PERIODONTAL PERIODONTAL DISEASEDISEASE

PERIODONTAL DISEASEPERIODONTAL DISEASEIs a result of accumulation of dental plaque Is a result of accumulation of dental plaque at the marginal gingiva leading to at the marginal gingiva leading to inflammation of the periodontal tissueinflammation of the periodontal tissue

Prevalent in most human populations Prevalent in most human populations premature tooth premature tooth loss in severely affected individualsloss in severely affected individuals

gingivitisgingivitisPeriodontal diseasePeriodontal disease- AcuteAcute periodontitisperiodontitis- ChronicChronic

Most cases Most cases chronic condition chronic condition

The Normal PeriodontiumThe Normal Periodontium GingivalGingival Periodontal LigamentPeriodontal Ligament Alveolar BoneAlveolar Bone CementumCementum

The function : to attach the teeth into jawsThe function : to attach the teeth into jaws and support them effectivelyand support them effectively during masticatory functionduring masticatory function

Healthy PeriodontiumHealthy Periodontium

0 - 3 mm sulcus depthNo suppurationNo bleeding

The fundamental elements of the The fundamental elements of the normal periodontiumnormal periodontium

The components of the coronal part The components of the coronal part of the normal periodontiumof the normal periodontium

Gingival : - Gingival : - protects the underlying connective tissue protects the underlying connective tissue during masticationduring mastication - the junctional epithelium attaches the- the junctional epithelium attaches the epithelium lining the mouth to the teeth.epithelium lining the mouth to the teeth.

Periodontal Ligament :Periodontal Ligament : fibers inserted into bonefibers inserted into boneand cementumand cementum

Alveolar Bone : Alveolar Bone : the part of the mandible andthe part of the mandible and maxilla which surrounds andmaxilla which surrounds and supports the teeth.supports the teeth.

Cementum : Cementum : anchors the periodontal ligament fibersanchors the periodontal ligament fibers

to the surfaces of the tooth.to the surfaces of the tooth.

AETIOLOGY OF PERIODONTAL AETIOLOGY OF PERIODONTAL DISEASEDISEASE

Primary factors : bacterial plaques; Primary factors : bacterial plaques; anaerob.anaerob. Secondary factors (modify the disease) :Secondary factors (modify the disease) :

- Locally : plaque traps, lack of saliva,- Locally : plaque traps, lack of saliva,occlusal traumaocclusal trauma- Systemic : infections, hormonal, drug-- Systemic : infections, hormonal, drug- induced, haemotologycal,induced, haemotologycal, nutritional, genetic.nutritional, genetic.

Local Secondary FactorsLocal Secondary Factors mechanical plaque traps mechanical plaque traps promoting promoting accumulation of specific siteaccumulation of specific site

CalculusCalculus Carious CavitiesCarious Cavities Overhanging Margins of RestorationsOverhanging Margins of Restorations Partial denturesPartial dentures Anatomic VariationsAnatomic Variations CrowdingCrowding Mal OcclusionsMal Occlusions Persistent mouth breathing Persistent mouth breathing lack of saliva lack of saliva

drying in the anterior regionsdrying in the anterior regions hyperplastic hyperplastic gingivitis gingivitis plaque accumulation plaque accumulation

Systemic Secondary FactorsSystemic Secondary Factorsa.a. Conditions which cause gingival hyperplasticConditions which cause gingival hyperplastic

PregnancyPregnancy increase progesterone secretion increase progesterone secretion alteration alteration in gingival vasculature and inflammatory response :in gingival vasculature and inflammatory response :

- pregnancy gingivitis- pregnancy gingivitis- pregnancy epulis- pregnancy epulis((pyogenic granuloma pyogenic granuloma of of

pregnancy)pregnancy) PubertyPuberty Contraceptive pillContraceptive pill Anticonvulsant drug phenytoinAnticonvulsant drug phenytoin Immunosuppressive drug cyclosporine AImmunosuppressive drug cyclosporine A Calcium channel blocker nifedipine Calcium channel blocker nifedipine

pregnancypregnancy

b.b. Defects in defenses resulting in Defects in defenses resulting in accelerated periodontal breakdownaccelerated periodontal breakdown

Insulin dependent diabetes mellitusInsulin dependent diabetes mellitus increased periodontal breakdownincreased periodontal breakdown susceptibility to periodontal abscesssusceptibility to periodontal abscess due to impaired neutrophil functiondue to impaired neutrophil function

Leukaemia Leukaemia severe destructive periodontitis severe destructive periodontitis associated with neutropeniaassociated with neutropenia

Ascorbic acid deficiencyAscorbic acid deficiency haemmorrhagic gingivitishaemmorrhagic gingivitis increased periodontal destructionincreased periodontal destructionassociated with defective collagen synthesis and associated with defective collagen synthesis and vascular vascular

leukaemia IDDM

GINGIVITIS /GINGIVITIS /CHRONIC GINGIVITISCHRONIC GINGIVITIS

Inflammations of the marginal tissues due to Inflammations of the marginal tissues due to accumulation of dental plaque.accumulation of dental plaque.

