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Periodontal Disease Zhang wanli Department of Periodontics Stomatology of Hospital Kunming Medical University •Introduction •The Anatomy and Periodontal Inflammation •Etiology of Periodontal Disease •Gingival Diseases •Periodontitis •Treatment of Periodontal Disease Introduction The left side shows healthy gum( normal sulcus depth). The right side shows periodontal disease( periodontal pocket). Periodontal disease are diseases induced by biofilm (dental plaque) and inflammation of the supporting structures of a tooth. Periodontal disease Gingival diseases Periodontitis Gingival diseases Inflammation that is confined to the gingival tissues. Periodontitis: Inflammation of the supporting structures of the tooth. •80% of American adults suffer from periodontal disease. • 90% of people over age 60 suffer from periodontitis. •In a 1999 study, researchers at the U.S. National institutes of health found that half of Americans over 30 had bleeding gums. The anatomy and periodontal inflammation The tissues that surround and support the teeth are known as the periodontium. It includes: 1. Gingiva 2. Cementum 3. Periodontal ligament 4. Alveolar bone gingiva free gingiva attached gingiva papilla Free gingiva free gingiva Color atlas of dental medicine periodontology The small space between free gingiva and the tooth probing depth< 3mm gingival sulcus One of the earliest signs of gingivitis is bleeding on probing Attached gingiva Attached gingiva Color atlas of dental medicine periodontology Color atlas of dental medicine periodontology interdental papilla Color atlas of dental medicine periodontology It is the most place that periodontal disease happened. microscopic gingiva ginginval epithelium gingvival connective tissue Sulcular Epithelium Junctional Epithelium Oral Epithelium 0.71 to 1.35mm JE Junctional Epithelium JE forms the base of the sulcus and joins the gingiva to the tooth surface ranges from 0.71 to 1.35 mm in length The junctional epithelium and the gingival fibers are considered a functional unit called the dentogingival unit or dentogingival junction. Junctional epithelium is firmly attached to the tooth, forming an epithelial barrier against plaque bacteria. It allows access of gingival fluid, inflammatory cells, and components of the immunologic host defense to the gingival margin. Diagram of junctional epithelium path taken by cells and fluids between the sulcus and the gingival connective tissue Arrows indicate CT, connective tissue JE, junctional epithelium OE, oral epithelium S,gingival sulcus SE, sulcular epithelium Small space---big world!!! biological width • 牙龈(gingiva) dentalgingival fibers, DGF 牙龈的组织学( dentoperiosteal fibers, DPF 牙龈结缔组织 Color atlas of dental medicine periodontology circular fibers, CF transeptal fibers,TF Color atlas of dental medicine periodontology Gingival fibers aid the tissue in withstanding the forces of mastication, and connect the free gingiva with the cementum and the attached gingival. Cementum Cover root surface protect dentin calcified layer of connective tissue The only tissue considered as both a basic part of the tooth and a component of the periodontium. functions •Seal and covers the underlying dentin. •Attaches the periodontal fibers to the tooth. •Compensates for attrition of teeth at their occlusal or incisal surfaces. Over time, teeeth experience wear at their occlusal or incisal furfaces. •Cementum is formed at the apical areas of the roots to compensate for loss of tooth tissue due to attrition. periodontal liganment 0.2mm functions Supportive function—suspends and maintains the tooth in its socket. Sensory function—provides sensory feeling to the tooth, such as pressure and pain sensations. Nutritive function—provides nutrients to the cementum and bone. Formative function—builds and maintains cementum and the alveolar bone of the tooth socket. resorptive function—can remodel the alveolar bone in response to pressure, such as that a during orthodontic treatment(braces). Lamina dura spongy bone cortical bone Color atlas of dental medicine periodontology More bone loss. Tooth migration and loose. periodontal inflammation Gingival changes Pocket formed Bone loss Tooth mobility Loss of attachment