Periodontology

GINGIVA PDL
Biologic Width:
distance from alveolar crest to junctional Connects cementum to the bone
epithelium (JE) Functions:
at least 2mm required to place a resto Supportive
Attached Gingiva Sensory - detects pressure and pain
Keratinized Nutritive
Usually where pigmentation is found Formative - builds and maintains cementum
Sulcular Epithelium (Sulcus) and bone (cementoblast + osteoblasts)
Where probe is inserted Resorptive - remodels bone in response to
Non-Keratinized and Permeable (allowing pressure
Gingival Crevicular Fluid (GCF) to flow PDL in innervated and vascularized (nerves
Gingival Crevicular Fluid and blood vessels)
Always present - more active when there is Fibroblasts are most prominent cell in PDLs
disease Terminal ends of PDL are “Sharpey Fibers”.
Junctional Epithelium Embedded in the bone and the cementum
Also non-keratinized (therefore more d
susceptible to disease) PDL Fiber Bundles:
Alveolar Crest Fibers
Gingival Fibers: resists horizontal movement
Composed mainly of collagen and elastic Horizontal Fibers
Circular resists horizontal pressure
circle tooth like a ring Oblique Fibers
supports free gingiva resists vertical pressure
Dentogingival largest
cementum to gingiva most significant group
attaches gingiva to tooth Apical Fibers
Periostogingival resists forces that pull tooth out of
periosteum to gingiva socket
attached gingiva to bone Interradicular Fibers
Intercircular stabilizes tooth in socket
encircles several teeth only present if there are multiple roots
Interpapillary
supports papilla
Transgingival
links adjacent teeth in an arch
Transseptal
connects adjacent teeth to another
Important for orthodontics

CEMENTUM BONE
Thin layer of hydroxyapatite crystals (calcium The presence of bone is dependent on the
and phosphate) presence of teeth
Trauma and infection may thicken cementum No teeth = bone resorbs
NON-vascularized and NOT innervated (no Alveolar Bone Proper/Cribriform Plate
blood supply and no nerves) Tooth socket lining
Gets nutrients from PDL Lamina Dura on Radiograph
2 types: Alveolus
cellular - near apex Hole in the bone that contains the root
a-cellular - more coronal Cortical Bone:
Cementum Enamel Relationship: Compact hard bone
Use “OMG” Rule Lines outside wall on facial and lingual sides
O - Cementum Overlaps Enamel Thicker in mandible
60% of the time Cancellous Bone
M - Cementum Meets Enamel Spongy Bone
30% of the time Porous Bone that fills interior or alveolar
G - Cementum has small Gap between process
Enamel Alveolar Crest
10% of the time Most coronal portion of the alveolar process
In health - 2mm apical to CEJ
First to be destroyed in disease
Periosteum
Layer of CT covering bone
 gingivitis
GINGIVITIS
GINGIVA
Pocket Depth: 4+ mm due to swelling, 10% or more bleeding index
Gingivitis is observed 4-14 days after plaque accumulation into the sulcus
Gingiva Consistency: edematous (swollen), or fibrotic (chronic gingivitis)
Gingivitis can either be plaque induced or a manifestation of systemic diseases - can be
returned to health with successful treatment (reversible)
Plaque-Induced Gingivitis is considered the most common form of periodontal disease

Plaque-Induced Gingivitis
Most common form of periodontal disease - REVERSIBLE
Can be modified by: sex hormones (puberty, menstrual, pregnancy and birth control)
Can be exacerbated by systemic conditions:
Hyperglycemia (gingivitis is commonly found in children with poorly controlled
Type 1 Diabetes)
Leukemia - clotting factor deficiency
Smoking - few signs of inflammation, gingivitis can be masked
Defective restorations (plaque accumulation)
Malnutrition - scurvy with Vit C Deficiency
Hyposalivation - can make plaque control more difficult

NON-Plaque Induced Gingivitis

Genetic
Specific infection of bacterial origin: (ANUG/ANUP)
Specific infection of viral origin:
Coxsackie (Hand-Foot-and-Mouth)
HPV
Herpetic Gingivostomatitis
Specific infection of fungal origin
Candidiasis (most common clinical characteristic of gingival candida is redness of
attached gingiva with granular surface)
Inflammatory and Immune Conditions
Contact allergy
Erythema Multiforme
Pemphigus Vulgaris
Neoplasms
Leukoplakia and Erythroplakia
Squamous Cell Carcinoma
20% of IO carcinoma and occur most often in mandibular premolar/molar region
Endocrine/Nutritional/Metabolic
Scurvy (VIt. C deficiency) - sore and bleeding gingiva

