Notes on Periodontal Disease - MDA Chapter 16

Nutritional Factors affecting Periodontal Disease

  • Poor diet can weaken the immune system and increase susceptibility to periodontal disease, but it does not directly cause it.
  • Nutrition influences:
    • Development, growth, and maintenance of periodontal tissues
    • Disease progression and healing of periodontal tissues and periodontium
  • Very important nutrients for periodontal health:
    • Vitamin C: promotes wound healing
    • Vitamin A, Vitamin D, and Calcium support tissue health and mineralization

Healthy Immune System

  • A healthy immune system sends an arsenal of defense organisms to limit bacterial attack.
  • Leukocytes and plasma proteins invade the site of attack or injury, causing swelling and edema.
  • If the immune system is healthy, this response helps resolve injury and the area heals itself.

Periodontal Disease Overview

  • Periodontal disease is an infection of the periodontium initiated by bacteria within dental plaque biofilm.
  • Gingivitis: if confined to gingival tissues (gums) and without bone loss.
  • Periodontitis: if the infection extends into connective tissue and supporting structures, including bone.
  • Once bone is affected, there is no turning back; bone loss is typically irreversible.

Unhealthy Immune System and Disease Progression

  • When the host is malnourished or immune-compromised, immune response can be dysregulated.
  • Overzealous immune response can occur, sending an overabundance of immune cells to the area.
  • Immune cells release cytokines and other enzymes that can destroy periodontal fibers and stimulate osteoclastic activity, accelerating attachment and bone loss.

Ascorbic Acid-Deficiency Gingivitis

  • Vitamin C deficiency can be associated with gingival inflammation (ascorbic acid-deficiency gingivitis).

Gingivitis vs Periodontitis

  • Gingivitis: inflammation of gingiva without bone loss.
  • Periodontitis: inflammation with loss of connective tissue attachment and supporting bone.
  • Distinction is clinically important for prognosis and treatment planning.

Mouth-Body Connection

  • Periodontal disease is associated with systemic conditions and diseases, including:
    • Cardiovascular disease
    • Cerebrovascular disease
    • Osteoporosis
    • Periodontal disease
    • Respiratory disease
    • Diabetes
    • Arthritis
    • Preterm birth
  • These associations highlight potential bidirectional or contributory links between oral and systemic health.

Plaque Biofilm and Periodontal Health

  • Plaque biofilm Develops at the gingival third; as colonies mature:
    • It spreads coronally (toward crown) and apically (toward bone).
  • A healthy epithelial lining of the sulcus is essential to prevent periodontal disease.
  • The sulcular epithelium has one of the fastest turnover rates in the body, making it responsive to biofilm challenges.

Epidemiology of Periodontal Disease

  • Periodontal disease is primarily caused by bacterial plaque/biofilm.
  • It results in loss of tissue attachment and bone loss.
  • Prevalence estimates:
    • About 47% of adults over 30 have some form of periodontal disease
    • About 70% of adults over 65 have some form

Infectious Process Involving the Periodontium

  • Periodontium includes:
    • Gingiva (gums)
    • Sulcus
    • Cementum
    • Periodontal ligaments
    • Alveolar bone

Signs and Symptoms of Periodontal Disease

  • Red or swollen gingiva
  • Bleeding gingiva
  • Loose teeth
  • Pain when chewing
  • Pus around the teeth

Classifications of Periodontal Disease (2018 AAP Classification)

  • The American Academy of Periodontology updated classification in 2018 to standardize diagnosis and treatment outcomes.
  • Three major categories:
    1) Gingival Health and diseases
    2) Periodontitis
    3) Other conditions affecting the periodontium
  • Rationale: improves consistency in diagnosis, prognosis, and therapy planning.

Old vs New Classification (Key Flaws of Old System)

  • Old system (Case Types I–IV):
    • Case Type I: Gingivitis
    • Case Type II: Early Periodontitis
    • Case Type III: Moderate Periodontitis
    • Case Type IV: Advanced Periodontitis
  • Flaws in old system:
    • Considerable overlap between categories
    • No gingival disease component explicitly
    • Lacked emphasis on age at onset and rates of progression

New Classification: Three Major Categories of Periodontal Disease

  • 1. Periodontal health and gingival diseases
  • 2. Periodontitis
  • 3. Other conditions affecting the periodontium

1) Periodontal Health and Gingival Diseases

  • Gingivitis causes swollen and bleeding gums but no bone loss.
  • A. Gingivitis caused by biofilm (bacteria):
    • If not removed, biofilm can lead to dental caries, gingivitis, and periodontitis.
  • B. Gingivitis not caused by biofilm (non-plaque-induced):
    • Gingival lesions can result from bacterial, viral, or fungal infections.
    • Not caused by plaque and usually do not resolve after plaque removal.

2) Periodontitis (overview and subtypes)

  • Periodontitis is a serious gum infection that damages soft tissue and bone supporting the teeth.
  • Can occur as a manifestation of systemic disease or in the context of systemic inflammation.
  • May arise due to weakened immune system, chromosomal disorders, connective tissue defects, or certain genetic diseases.
  • Necrotizing periodontal diseases are a distinct rapid-onset form characterized by interdental gingival necrosis, gingival pain, bleeding, and halitosis.

