LUNES OF HENNE ND YUEN LU APCCA CI OF Dv ee ALEXANDRA ROMAN ANDRADA SOANCA CLINICAL MANUAL OF PERIODONTOLOGY CLUI-NAPOCAMEDI TARA“ HATIEGANU” CLUI-NAPOCA ‘ALEXANDRA ROMAN CLINICAL MANUAL OF PERIODONTOLOGY cof Fei nn a ee “ia tea Test emia, oo rt ne eh Pato rel Si 9 mt 0 OE ‘So stl eb ct ac el sc, Geoyrgne® 2011 SERGE Steet unvenstrant wort matecase- cus ar Maal Unearth ACA Unvestatnde Hels ramode “ka Hater Gy “Rep, Sone} Cpe 13, el nse a0 aee SESS, feu so aeees ‘rec Et oon Reb (prt oe Desgh & ae Pore SRL, ‘ett rearot a ogre Uerstil de Ms Famace els terra open, Mo 3, tte + HO ‘sera ‘Prunreo 1m Rowinaa The authors are indebted to. the folowing Calaorator for eral ear the manus ‘stor comin Gotan ‘st Br Dolls Cone ‘sat Br Adrian PetreSUMMARY ‘UAPTER 1. STRUCTURE OF PERIODONTAL TISSUES [Revol tues ne ps {Dees open ilogeal alsa semen of ie ag "Seon xmas Taboo biwe eros ‘CHAPTER 2, SUBGINGIVAL DENTAL PLAQUE 22.0nltate 23D pln maton 2.Deia slo: ton an compen 2SConpaen ef esl poe ‘Acc cri fr a pret pope 2 eral poe 1996 28a pubes ay Reon (HAPTER 3. BACTERIAL INTERACTIONS IN DENTAL BIOFILM 31 Theda tim enep 12 Tasco fi tie Ieeenes ‘CUAPTER 4 BACTERIAL SPECIFICITY IN PERIODONTAL DISEASE ‘eet tena iat) actnampctoncons Peron eal Tamers 15 Mol connie eta page ‘Gente othrperns 01) peal dese Rewon ‘CHAPTER S PATHOGENIC MECHANISMS INGINGIVITIS Smtr 5.2 mic anya thy a sted pa sss 5S pomeranian psoas Rath ‘Litoupebpal changer ingyen sation Shomer tats " it » 2 2% as 2 ® x M a ° st st a o * a n a 25510s 552. Protagonis 55:4Chomatins Refrncr (CHAPTERS, PATHOGENESIS OF PERIODONTITIS CONDITIONS NEEDED TO BE REUNITIED POR PRODUCING SSTIACHMIENT LOSS. 6 1G 63:Thetae of phox inte aos pero ee {Thera f RANKL RANK-ORG atin sel oe oracton SConion nodes berated e radi tac os Reformer ‘urn 7:7H6 PERIODONTAL EXAMINATION TH EXAMINATION OF THE GINGIVA AND LOCALRISK FACTORS. Piece 13. Ging Theres pce 7Stmaomist ging tes 73.2he chest na hh of he nama ging 75:1Namal sneer he sige. 74Gingliafaration 315 Ginga mai Pct ass of cain 316 Pre Tht apes 11 Free. rca apane 42 ype 4 cali nh ret et 784 Pare epect rele oa ist fos 73. rectal we es eto Refer CHAPTER 8, PERIODONTAL CLINICAL EXAMINATION. CLINICAL, SGASOF AETACHMENT LOSS ‘Peo poke. Tees asec "2Perinonat pede Praca eps 1 3.Gingal sion Thre pce "Ginga reson Pas pecs 1S urease oleae 1. Abarat nba Palo oe aon S a o saases 10 ro ro 10 toe tos nt 12 m2 id id hs Rt 13 126 a Die ypesestivty Befooeer ‘CHAPTER 9. RADIOGRAPHIC EXAMINATION IN PERIODONTICS 9. nea aon ‘2Radnoptl rcs of psa doen 5st eects Refrones ‘CHAPTER 10, MICROBIOLOGIC. MOLECULAR TEST IN ERIODONTICS Th dkertaopeal Sagi sig Gena pecs 102 Mbp ping mts Teena Ws opp samples 103. Clsifee 1032 Niersep mito 103. ideetion oar mesa opr 10 Gone proter 103.4 Checorbardyraon 104.Pabmense chan econ 104 Commer robo ater pave petite Refroces ‘CHAPTER 11, CLASSIFICATION SYSTEM FOR PERIODONTAL, Diseases. GINGIVAL DISEASES Tithe ceo chon fp ee 113.Paqse ost gees 1A canes ie poemeny 1S Dagamae ie 115 .Pomeigond pas 1152 Decpamar ngs i pois SAG oct ethane mime Refeoees ‘CHAPTER 12. CLASSIFICATION OF PERIODONTAL DISEASES, FE Theat cient eases 122.Chrenepraenis 23 Aagesie perce a 2 13 13 be 18 Bo ut i i is as re 1 Iss Iss 160 Ist rr tes ir m ms 4 612.3 Revdonal des scl ih ti ores erences (CHAPTER 1, CLASSIFICATION OF PERIODONTAL DISEASE. SECKOTIZING PERIODONTAL DISEASE. PERIODONTAL ABSCESS. TS Neca te pgs 13 3.Acse eet pape-sonatis Refer Ta Detton nd cent ig neon 142. ad igh