overview of diseases of the periodontium chpt 3

3 basic states of the periodontium

• health

• gingivitis

• periodontitis

healthy periodontium

• pink tissues

• firm

• no bleeding

• healthy sulcus

• alveolar bone intact

• PDL intact

• supragingival fibers intact

• JE coronal to CEJ

gingivitis

• red tissues

• swollen

• JE at CEJ

• supragingival fiber destruction

• alveolar bone intact

• PDL intact

periodontitis

• red or purplish

• swollen or fibrotic (leathery)

• bleeding

• JE on cementum

• supragingival fiber destruction

• alveolar bone destruction

• PDL destruction

periodontium in health

color

pink, may be pigmented, tissues resilient

periodontium in health

gingival margin

scalloped, located above CEJ

periodontium in health

interdental papillae

firm, in embrasure spaces, apical to contact area

periodontium in health

bleeding

none

periodontium in health

probing depths

1-3 mm

periodontium in health

JE location

firmly attached by hemidesmosomes to enamel slightly above CEJ

periodontium in health
epithelial ridges

none

periodontium in health

supragingival bundles

intact

periodontium in health

crest of alveolar bone

intact; located 2-3 mm apical to base of JE

periodontium in health

PDL fibers

intact; stretching between wall of socket and cementum

in health, the probe will

penetrate into the junctional epithelium

in periodontal pockets, the probe will

penetrate into the connective tissue attachment

onset of gingivitis

can occur 4-14 days after plaque biofilm accumulates in the sulcus

acute gingivitis

• lasts a short period of time

• has fluid in the gingival connective tissue that results in swollen gingiva

chronic gingivitis

• can last for months or years

• body tries to repair damage by forming new collagen fibers in the connective tissue

• excess collagen fibers leads to enlarged and fibrotic (leathery) gingival tissues

• excess collagen fibers conceal redness caused by increased blood flow, making them appear less red

gingivitis definition

a type of periodontal disease characterized by changes in color, contour and consistency of gingival tissues

gingivitis tissue enlargement/ damage/ duration

• may be caused by swelling (acute) or fibrosis (chronic)

• gingival margin covers more of the crown due to swelling

• results in deeper pocket depths; aka pseudopockets

• depth is over 3 mm due to enlarged gingival tissue

• JE remains at normal position coronal to CEJ

• tissue damage is REVERSIBLE with good home care

• can persist for years without progressing to next stage

• in some cases, a combination of risk factors may result in progression to periodontitis

gingivitis
color of gingiva

red or reddish-blue

• increased blood flow causing gingiva to appear red

• if blood vessels become congested, then bluish color results

gingivitis

margin

swollen and loses knife edge shape

gingivitis

papillae

bulbous and swollen

gingivitis

bleeding

bleeding upon probing

gingivitis

sulcus

greater than 3mm due to swelling of tissues

NO APICAL MIGRATION OF

JE IN GINGIVITIS

gingivitis - microscopic picture

JE

hemidesmosomes still attach to the enamel coronal to the CEJ

gingivitis - microscopic picture

CEJ

JE extends epithelial ridges down into the connective tissue

• this can occur because destruction of the gingival fibers creates space for the growing epithelium

gingivitis - microscopic picture

gingival fibers

damage to supragingival fiber bundles; is reversible

gingivitis - microscopic picture

alveolar bone

no destruction

gingivitis - microscopic picture

PDL fibers

no progression to PDL fibers

gingivitis - microscopic picture

cementum

covering is normal

periodontitis is characterized by

• apical migration of JE

• loss of connective tissue attachment

• loss of alveolar bone

process of tissue destruction

• not continuous

• occurs in intermittent manner

• extended periods of disease inactivity followed by short bursts of destruction

• progresses at different rates throughout mouth

periodontitis definition

permanent tissue destruction

periodontitis

color of gingiva

visible alteration in color, contour and consistency

periodontitis

edematous tissue

bluish or purplish red; smooth and shiny appearacne

periodontitis

fibrotic tissue

light pink with a leathery consistency

periodontitis

gingival margin

may be swollen or fibrotic and lacks knife-edge adaption

periodontitis

position of gingival margin

can vary greatly; may be apical to the CEJ resulting in a portion of the root being visible

periodontitis

interdental papillae

may not fill interdental embrasure space

periodontitis

bleeding

upon probing

periodontitis

suppuration (pus)

may be visible

periodontitis

probing depths

4mm or greater probing depths bc JE is attached at the root surface

periodontitis

pain

lack of pain although probing may cause pain due to ulceration of the pocket epithelium

periodontitis

junctional epithelium

• located on cementum

• as infection progresses, apical portion of the JE moves further down the root

• destruction of the ECM of the gingiva and attached collagen fibers at apical edge of JE

periodontitis

epithelial - connective tissue junction

• JE proliferates and extends epithelial ridges into connective tissue

• sulcular epithelium of pocket wall thickens and extends ridges deep into connective tissue

what indicates periodontitis?

