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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