nr 142.1 Prensa lg 142.2 Pahogvs fing nogenent 142..Gingal nro n lapse een! 142.4 Magione gad gl nargemer 143 wl gine omen 134Syrome ginal oats Rebrinees DISEASE" GENETIC FACTORS, SMOKING, ORAL HYGIENE AND 1.8 da sa he ene of ome fos pra 12 Gente pobmorpiom 151 inkgor socom comple 154m sce as 152. Thcorcton ten soking and pods 152 Lng of ekg on prado tes 153. Onihypine 14S bark tr paso disse eons 180 ie 18 i" 9 9 95 ais 25 ni 2 Ea Ea Be Bo DISeASE DIABETES MELLITUS. ebaes etn Gone a Tete of pee Testers by is bet ty fees the prot 16SComplsaonr faba elie TeeDabee elt eleven pesos 17 Pool einen! of bec js 1st of pert on des li "ean pans with dabei de practice Ryo, (CHAPTER 17. RISK FACTORS FOR FERIODONTAL DISEASE CARDIOVASCULAR DISEASE TN Gamrl axe 17.1 eatin too prota canbracer dss 1713S platy Bovec erent nd crise ase 172m pouble ri rr peed diese Reece as ns Fn Be a9 a 2 30 23 ae ae 251 I 6 ae a0carrer 1 STRUCTURE OF PERIODONTAL TISSUES. EdactonlobjectvesKoowing the ssctze of the prodatum bps 0 ndersd the cellar and molecular mechanisms asiocted_ with the regzoeraton of periodontal ties. Revealing the wuleble periodontal zone pons he inte of riary a econ revenin of periodotl ses Periodontal anes genera aspects ‘The component af he prion (he cementum, pcodoillipument and gngina) fonction titer to ripport the tot wihin is soeket. The periodontium nga the tooth wth tebe components of th ets boy. ‘The widesread occurence of periodontal sass and the en tht ls ser canbe seed and, sometimes, regener, has generated considerable {ns inthe fists a el replat peridot formation and interme. Its import fo uestnd tt each of he perodotleompoaets Is 2 very sesnze stctue, and these sacral charsctitcs deelly deine ther funaton, Proper fectioning of the peridonim is only achieved trough srl inert interaction eee ts components 1.2.Peiodntiom devlopment “The development of the perodostm osu during the development and formation of eth Thi process stars eatin te embryonic plas when els fom th aes ees marae into the fst Ranchi ach, In tis poston, the earl cet cel orm band of ecomesenhyme beneath the epi ofthe stomodeum (itive ol cv). Afr the wconaited neural rest ells have reached tet lato in he jaw pe, hep ofthe omndeu releses factors which nine epithelia etomesencymalinerctions, These interactions occured; the eomestchyme takes the dominating sole in the fakerevelopment. Following te fermation of dnt lamina, seis of processes are init (bd tgs, exp stage, ell tage wit oot development) resin in the foumition of the tonth and as siroundng parodia tues (Linde et a12003K0, Daring the cape sage, ectorsneymal cells condense in elation tthe eat epithelium forming Pike del papilla which eves rit he data an the pl, and the deal file dat gies es othe pion supporting ise. The dent org be frmatie organ of enamel the dat pois the formative organ of he dentin-plp complex andthe dtl lise the oratve in of he ache apart (Linde et a12003X1). The development ofthe root an the periodontal sppatng sues flows that of he cow. pita cells of he extra nine detl epithelium the del orga) prolate nial deton fing dole yer of cells samed Hetwi's ep roe tenth The odooblnts forming ot dent differentiate om xtomsencyal cells inte deal pupils der ndtv in ence of he ner epi el “The dete contin o form in ap dston producing the amework othe ro, Ding the formation of te root, the period suppring ses ining acl cenestum develo. At the st of dentin formation the ne el of Herwig’ sheath