• epithelial ridges

• swollen tissue

• periodontal pockets

• gingival fiber destruction, collagen destruction in connective tissue

• bone and periodontal ligament destruction

CAL (clinical attachment loss)

best measurement for assessing periodontal stability

CAL is used in

the classification of periodontal disease

stages of periodontal disease

gingivitis

plaque inflame the gums and bleed easily

stages of periodontal disease

mild periodontitis

the beginning of bone and tissue loss around the tooth

stages of periodontal disease

moderate periodontitis

more bone and tissue destruction

stages of periodontal disease

severe periodontitis

extensive bone and tissue loss. teeth may become loose

periodontitis

gingival connective tissue

• severe changes

• collagen destruction in the area of inflammation is almost complete

• widespread destruction of supragingival fiber bundles

• continual regeneration of transseptal fiber bundles

• epithelium grows over root surface in areas where the fiber bundles have been destroyed

periodontitis more info

• permanent destruction to alveolar bone

• tooth mobility may be present

• destruction of all or some of the PDL fibers bundles

• cementum in periodontal pocket is exposed to dental plaque biofilm

changes in alveolar bone height

in health and gingivitis

crest of alveolar bone is located approximately 2mm apical to CEJ of the tooth

changes in alveolar bone height

in periodontitis

bone loss can be slight/mild, moderate or severe

horizontal bone loss

• most common type

• fairly even, overall reduction in height of alveolar bone

• alveolar bone is reduced in height, ut the margin of the alveolar crest remains more or less perpendicular to the long axis of the tooth

vertical bone loss

• less common pattern of bone loss

• aka angular bone loss

• uneven reduction in the height of alveolar bone

• resorption progresses more rapidly in the bone next to the root surface

PDL fiber bundles act as an effective barrier to

the spread of inflammation

spread of inflammation path of least resistance

• into alveolar bone

• into periodontal ligament space

bone defects in periodontal disease

• results when bone resorption is in an uneven, oblique direction

• usually affects 1 tooth

• are classified on the basis of # of osseous walls

• defects may have 1, 2 or 3 walls

osseous craters

bowl-shaped defect in the interdental alveolar bone with bone loss nearly equal on the roots of 2 adjacent teeth

• defect affects 2 adjacent root surfaces to a similar extent

• presence of crater causes dental plaque biofilm to collect and makes it difficult to clean

furcation involvement occurs

on a multirooted tooth

bone loss in furcation areas

• periodontal infection invades the area between and around the roots

• results in bone loss between the roots of each teeth

• may be hidden by gingival tissue or clinically visible in mouth

characteristics of periodontal pockets - attachment loss

• destruction of fibers and bone that support the teeth

• destruction spreads apically and laterally

• pocket on different root surfaces of the same tooth can have different depths

• can vary from surface to surface of the tooth

• base of pocket can exhibit very irregular patterns of tissue destruction

disease sites

area of tissue destruction

• may involve a single surface, several surfaces or all surfaces

• inactive and active types

• a probe is used to assess disease

• 6 measurements are recorded for each tooth

inactive disease sites

stable, with attachment level of the JE remaining the same over time

active disease sites

shows continual migration of the JE over time

periodontal pockets

• an area of tissue destruction left by disease process

• a pocket does not necessarily indicate ACTIVE disease

• the majority of pockets in most adult patients with periodontitis are inactive disease sites

what is a gingival pocket?

a deepening of the gingival sulcus as a result of swelling or enlargement of gingival tissue

why are gingival pockets often called false pockets?

“pseudopockets” means false pockets because there is no apical migration of the junctional epithelium

what causes increased probing depth of a gingival pocket?

• detachment of the coronal portion of the JE from the tooth

• increased tissue size due to swelling of tissue

SUPRAbony pockets

from horizontal bone loss

JE is coronal to crest of alveolar bone

INFRAbony pockets

from vertical bone loss

JE is apical to the crest of the alveolar bone

base of the pocket within cratered-out area of bone alongside the root surface

what is epidemiology

the study of health and disease within the total population

the behavioral, environmental and genetic risk factors that influence health and disease

periodontal disease includes both

• gingivitis

• periodontitis

epidemiology of periodontal disease

• a large percentage of the population has periodontal disease

• useful for determining risk factors

• studies also explore the differences in disease patterns

prevalence

refers to the number of all cases (both new and old) of a disease that can identified within a specified population at a given point in time

incidence

is the number of new disease cases in a population that occur over a given period of time

variables associated with periodontal disease

gender

males have a greater prevalence of periodontal disease

variables associated with periodontal disease

race/ ethnicity

black and hispanic males have poorer periodontal health than white males

variables associated with periodontal disease

education

if less than high school education, increase in periodontal disease

variables associated with periodontal disease

socioeconomic status

underdeveloped countries have higher incidence of disease

variables associated with periodontal disease

age

risk increases with age

variables associated with periodontal disease

behavior

tobacco use increases incidence

variables associated with periodontal disease

access to dental care

if limited access, increase in disease

in 2010, 64.7 million (47.2%) americans had some form of periodontitis

• if older than 65, rises to 70.1%

• men have higher rates (56.4% vs. 38.4%)

• smokers 64.2%

• mexican americans 66.7%

• living below federal poverty level 65.4%