plate of cortical bone - is seen as a clear-cut strip on the edge of the alveoli. The structure of cancellous bone looped.

Blood supply

Periodontal tissues are supplied with arterial blood from the external carotid artery and its branches - the maxillary artery.The teeth and surrounding tissues of the upper jaw receive blood from the upper alveolar artery and the upper anterior alveolar artery.

Fig. Vascular Supply to the Periodontium

On the lower jaw - blood supply mainly from the lower alveolar artery. Each of the inter-alveolar septum leaves of the several branches– inter-alveolar artery (giving branches to the periodontal and root cement).The vertical branch through the periosteum penetrate the gingiva. From the dental arteries are branches at periodontal and alveoli. Between the branches of dental inter-alveolar arteries and vessels extraossal system are anastamozy.The structural formation of periodontal microcircular channel of periodontium: Arteries; Arterioles; Precapillaries; Capillaries; Postcapillary; Venules; Venous; Arteriolovenular anastamozy.


Fig. Branch Arteries. Supply blood to the teeth and periodontium

Fig. Nerve Supply to Periodontium (Lateral View). The nerve supply to the periodontium is derived from the branches of the trigeminal nerve.

Capillaries and the surrounding connective tissue along with lymph supply power to the periodontal tissues and the protective function.Permeability and capillary resistance is of great importance to the development of pathological webs in the periodontium.Innervation of periodontal carried out by plexus zone of second and third branches of the trigeminal nerve.In the deep of alveoli the bundles of nerve fibers can be divided into two parts: one goes to the pulp, the other on the surface of the periodontium is parallel to the main nerve trunk of the pulp. Periodontium has a large number of nerve receptors and is a vast reflexogenic zone.


Lymphatic vessels

In the periodontium has an extensive network of lymphatic vessels, they provide for its functioning, especially in diseases. When inflammation of the lymphatic vessels are dilated and contribute to the removal of material from the interstitial lesion.

Periodontal Functions

There are the following features of periodontal: Barrier; Trophic; Reflex regulation of masticatory pressure; Plastic; Amortization.

Barrier function - the ability of the gingival epithelium to the keratinization (with inflammation, it is broken):1. The features of structure and function of the gingival sulcus.2. A large number of areas and features of bundles of collagen fibers3. The presence of plasma cells, mast play an important role in the production of antibodies4. Turgor gingiva5. Condition of glycosaminoglycans in connective tissue of periodontal structures6. Antibacterial function of saliva due to the presence in it of biologically active substances like lysozyme, inhibin, etc.

Trophic function caused by a widely ramified network of capillaries and nerve receptors.

Reflex regulation of masticatory pressure - due to being in periodontal numerous nerve endings (receptors).

Plastic function - is to constantly re-establishment of its tissues, which were lost during physiological and pathological processes. It is realization by сementoblasts and fibroblasts. Plays a role in trans capillary nutrition.

Amortization function – holds by collagen and elastic fibres. Periodontal ligament protects the tissue of the tooth alveoli, blood vessels and nerves of periodontium of injury.

CLASSIFICATION OF PERIODONTAL DISEASE

It is currently used classification of periodontal diseases, adopted in1983:

Gingivitis - inflammation of the gingiva caused by the impact of local and general factors and flowing without breaking the dentogingival connection.Form: catarrhal, ulcerative, hypertrophic.Severity : mild, moderate, severe.Currents: acute, chronic, exacerbate.Prevalence : localized, generalized.

Periodontitis - inflammation of the periodontal tissues, characterized by progressive destruction of periodontal and alveolar bone jaw.Severity : mild, moderate, severe.Currents: acute, chronic, exacerbation, remission.Prevalence : localized, generalized.


Periodontal disease - Periodontal dystrophic damage.Severity : mild, moderate, severe.Currents: chronic, in remission.Prevalence : generalized.

Idiopathic disease with progressive periodontal tissue lysis ( parodontoliz) – Papiem-Lefevre syndrome, neutropenia, agammaglobulinemia, uncompensated diabetes, etc. Parodontomy - tumors and tumor-like illness (epulis, fibromatosis, etc.).

Recently, isolated rapidly progressive form during periodontitis : Localized juvenile periodontitis. juvenile periodontitis. Generalized juvenile periodontitis. Rapidly progressive post-juvenile periodontitis. Rapidly progressive periodontitis adults.

CLASSIFICATION OF PERIODONTAL DISEASE:1. Gengivitis

Childhood gingivitis Chronic (adult) gingivitis Acute necrotizing ulcerative gingivitis

2. Periodontitis Adult periodontitis

High risk Normal risk Refractory periodontitis

Early onset periodontitis Localized juvenile periodontitis Rapidly progressive periodontitis Pre-pubertal periodontitis

Localized Generalized

3. Periodontal disease associated with systemic factors

CLASSIFICATION OF PERIODONTAL DISEASES AND CONDIFIONS:

Gingival Deseases: Plaque-induced gingival diseases; Non-plaque-induced gingival lesions.

Chronic Periodontitis: Localized; Generalized.

Aggressive Periodontitis: Localized; Generalized.

Periodontitis as a Manifestation of Systemic Diseases:

Necrotizing Periodontal Diseases: Necrotizing Ulcerative Gingivitis (NUG); Necrotizing Ulcerative Periodontitis (NUP).

Abscesses of the Periodontium: Gingival Abscess; Periapical Abscess;


Pericoronal Abscess.Periodontitis Associated with Endodontic Lesions:

Endodontic-Periodontal Lesion; Periodontal-Endodontic Lesion; Combined Lesion.

Developmental or Acquired Deformities and Conditions: Localized tooth-related factors that predispose to plaque induced gingival diseases of

periodontitis; Mucogingival deformities and conditions around teeth; Mucogingival deformities and conditions of edentulous ridges; Occlusal trauma.

CLASSIFICATION OF THE VARIOUS FORMS OF PERIODONTITIS:

Classification Forms of periodontitisAAP (American Academy of Periodontologe) World Workshop in Clinical Periodontics,1989

Adult Periodontitis

Early-Onset Periodontitis(May be Prepubertal, Juvenile, or Rapidly Progressive )Periodontitis, Associated with Systemic DiseasesNecrotizing Ulcerative PeriodontitisRefractory Periodontitis

European Workshop in Periodontology, 1993 Adult PeriodontitisEarly-Onset PeriodontitisNecrotizing Periodontitis

AAP International Workshop for Classification of Periodontal Diseases,1999

Chronic Periodontitis

Aggressive Periodontitis Periodontitis as a Manifestation of Systemic Diseases

lecture 01еn periodontium _v08

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