Necrotizing Ulcerative Gingivitis (NUG)

tissue necrosis (death) - limited to the gingiva only
Stress related and seen most often in young adults (college students, and soldiers on
the front lines)
ANUG and ANUP are most commonly seen in those who are immunocompromised
(HIV/AIDS, Uncontrolled Diabetes, Chemotherapy, etc.)
Characteristics of ANUG:
Crater-Like “Punched Out” interdental papilla
Pseudomembrane (yellow/white/gray tissue sloughing)
Strong Fetid Odor
Pain, Fever, Swollen Lymph Nodes
Involves a diminished host response to spirochetes: Treponema, Selemonas,
Fusobacterium, and P. Intermedia
Treatment for ANUG:
Removal of pseudomembrane and limited debridement - provide OHI
Rebook 1-2 days later for periodontal treatment
Systemic antibiotics may be needed for systemic issues (fever, swollen lymph
nodes)
Local antibiotics are contraindicated**
 GINGIVA Random Note:
Inadequate attached gingiva = less than 1mm

No bone loss still Bone loss present

Increase in GCF Redness visible clinically
Progress depends Irreversible
No signs visible clinically BOP
on host response
JE forms rete pegs
 periodontitis
PERIODONTITIS
Defined as a loss of clinical attachment due to destruction of the periodontium
It is a Multi-Factorial Inflammatory Disease
NOT reversible - “once a perio patient, always a perio patient”
The appearance of gingival disease is not a reliable indicator of the presence, severity or
extent of the disease
Signs:
Color: Dark Blue-Purple, or Red
Can also be pink in chronic periodontitis (due to production of new collagen fibers)
The fact that it can be pink is why appearance is not a reliable indicator
Consistency: edematous (spongy), or smooth and shiny (no stippling)
In chronic conditions - it can appear leathery.
No knife-edge
Interdental papilla may be blunted
Bleeding: BOP and/or supperation
Pockets:
4mm+ due to inflammation and apical migration of JE
NO PAIN
Bone: permanently destroyed, mobility may be present.

Bone Defects:
Horizontal bone loss is the most common - produced a suprabony pocket
Vertical bone loss produced an infrabony pocket
Interradicular defects are between the roots of multi-rooted teeth

Treatment outcomes of periodontitis can either be:

Periodontal Disease Stability
Periodontitis has been successfully treated, disease signs do not appear worsen
despite the presence of a reduced periodontium
*note - you CAN have gingivitis on a reduced periodontium
Periodontal Disease Remission/Control
Period in the disease when symptoms become less severe but are not fully resolved
Acute Necrotizing Ulcerative Periodontitis (ANUP)
Similar to ANUG - but involved loss of attachment and alveolar bone
Rapid loss of bone and soft tissue
Signs (pseudomembrane, fever, cratered papilla) are the same as ANUG
Treatment is the same
Systemic Diseases Related to Periodontitis:
Down Syndrome: predisposed to periodontitis due to intrinsic abnomalities
Papillon-Lefevre Syndrome: severe inflammation and rapid bone loss (early tooth loss)
Congenital Neutropenia: severe perio is common (high risk for uclers & tooth loss)
Systemic Lupus: Increased prevalence of gingival inflammation + perio
HIV: increased risk for ANUG/ANUP, Kaposi Sarcoma, oral candidiasis
Arthritis: Increased risk for attachment loss
Staging And Grading:
Staging - Severity + Complexity - extent and distribution
Grading- Rate of Progression. -smoking and diabetes automatically puts them in Gr.B
You should always assume Grade B unless you have specific evidence to shift toward Grade A or Grade C
 Periodontology

IMPLANTS
Peri-Implant Health
No signs of inflammation or bleeding.
Peri-Implant Mucositis
Essentially gingivitis around an implant - is reversible
BOP + signs of inflammation (no bone loss)
Strong evidence that peri-implant mucositis is primarily plaque induced
Peri-Implantitis
Plaque associated condition around implants
Inflammation and loss of supporting bone
Associated with poor plaque control and patients with a history of periodontitis
Hard and Soft Tissue Implant Site Deficiencies
Bone loss is common due to normal healing following tooth loss
Sometimes, larger areas of bone loss can occur at sites where there has been severe
periodontal infections, extraction trauma, or infections.