3) Other Conditions Affecting the Periodontium

  • Systemic diseases affecting the periodontium
  • Periodontal abscess or periodontal/endodontic lesions
  • Mucogingival deformities and conditions (e.g., high frenum, tooth malposition, osseous dehiscence)
  • Traumatic occlusal forces
  • Tooth- and prosthesis-related factors

Describing Periodontitis: Staging, Extent, and Progression

  • When describing periodontitis, specify:
    • Stage: based on severity and complexity of management
    • Extent: Localized, Generalized, or Molar/incisor pattern
    • Progression: potential for continued loss and response to therapy

Staging (Summary)

  • Stage 1 (Initial):
    • Pocket probing depth (PPD) ≤ 4 mm
    • Interproximal attachment loss (IAL) 1–2 mm
    • Bone loss: Mostly horizontal; % bone loss ≤ 15%
    • Teeth lost: None
    • Appropriate treatment: Traditional (blind) scaling and root planing (SRP)
  • Stage 2 (Moderate):
    • PPD ≤ 5 mm
    • IAL 4–5 mm
    • Bone loss: Mostly horizontal; % bone loss 15–33%
    • Teeth lost: None
    • Treatment: Repeat SRP; maintainable via non-surgical therapy
  • Stage 3 (Severe):
    • PPD ≥ 6 mm
    • IAL ≥ 5 mm
    • Bone loss: Vertical + horizontal; % bone loss > 33%
    • Teeth lost: Four or fewer
    • Complexity: Increased, may require advanced therapy beyond SRP
  • Stage 4 (Very Severe/Advanced):
    • PPD ≥ 6 mm
    • IAL ≥ 5 mm
    • Bone loss: Vertical + horizontal; % bone loss > 33%
    • Teeth lost: Five or fewer
    • Complexity: Requires advanced rehabilitation and multidisciplinary care (e.g., prosthodontics, implant planning)
  • Management sequencing:
    • Initial stabilization and SRP for Stage I–II
    • Advanced therapy for Stage III–IV
    • Re-evaluation and maintenance programs
  • Timeframes:
    • Re-evaluation and maintenance every 3–6 months (3–6 months typical; 4–6 weeks if returning to Stage I)
    • If remaining at Stage II, continue prophylaxis and risk management

Detailed Periodontal Parameters by Stage (Stage I–IV)

  • Stage I (Initial)
    • Interdental CAL: 1–2 mm
    • Max probing depth: ≤ 4 mm
    • Extent: Localized or generalized; mostly horizontal bone loss
  • Stage II (Moderate)
    • Interdental CAL: 3–4 mm
    • Max probing depth: ≤ 5 mm
    • Extent: Generalized or localized with horizontal bone loss
  • Stage III (Severe)
    • Interdental CAL: ≥5 mm
    • Max probing depth: ≥ 6 mm
    • Complexity: Local; may include vertical bone loss ≥ 3 mm; furcation involvement (Class II or III); moderate ridge defects
  • Stage IV (Advanced)
    • Interdental CAL: ≥5 mm
    • Max probing depth: ≥ 6 mm
    • Complexity: Additional factors such as masticatory dysfunction, secondary occlusal trauma (mobility ≥2), severe ridge defects, bite collapse, pathologic tooth migration, or fewer than 20 remaining teeth (10 opposing pairs)

Implant-Related Periodontal Conditions

  • Baseline clinical parameters help distinguish peri-implant health vs mucositis vs peri-implantitis.
  • Peri-implant mucositis: inflammatory lesion without progressive marginal bone loss.
  • Peri-implantitis: inflammatory process with progressive bone loss around an implant, leading to bone loss and inflammation.
  • Peri-implant soft- and hard-tissue deficiencies: biofilm on implant surfaces and peri-implant tissues drive bone loss and tissue destruction.

Peri-Implant Health, Mucositis, and Peri-Implantitis (Clinical Signals)

  • Absence of inflammation and bleeding/suppuration on probing indicates peri-implant health.
  • Bleeding and/or suppuration on gentle probing, with or without increased probing depths, indicates peri-implant mucositis or peri-implantitis depending on bone loss.
  • Probing depths of ≥6–7 mm with bone loss apical to the coronal portion indicate peri-implantitis.

Periodontal Pockets and Calculus

  • Periodontal pocket is a deepened sulcus due to loss of attachment fibers or bone.
  • Probing depth > 4 mm warrants evaluation for attachment loss.
  • Calculus location:
    • Supragingival: above the gingival margin
    • Subgingival: below the gingival margin
  • Removal of calculus cannot be achieved by brushing alone; it is mineralized plaque and resembles cement on the tooth surface.
  • Effects of calculus:
    • Acts as a persistent irritant to gingival and periodontal tissues
    • Leads to gingival recession and bone loss if untreated

Systemic and Lifestyle Risk Factors

  • Conditions that increase susceptibility to periodontal disease (and vice versa):
    • Heart disease: bacteria may enter the bloodstream contributing to clot formation and cardiac events
    • Respiratory disease: bacteria can alter the respiratory tract lining, increasing pneumonia risk
    • Smoking: greater loss of attachment and bone loss
    • Diabetes: strong risk factor for periodontal disease
    • Stress
    • HIV/AIDS
  • Other systemic conditions are linked to periodontal disease via inflammatory pathways and immune response interactions

Miscellaneous

  • Visuals and figures in the lecture illustrate connections between periodontal health and systemic conditions, and how inflammatory processes contribute to tissue destruction.
  • Note: A humorous slide appears at the end; not essential to study content, but included as a classroom reminder.