RednessRedness SwellingSwelling BleedingBleeding Painless ; may persists unchanged for many Painless ; may persists unchanged for many

yearsyears Fully reversible following treatmentFully reversible following treatment Untreated gingivitis Untreated gingivitis to be a prerequisite for to be a prerequisite for

development of periodontitis development of periodontitis

Plaque Associated Plaque Associated GingivitisGingivitis

Disclosing solution to revealplaque

ANUGANUG(Acute Necrotizing Ulcerative Gingivitis)(Acute Necrotizing Ulcerative Gingivitis)Affect young adults : - poor oral hygieneAffect young adults : - poor oral hygiene

- defecting host response- defecting host responseClinical features :Clinical features :- Severely inflammed gingivaSeverely inflammed gingiva- Necrotic ulcersNecrotic ulcers interdental papillae interdental papillae gingival margins gingival margins- The ulcers are painfull, covered by grayish slough, with The ulcers are painfull, covered by grayish slough, with

‘punched out’ appearance‘punched out’ appearance- Localized, or generalizedLocalized, or generalized- ‘‘foetor oris’foetor oris’- Acute, in absence of treatmentAcute, in absence of treatment may loss for a couple of may loss for a couple of

weeksweeks a chronic gingivitis a chronic gingivitis- Tends to recur unless it is treatedTends to recur unless it is treated destruction of periodontal destruction of periodontal

tissues tissues loss of interdental papillae, ‘gingival craters’ loss of interdental papillae, ‘gingival craters’

Predisposing factors :Predisposing factors :- Pure oral hygienePure oral hygiene- SmokingSmoking- emotional stressemotional stress

Mixed bacterial infection by anaerobic organisms : Mixed bacterial infection by anaerobic organisms : spirochaetes: fusiform : F. nucleatum, spirochaetes: fusiform : F. nucleatum,

Resolves rapidly following short term treatment Resolves rapidly following short term treatment with metronidazolewith metronidazole

Pain and Pain and (spontaneous) (spontaneous) bleedingbleeding

Fetor ex orisFetor ex oris punched out punched out

papillaepapillae Grey pseudo-Grey pseudo-

membranemembrane Fusospirochetal Fusospirochetal

infectioninfection

HIV- associated gingivitis/ linear HIV- associated gingivitis/ linear gingival erythemagingival erythema

It occurs before other opportunistic It occurs before other opportunistic infections, can be an early presenting infections, can be an early presenting symptomsymptom

Un usually erythematous generalized Un usually erythematous generalized marginal gingivitismarginal gingivitis

Affecting wide band of both the free and Affecting wide band of both the free and attached gingivaattached gingiva

HIV- associated gingivitis/ linear HIV- associated gingivitis/ linear gingival erythemagingival erythema

PeriodontitisPeriodontitis Defined as plaque-induced inflammation of periodontal tissues Defined as plaque-induced inflammation of periodontal tissues

which has resulted in:which has resulted in: - destruction of the periodontal ligament- destruction of the periodontal ligament - loss of crestal alveolar bone- loss of crestal alveolar bone - apical migration of ephitelial attachment - apical migration of ephitelial attachment (junctional epithelium)/ loss of attachment(junctional epithelium)/ loss of attachmentClinical features : Clinical features : - inflammation of marginal gingivainflammation of marginal gingiva- Loss of attachmentLoss of attachment- Pocket formationPocket formation- Radiographicaly : loss of alveolar boneRadiographicaly : loss of alveolar bone- PainlessPainless- Adequate treatment result in resolution of inflammation, reduction in Adequate treatment result in resolution of inflammation, reduction in

pocket depth, but the tissue destruction in periodontitis is pocket depth, but the tissue destruction in periodontitis is irreversibleirreversible

Adult periodontitis (chronic periodontitis)Adult periodontitis (chronic periodontitis) - seen in adult population- seen in adult population - acute exacerbation - acute exacerbation lateral periodontal lateral periodontal abscess : pus, swelling, painabscess : pus, swelling, pain

Early onset periodontitis :Early onset periodontitis : - in young people, onset and rapid progression- in young people, onset and rapid progression - localized juvenile periodontitis- localized juvenile periodontitis rapidly progressive periodontiitisrapidly progressive periodontiitis prepubertal periodontitisprepubertal periodontitis

Generalized Severely Advanced Generalized Severely Advanced Chronic PeriodontitisChronic Periodontitis

The stages of the diseaseThe stages of the disease Swollen, reddened Swollen, reddened

gingiva, bleeding on gingiva, bleeding on probingprobing

Increased crevicular fluid Increased crevicular fluid flowflow

Increased numbers of Increased numbers of neutrophil in junctional neutrophil in junctional epithelium and gingival epithelium and gingival crevicecrevice

Vascularity increasesVascularity increases Perivascular collagen Perivascular collagen

lossloss

The connective tissue The connective tissue infiltrate becomes infiltrate becomes dominated by : dominated by : lymphocites, lymphocites, macrophagemacrophage

Cell damage, Cell damage, collagen losscollagen loss

Establish lesion (chronic marginal Establish lesion (chronic marginal gingivitis)gingivitis)

More marked edema More marked edema and reddening of and reddening of gingival margin and gingival margin and interdental papillaeinterdental papillae

Gingival crevice Gingival crevice becomes deepened becomes deepened due to gingival due to gingival swelling, no loss of swelling, no loss of attachmentattachment

The advanced lesion (destructive The advanced lesion (destructive periodontitis)periodontitis)

True pocket formationTrue pocket formation Loss of connective Loss of connective

tissue attachmenttissue attachment Loss of alveolar boneLoss of alveolar bone

Tissue Damage and disease Tissue Damage and disease progressionprogression

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