RISK FACTORS FOR PERIODONTAL DISEASE

Tobacco: one of the most significant
inhibits collagen production and slows healing following therapy
Can appear health (disease is masked) due to impaired vascularization
Genetics
Despite good OSC, some people are more likely to get periodontal disease
Occlusal Trauma
Damages periodontium directly
Primary Occlusal Trauma
excessive force on a healthy periodontium
Secondary Occlusal Trauma
normal or excessive on an unhealthy periodontium/damaged periodontium
Impingement on biological width:
Restorations placed to close to alveolar crest can destroy periodontium
Remember - must be placed at least 2mm away
Age:
Elder patients have the highest rate of periodontal disease
Age itself does not cause periodontal disease
Diet, lack of dexterity and medications contribute to periodontal disease
Obesity and Poor Nutrition:
lack of nutrients can compromise immune system
Vit. C - important for wound healing and collagen production
deficiency = scurvy = sore and bleeding gingiva
Protein - important for repair
Stress:
makes it hard for the body to fight infections
Systemic Diseases:
Medications for treatment can cause:
Xerostomia
Gingival Enlargement (phenytoin - antiseizure, cyclosporine - antirejection,
nidifipine - calcium channel blocker)
Diabetes Mellitus:
increases glucose in GCF which provides nutrition for bacteria
Patients often have: delayed wound healing, increase risk for infection, lowered
sensation, burning mouth, parotid gland enlagement
Cancer Treatment:
Side effects often include: xerostomia, mucositis, infection, dysgeusia, and
necrosis of the jaw (BRONJ)
Hormonal Changes:
higher levels of hormones can increase sensitivty to things, such as plaque.
Pregnancy: pyogenic granuloma - associated with P. Intermedia
Birth Control: can increase risk for plaque-induced gingivitis
Menopause: xerostomia, burning mouth, dysgeusia (altered taste)
 Periodontology

CLINICAL ASSESSMENT NOTES

Embrasure Spaces:
Type 1: interdental papilla fills space
Can also be called a “closed” or “complete”
Regular floss
Type 2: Interdental papilla does not fill space
Tufted floss, interdental brush, toothpick
Type 3:Interdental papilla is missing
Can also be called an “open” embrasure
Tufted floss, interdental brush, end-tuft brush, toothpick
Probing Depths
Gingival Margin - in health - is 1-2mm coronal to CEJ
Probing pressure should be between 10-20 grams
A PSEUDOPOCKET: aka as a gingival pocket, is caused by inflammation without
attachment loss
Suprabony pocket:
caused by horizontal bone loss and more common.
Base of pocket is above the alveolar crest
Infrabony pocket:
Caused by vertical bone loss, less common.
Base of pocket is below the alveolar crest.
Can occur in many forms:
1-Wall Defect: worst prognosis
2-Wall Defect:
3-Wall Defect: still has 1 wall affected, 3 walls remaining, Best prognosis
Recession
Root surface is more susceptible to caries, sensitivity and abrasion
Bleeding On Probing (BOP)
If inflammation is present, BOP is expected due to ulcerated pocket
Absence of disease - usually means stability however is not a guarantee of absence
Suppuration (Pus)
Sign of active infection
Fistula - opening for draining of infection - can be a small bulge on gingiva
Tooth Mobility:
Use 2 blunt ends of instrument handles
Class 1: Less than 1mm horizontal movement (facial-lingual)
Class 2: 1-2mm horizontal movement (facial-lingual)
Class 3: >2mm horizontal movement OR vertical movement (into socket)
Furcation:
Naber’s Probe is used to measure furcation
MANDIBULAR MOLARS - usually bifurcated
MAXILLARY MOLARS - usually trifurcated
Maxillary First Premolars (14/24) can be bifurcated
Plaque and Calculus:
Plaque is the primary etiology for periodontal disease
Plaque is measured (total # of surfaces with plaque / total # of surfaces) x100
Every calculus surface is covered with plaque because its porous
Calculating Clinical Attachment Loss (CAL):
More accurate for determining periodontal support than probing
First - measure gingival margin to CEJ
Second - Probing Depth
Probing Depth (+/-) Gingival Margin to CEJ = CAL

Dehiscence and Fenestration

Dehiscence - oval, root-exposed defect from CEJ apically
3 features: recession, alveolar bone loss, and root exposure.
Fenestration- “window” of bone loss on facial or lingual
 Periodontology

RADIOGRAPHIC ASSESSMENT NOTES

Bone Levels
Normal bone levels is 1-2mm apical to CEJ
The alveolar crest is the first area to be involved in bone destruction.
Can look blunted or “Fuzzy”
The lamina dura - a sheet of bone lying next to PDLs - appears radiopaque and thick
will appear thin in disease
Horizontal bone loss is the most common (suprabony)
A radiograph with High KVp produces a longer scale of contract (many gray shades)
and is prefered to detect periodontal diseases
Abscess
Periodontal Abscess:
Peri-aplcal Abscess: at the apex of the teeth, caution: dont mix up for mental foramen
PDL
Thin, radiolucent (black) line that surrounds the root
Widened PDL can indicate trauma or infection
Ankylosis and Impaction
Ankylosis:
fusion of tooth to alveolar bone
Occurs more common in primary teeth
Creates a “hollow” sound when tapped
Impaction:
Third molars are most commonly affected (wisdom teeth)
Limitations of Radiographs
By the time bone loss is seen on xrays, disease has progressed out of early-stages
Do not reveal soft tissue defects or tooth mobility