is the primary clinical and diagnostic difference between gingivitis and periodontitis. Etiology of Periodontal Diseases • Initiated by bacteria that colonize in the tooth surface and gingival sulcus. • Host response is believed to play an essential role in the breakdown of periodontal tissue. • Local contributor • Systemic contributor Dental Plaque • is a biofilm • contains more than 600 different identified species of bacteria • there is harmless and harmful plaque • salivary pellicle allows the bacteria to adhere to the tooth surface, which begins the formation of plaque Supragingival plaque Only supragingival plaque can be seen by naked eyes. Supragingival plaque acquires nutrition from saliva and host diet in the oral cavity. Subgingival plaque Below the dentogingival junction. Usually divided into a tooth adherent, epithelial adherent and non-adherent zones. Subgingival plaque is comparatively thin. And acquires nutrition only from the host cells and gingival crevicular fluid. There is a characteristic shift in the microbial population from mostly gram positive bacteria in supra-gingival plaque to mostly gram negative bacteria in sub-gingival plaque supra-gingival plaque Streptococcus sanguis Streptococcus mitis Actinomyces naeslundii Actinomyces viscosus sub-gingival plaque Fusobacterium nucleatum Eikenella corrodens Porphyromonas gingivalis Prevotella intermedia Bacterial species associated with different periodontal clinical states Health: Gingivitis Streptococcus sanguis Actinomyces species Porphyromonas gingivalis Streptococcu s mitis Streptococcus species Bacteroides forsythus Veillonella parvula Actinomyeces naeslundii Actinomyces viscosus Rothia dentocariosa Veillonella species Periodontitis Actinobacillus actinomycetemcomitans Treponema dentacola Fusobacterium species Prevotella intermedia Porphyromonas gingivalis Different bacterial species associated with different periodontal clinical states. These specific bacteria cause the periodontal diseases. We called them periopathgenic bacteria or Periodontopathogens. Protective aspects of the host response • • • • Recruitment of neutrophils Production of protective antibodies Release of anti-inflammatory cytokines Also, a number of immune deficiency conditions are associated with enhanced bone loss, such as – Leukocytes adhesion deficiency – Che´diak-Higashi syndrome – Papillon-Lefe`vre – Acquired immune deficiency syndrome Niederman R2000 Destructive aspects of the host response • The role of the host response in periodontal bone loss is complex – There is evidence that a deficient host response increases periodontal destruction • At the same time – Evidence that a too vigorous response leads to periodontal disease Summary Periodontal diseases are initiated by bacteria. The bacteria can exert direct effects on the periodontal tissues by production of enzymes and cytotoxic agents. Agents from dental plaque biofilm are also capable of stimulating host-mediated responses that can lead to destruction of the periodontal tissues. Local Contribution Factors Dental Calculus Anatomic Factors Malalignment Crowding and Malocclusion Faulty Dentistry Traumatic Occlusion Food Impaction Habits Dental Stains Dental Calculus Color atlas of dental medicine periodontology etiologic significance composition and structure formation and mineralization Color atlas of dental medicine periodontology Systemic Contribution Factors It is now becoming widely recognized that certain systemic diseases, such as osteoporosis, diabetes , blood dyscrasias ,neutropenia and immune disorders, may increase the risk for periodontal disease. Decrease resistance of the tissue to infection. Lowered resistance makes periodontal disease more severe and more difficult to treat. The healthy history is used to gather information about conditions that could indicate periodontal disease. Periodontal disease in diabetic patients •increased incidence of periodontal abscesses •increase gingival inflammatory reaction to plaque •increase risk of periodontal disease 2.8 to 3.4 increase •increase severity and rate of destruction. Attachment and bone loss twice as much in diabetic compared with controls Role of Diabetes in Periodontal disease •Reduce vasculature efficiency •PMN defects •Macrophage increase cytokines with P. Gingivalis 24 to 32 times more TNF 4 times increase in PGE and ILI. •Increase collagenase Increase in cross linked collagen by AGEs.Delayed healing and repair. Poor diabetic control and length of time increase risk of periodontal breakdown and increase chances of poor response to therapy. Gingival Disease Chronic Gingivitis Puberty-Associated Gingivitis Leukemia-Associated Gingivitis Drug-induced Gingivitis Hereditary Gingival Fibromatosis Epulis Acute necrotizing ulcerative gingivitis,ANUG Localized Papillary Gingivitis Acute Multiple Gingival Abscesses Case 1 21 years old,female, non smoker Main Complain:My gum bleeding when bite an apple . It last half a year. Health History:No any history with systemic disease or allergy. Radiographic Examination: no bone loss . dignosis ? Chief complaint Bleeding when biting Gingival changes-color size shape texture Bleeding on probing Main problems One of the earliest signs of gingivitis is bleeding on probing. chronic marginal gingivitis (marginal gingivitis)(simple gingivitis) •A diagnosis of gingivitis implies that the actual level of the junctional epithelial attachment has not migrated apically, but is still on the cementoenamel junction. Because? •Gingivitis is a common clinical finding that affects nearly everyone at some time during the life cycle. •Gingivitis can be reversed by the use of primary preventive measures. Because? Clinical Feature •Free gingiva and papilla changes : dark red swelling rolled spongy •Fake pocket •Bleeding on probing Case 2 16 years old female patient chief complaint: I have gum swelling on the front upper and lower teeth and bleeding when brushing since 1/2 year. Health History: There was no history of any drug intake or any systemic illness. Radiographic Examination: no bone loss dignosis ? Chief complaint Gum Swelling Gingival changes-color shape texture papilla overgrowth Bleeding on probing Main problems The age of the patient puberty gingivitis •A diagnosis of puberty gingivitis implies that the level of the junctional epithelial attachment has not migrated apically. • The marked gingival hypertrophy. •The age of the puberty. •The gingival inflammation is caused indirectly by excessive sex hormones in the circulation. •These act as ecological determinants for certain oral anaerobic bacteria (e.g., Prevotella intermedia) which become more numerous in plaque and induce gingival inflammation which can sometimes be acute.. Clinical Feature •Free gingiva and papilla changes : dark red swelling rolled spongy •Fake pocket •Bleeding on probing •Lower plaque scores(OH) 26 years old female patient Chief complaint: I have gum swelling all mouth and difficult to eating for 1 month. Health History: she fainted at home a week before and got some infusion in the hospital. She also had slight fever and loss of appetite. No doing systemic health check before. dignosis ? Chief complaint Gum Swelling Gingival changes-color size texture all gingiva overgrowth very firm Bleeding on slight press Main problems The health history of this patient is not clear. The patient is so weak. Leukemia-Associated Gingival lesion Clinical Feature •Diffused enlargement of gingiva. •The other changes in gingiva: bluish red, shiny surface. •A tendency toward hemorrhage on slight irritation. •Health problem. Periodontitis •Chronic Periodontitis •Aggressive Periodontitis •Periodontitis as a Manifestation of systemic diseases Case 1 40 years old female patient Chief complaint: my teeth loose about more than 1 year and cannot bite food very well. Health History: There was no history of any drug intake or any systemic illness. Dental History: did not to visit dentist for long time. Chief complaint Teeth migration dignosis ? Gingival changes: color, size, texture, shape Bleeding on probing Gum recession Attachment loss Main problems Chronic periodontitis •A diagnosis of periodontitis implies that the junctional epithelium has migrated apically at the cementoenamel junction. •Loss of attachment is the primary clinical and diagnostic difference between gingivitis and periodontitis . •Damage caused by periodontitis usually is not reversible with primary preventive measures; however, these procedures aid in the control of