scrteemamelreaed protein, belonging tothe ansogein family, At the end of tis stage, the eptolroot heath booms estate a iru these enero evtomesnchymal cals fom the denial ‘lice Penetate an oot he root mrfice. The etomeserhymal alsin cont with amelogenin diferente into centetobas and start to frm cementam. This cement epesets th orane mati ofthe cementum, The cement eolagen ‘iors ass the fem atchent betwen dentin apd eemeaum (Linde e 12005(1). The reining pars of the peiogoatum are formal by ‘slomesenhytal ll fom the dena fil ater te eametum. Some of them fret into prindontal Solas an form the gament es, while cus tecome othe producing the alveolar boos in which the peiogotal ‘bers ae anchored. ‘The tase components of the dewtowagvl repon achieve ther lal struc characteristics in conjunction with the erin ofthe test. When the eure filly devsope, the amelbl farm tops with cells om the oar cane pti the oad reduced dental epi, The al amin er indices contact with then covers il the tot arto crap. Ste ering loth apecahss the onl eitblum, the cls ofthe ote lye ofthe reds dnt pti and the el of he asl ayer ofthe ol epittim, art 19 mignte feo the undying comocive tse. When the toot has ented i the ol iy, age portions immedi inthe cna ara of the are recovered y uncon epteiam contsnng oly aw layer fel “The cervical region fe ese i ail covered by ameloblasts and outer oe of the ed ral epeliom. Daring the ner pha of tooth roti, cls of the reduced enamel epithelium ae replaced by junctional eptsam, which provide the ace ste the tat nd he gingiva (Linde t 203K) “The ath fren» epee bone. A matron paces aks Pine; he colgen Snes produced around the oth Wa arcebeded it the newly red cementum immelatly apical CEJ, Thse Hes rete towards the coronal orion ofthe bone cot will orm te spears Ses. The Pricpl prion! fies develo ia cojuction with he erin of he oth “The retaton of the olga fe Pals aes consul rng the tat ngtion. When the tooth ha eachad conte in oecson and & functioning Propet, the Stes of pecodoul ligament are wel-ointed (Lindbe et 11203). Detling te sve mestoned proces, smal, is, bsb-lke Ais are det arking om the root cementum and projing ito the periodontal limes! space Te sire ofthe hoe a thi tae, covered by stan, bFrom the surf ofthe bone only «soll umber of ating hin collagen ris a be sen, Late, he mmber so hicks of ves etring the Bone nee tx rate tovanls the ose consstive tebe in the midporion of the evidonal igaest spe. The Ses originating fom the cementu ae stil, sot wile thot etring he tone are longer. In a subsoquest maurtion pas, the es originating fom the cemestum increase and fse inthe pogo lamest space wih the Ses origin rom be colar ane, Whe the oh ropa etches coat in oschison, the priacipl es become ogaizd in bundles and rin contimoly fom the howe 10 the cemeatum (Linde 12008x1), 1.3. Mislagicalvlaerabl clement of the aga casein periodoties"l” ems to begin al ish ate gingiva oth Inerfice, knowing the stutre ofthe tw9 ete is portant. Atte level of nga ooth nrc, prastiions ad patient wil pend mest of he tine for stbishing he dingo, ealzing the estes maintenance o prevention Gingival cos form by an pti ann connective sue ayer (amin propria) (Linde etal 2008X1). ‘The fie gingiva compris ll etl and conective tise structures Iocted coronal to the level of the cemento-namel junction, The epithelium covering the oe gingiva my be diferente at flows: oral epithelium, which fies the oral avy, oral sel pitt which fse the tooth vioot being