PERIODONTAL TREATMENT
Goal of Treatment:
Stop disease progression, reduce inflammation/bleeding/plaque/probing depth
Alter or eliminate risk factors (ex: smoking)
Assessment Phase / Preliminary Therapy:
To collect data
Prognosis:
predication of duration, course and outcome
Classification Of Prognosis:
Very Good: <25% attachment loss
Good: <25% of attachment loss and/or CL1 Furcation
Fair: 25-50% of attachment loss and/or CL1 Furcation
Poor: 50-70% attachment loss and/or CLII or CLIII Furcation or CL2 Mobility
Hopeless: >75% attachment loss, CL3 mobility
Non-Surgical Periodontal Therapy (NSPT)
Includes all non surgical treatment (education, debridement, antibiotics, chx, etc)
Oral prophylaxis is only preformed for those with a healthy periodontium
6mm+ pockets cannot be successfully treated with NSPT alone
Re-Evaluation
Preformed 4-6 weeks after completion of therapy
For non-responsive sites:
Check for residual calculus
Determine other factors (systemic, smoking, etc)
Periostat:
Systemic Delivery of a 20mg cap of doxycycline hyclate
Arestin:
Local Delivery of microspheres of minocycline into pocket
Bacteriostatic for up to 14 days
No brushing for 12hrs and no flossing for 10 days.
Atridox:
Local delivery of Doxycycline gel into pocket
No brushing/flossing for 7 days
Periochip:
Chx Chip inserted into pocket
No flossing for 10 days
Tetracycline HCL Fibers:
Tetracycline soaked cord put into pocket
Perio-Maintenance:
3mo: perio patient with poor OSC
4 mo: perio patient with adequate OSC
6mo-1 year: good OSC and stabilized oral health
 Periodontology

PERIODONTAL SURGERIES
Used when NSPT is not effective
Periodontal Flap Surgery
Gums are lifted away from tooth to allow for removal of deposits on roots
Also allows for repositioning and shaping of periodontium.
Gingiva is replaced in an apical position to reduce pocket depth
Gum/Connective Tissue Graft
Tissue is harvested from another side, usually the palate and placed on desired area
Can be used to even out gum line and reduce sensitivity
Gingival Curettage
Removed soft tissue lining of perio pocket to remove bacteria and diseases tissue
Gingivectomy
Pocket reduction by removing part of soft tissue pockets
Commonly used for gingival hyperplasia
Gingivoplasty
Reshape gingiva to obtain better contours
Ex: eliminate cratered tissue from ANUG/ANUP
Osseous Surgery
Reshaping bone for better contour
Bone Graft
Replaced lost structures
Types:
Autograft: from the patients own body
Allograft: from human cadavers
Alloplastic: synthetic material
Xenograft: from another species, usually a cow (bovine)``
Guided Tissue Regeneration
special fabric sewn around tooth to cover crater in bone, then gum is sewn on top of
fabric. used for infrabony pockets (vertical bone loss)
Crown Lengthening
Excess gum and bone tissue are reshaped to expose more of the natural tooth
Can be done to make a restorative possible (access decay below gingiva)
Implants
Artificial device used to replace a missing tooth
Types:
Endosteal: in the bone; Most common type of implant.
osteointegration - fusion of bone to implant. #1 sign of implant failure: mobility
Subperiosteal: on the bone; Used for those with minimal bone height and cant wear
dentures.
Sinus Lift
Sinus floor is raised to allow sufficient bone for implant placement
Increases both quantity and quality
More commonly preformed in maxillary posteriors
POST-SURGERY CARE
Blood is normal. Do not forcefully spit on the first day as it may disturb blood clot.
After the first day - rinse with warm water and salt.
Ice can be used to control inflammation.
Periodontal Dressing:
bandage placed over treatment area
Sometimes contains eugenol - calms pulp (could be irritatating)
provides comfort, maintains blood cloth, protects wound
The material itself does not have any wound healing properties
Dressing can be removed in 5-7 days
CHX Rinse: Can be prescribed
High substantivity - can be used for Gram +, Gram -, and fungus.