periodontitis . Chinical feature •The changes of gingiva. •Pocket formed, >3mm. •Attachment loss •Pocket bleeding on probing. •Bone resorption. •Tooth mobility and migaration. Case 2 16 years old female patient chief complaint: one of my lower front teeth lost 2 month before and others loose and migration just in half a year. Health History: There was no history of any drug intake or any systemic illness. Dental History: never before has the dental check. dignosis ? Chief complaint Teeth migration and loose No significant gingival inflammation Gingival recession advanced alveolar bone loss Main problems Aggressive periodontitis clinical features •Rapid periodontal tissue destruction extreme bone loss. •No plaque and inflammation, good OH. •Tooth-Specificity upper first molar and upper/lower front teeth •Age : generally before 35 years old. •Family aggregation Treatment of Periodontal Disease •Goals of Periodontal Treatment •Treatment Sequence(treatment plan) Goals of Periodontal Treatment •Removal of the plaque and retention factors. •Recovery of the shape of periodontium. •Recovery the function of periodontium. •Stimulate the regeneration of periodontium. Treatment Sequence(treatment plan) •phase Ⅰ: initial therapy •phase Ⅱ: surgical therapy •phase Ⅲ: restorative and orthodontic therapy •phase Ⅳ: maintenance therapy phase Ⅰ: initial therapy •Explaning the treatment plan to the patient. •SRP(periodontal debridement,) scaling and root planing •Treatment of emergencies •Removal of irritational factors •Extraction of hopeless teeth •Evaluation of systemic health •OHI(oral hygiene instruction) performed OHI Brushing (Bass Technique) The principles of the bass method have two advantages over other, more complex techniques. •Short ,back-and-forth motion is easy to master because it is similar to the scrubbing that most patients normally perform. •Cleaning action is focused on the cervical and interproximal portions of the teeth, where plaque accumulates first. Bristles along the gum line, angled in, where the teeth rise up out of the gums. Use”micromovements”, very small back-and-forth motor control to do these tiny movemnets. Count to five in each position before moving on. Complete several stroksin the same position. Lift the brush and move it to the next three or four teeth. Flossing • First, using 18 inches of dental floss, wrap it lightly around your middle fingers. • Next, firmly grasp the dental floss with your index fingers. • Then, forming a C-shape, carefully slide the floss up and down between your tooth and gum line. • Finally, gently slide the floss in between both sides of your teeth and repeat until finished. Interdental Brush Toothpick Waterpick SRP Scaling • Process by which plaque and calculus are removed from both supra and subgingival tooth surface. Root Planing • Process by which residual embedded calculus and portion of cementum are removed from the root to produce a smooth, hard and clean surface Power and hand instrument Slight perio pocket(4-5mm)responds well to SRP and OHI. phase Ⅱsurgical therapy Performed to provide practitioner with better and faster access to deep periodontal pockets. pockets>6mm, SRP less predictable. •Gingivectomy Gingivaplasty) •Flap Surgery •Crown Lengthening •Regeneration Surgery •Resective Osseous Surgery phase Ⅲ: restorative and orthodontic therapy Ideally, periodontal and prosthetic and orthodontic specialists work together to design restorations and orthodontic treatment that stisfy aesthetic, comfort, and functional needs without compromising future periodontal health. phase Ⅳ: maintenance therapy •Clients with persistent or chronic periodontal problems are in need of professional care at regular intervals. •Prevent recurrence or development of disease affecting dentition & soft tissues. •Periodontal maintenance schedules around every 6 months. References 1.K.H. &E.M.Rateitschak,.Color atlas of dental medicine periodontology 2.Newman MG. , Takei HH., Carranza FA(ed). Carranza’s Clinical periodontology. 8th ed 3.Periodontology 2000,Vol.34,2004,22-33 4.The Journal of Contemporary Dental practic, Volume 1, No.3, Summer Issue,2000 5. The Journal of Contemporary Dental Practice, Volume 5,No. 3, August 15, 2004 6. Periodontology 2000, Vol. 43, 2007,267-277