in cnt with and unctiona epi, which provides the coat twos the gia andthe oe, The microscope aspect of the singhal epthelio The oral gingival itis begin on he ost corona par of marginal ging anes the macogigial junction, The bounéary between th orl epithelium and the dering comesive te has a wavy couse. The conecive tise portions which projet in the epiteism ae ced connective ime papillae ad are sept fom each ter by pti (or eps) (Linde 3.2031). ‘The gingivs comprises s staid squamous epithelium fly atacbed 0 the undeying lamin prop wich ataced eter oslo one ofthe tooth vin peridontal gamer. The cell composing the epi are ernnoyts, whieh are dosed on several yes (Atkinson et White 1952, inde 20092, bus layer (stratum germina). The cele in the baal yer are ‘olindcal or cabo, and are in contact withthe Iaseneat membrane, tat sepa the Gita athe conestive tive. The haa els possess the ily to vide, Cobesion betwen the el i provided by desmosomes, which tue loa between the extopssmie processes of ajcet cells. The “OM” tas ells re pase ino the spines lye bythe new bas el, I aes one oath for aerate o ech the oer etl ure. prick cll ayer (stratum spinsumis famed by a fw kyers of ‘tne Kenting ‘granular cll yer, Once she kertnoytes lave et the basement membrane they can ao lege vide but nanan x capacity fr produto of ersayalin rales In the satu grarlomim eletzon dase keratobyalin bods and castes of ucogen oraninggranles occur circu gingival es, wich are steed othe tothe ma car arizona cin the amin propria atthe el ofthe cee csme juction| Ptansvooer (rnsepa fees, which are Boronia es thar ess hose the tp ofthe venir cet ofthe ierdensl septum, inserting iat the cemeatum oftwo ajacen teeth ‘> demosigival es, which are embeded in the ementum ofthe spe lvcolar ofthe ots projet om the cement out io the fe ging ‘nso the hea, igual and intrroxiol sures, dente fies, whish are embalded inthe cervical spe tvcolar ae ofthe cementum an ran the course spicy over the uccl and lingua bone crt and erie i te tise of te stashed ing (Linde e 12003K0), Pancras, wich rn onthe gia sue a ins no tte shoo rt Psiodnal Soblsts ae pheoopcally difeeat ftom gngial ‘oblast hey mann oc enmetive tue homeostasis ‘The mario he onmetv tise i produced mainly bythe rb. It ‘the nedum in whic he connective sue cell are embeded andi ese forthe msintnance of the nol unton ofthe comeste te. The mia cosine marae the rein arokydee macromolecules ‘The mirscople apt of the sue epithelium ‘The slulr pti the intra prof th pngleptela which ‘soo tached onto the del sree (Sereda et state 199743): ms ‘etal wal of the ulus. Sueur paliam begins athe most coronary a of he jnstions epithelia and end a tei te marginal gingiva‘The ule i «sid pitts presenting the els ayes estond ans, at ts nomkeratnzed, een tbe salut epithelium tna the ora gingival epithelium are cilly soporte by nila amine propria. The siferences i epi expression may be attbuted to inarmation consecutve to the prosnce ofthe subgingival bilin. IF he laatory proces was removed by implementation of suit regimen of or hygiene combine with antiboi coverage (in animal, the ua pti keratrized Nance Bosshard 20069) suse itis oor the scalars more vucable 10 necanice or microbi apeesions The histological aspect of the jimctonal ope THe junctional nih frm «clla around the cervical portion ofthe ot that lows the ceceao-cnmel junction and adheres othe tot sree. The fee srice of this collar onsite he foe af th gingival sles, The juno epitilam lays ri oe since teenie ff periodontal ses fom the oral aviramen, 1s inepriy it thas ssesal for manning beahy ridontiom. Pein dase st in when the srt ofthe jet nie sans to Si an excellent example of how stuctwe deeenines finsion (Nant Rows 2006). ‘The junctional epithelium i « nondifremited, srtfed squamous ihm wi ery igh ate of el nowt sticker near he Bio of the png sles and apr tikes of ew ols it dscends apically ong he oth sure. ‘The wilh ofthe justia epithelium is appoxinely 16 3 celular layers apically and 10 cela yrs coward the crown. The mum wih and length sre 100) and 057 mu, respectively. The apical init ofthe junction epithelium iste CE, In ther words, junctional eitelum is positioned on the tooth row (Naneot Bosshard 2005) nis made up of fattened cel oid in paral the tooth and dvives ‘oma ae of cba el ited may om th tot ce hares on the basement umbrane, Junction epi ells die considebly fom toe of the ri gingival epeliam, Thy contain mre cytoplasm, ro¥gh ‘loplasieretulim anl Golgi Bois. They exhibit ewer toooisments and emosomes, and wider ‘trelar space. These spaces contain PMNS and rmonoeytes (13% of nterceular space) tht pass flo the saben eapesive tissu tough the junctional eitbelum an into the gingival ues. These cells represent the fit ie of defence inthe contol ofthe pepe rico chalenge (Nan et Bosshard 20063). Thee i alo a are formed by PMNs insposed between the plague ad the most cram cls of the jin eit (eplagu ez) “The cll layer icing he oth proves the acta tachent ofthe gingiva to the tooth surice by me of a srctiral complex ell the epilal atch This complex consists of bus amine structure tht i adhere 1 the woth surtce and to which the sopeticilcell yer is otacbed by emideosomes The cpt stachment is a specie extract sarc in which epizal hasomeat membrane costuets have not been immune- dtd in ay signin qn bet which contain nmin collgen VI, and protons, The wih fe eptalatacment 60180 nm (Nance ona 20055) An intr ayer ving ter origin iret Between he eit stachent andthe tot sures this yer i 18 in Width adi considered to ‘be “oho ga” Phe istolgia vudnerabe lemons of he fiona ptm a the cpibliomcooneine thsue inerice i pine, with no projections of the pilin io the convective tisur being sen (Sehoeer et Lingaten 199743); dered rviance towards mechanal aggressions may be »soca wi this hilo fers; the later spaces ae wider compare to those ia the ora Glin, and no rales ae son inthe inertial spaces, thos sensing the ermesity of he junto ptm, (Cindde 91.2003)» decreased resicance towards detachment, even if & sophisticated tachment structure epee (Laren 1980(6), Al he lines! Imanocieesrallas! in the proxy of the juetionl epitiom ichding robin. marx placement for resoratveLecinaues pombeis mabocure, scaling, et be rized wih ee “The junto epithclium Rel in approximately 5 day ater deweucon (sugeal ges) (Strode Ligaen 195730). “The comesive true supporting the junctional eptim is socal eres for tht sporting the ol gingival eiteliom. Even im cially oral ccansanoes, i shows an infantry cel init. The ggival ‘sonnetve tse ace! to the justia els coins an extensive ‘seul pens which allows infamy elo exrvate om this scalar corks gate ars the jnctinal epithelium nto the aga ulus 1A Cementaen “The cen sth a, avascular connective tse hat coal the oats ‘txt and that serves primary to sta te peincipal periodontal Iigament Ses A continous cementum ppsiton was nate (Linde eo 2003), roa macrscope point of view the cementum i more yellawish, mse ull sn “oes” than the emma. The thickness ofthe cementum is 2-50) (102.005 mn) x CE eel and 150-250 aps (Linde 31200341). The rans ceectumetamel tay’ be flows: the cementum cove esl the ramet (60% of the cats), th cementum iin tit contact with the enue (40%) sd the cementum the eel et in ona (1080 ‘Some cement varies have be desert 2» Primary cementum of asa cementum (acer exiasie Are ecu) found on cereal oo tis ofthe rot I develope very sow ds consdered ob asl since the els ht orm tein ea its ure. Acer cemeatum contuins mainly bunlles of Sharpey’'s ives a exisic Fives (ac et Boat 2006) ‘Primary coment isso iportnt pst of he atachnest appara and ‘sonnets the tooth withthe iver tose prope. The potion ofthe psp Aves of the pido lige whic te embeded inthe root cementum and in the aloe bone proper are clled Sbarpey's res (Nancie Bosshard 20095), The deny of Sarpy’ resis appoxinately 30000 Cellar comentom or secondary coment (ela inrice Sire emu) dst song the pil hi of be oot and in aration reas, itisalo produced sa epi ue hat ie eortve cs nd tates. Collagen produced by cementobass (asic collagen bres) an he presse fof cemnobists eaapped ia eamae within the muti they podice (ements) ae the chic fetus of celular aise ie emetum (anc et Bost 200645), The intinsi re stem i orited mare ors alll tothe longa ofthe oot (Linde et 20031), The cellar coment ss ier han th acl pe 3), mit rnd cemontn contin ots extn and iniasic fies as wellascemenoctes. “The sompoion of the cement sens that of bone it contains aout 0% inal an 5% organic matt Typ collage she predominant egaic ‘component, consiuing wp to 90% of th organic mai. Orber collagens ssoced with cementum inde type II and spe XI Amst onclisnous mat roto identified in coment are al found in bone: tone and decinsilptin,detin matrix protea 1, ones, oxen, ‘contin, oseoneci, tems, proteoglycans, and seve grow fos.nan! atric roti may ound Ht presence init 1 very shot ovis repos prosence i ot sonst (Nano et Bosh 20065). |LSPerodontal ligament ‘he perodowalHigament the so, spciized comestive tise sated ‘exwoon the cementum covering the out of the touth and bone foring te socket wal alveoodentalligmen), The wath anges fom 02 tO an (0.28 san riedum vo), Prod gamen is party well adapted 0 pipal function, sipping the tat the sockets and at these ime prmiting them to wind the cosierable orses of mastation. Moreover, the psviodtl ligament ha the eapacy to seta sensory rcpt sees for ‘the proper posting ofthe ows rng mastication andi el reser for ‘ius homeostasis and epaiepenertion (Nanci et Bosh 20063) “The pevodotal ligament is formed by the following consivents: Wel, inclidingosteotans and otocts, Srblts, pti cel et of Malaser, rosoeytes and macrophages, unilfeemined mesenchymal cells and ‘ceneiolas; the extrselblar compartment consists mainly af welled ‘llgen fire bands embeded in an amorphous hakground material. Thee ae several groups of pimp les: alveolar rest les, horizon es, blige flrs an pial irs (Linde et 2003K1). ‘The perianal ligament fibrola are the rncipal cols of he iodo lgament. They ae characterized by ter pid tarover of the ‘llge, are age cll with exemsve cytoplasm coining an abundance of orgnelisamocated with protein sytess and section, They have a we developed etskoletonreftig the functional ema, Ligamet fobast are aligned slong the general dzecon of the Srcunils and extend ‘toplasmie proces ht wraparound them The ellge iso the bundles are contiomualy being rotiodled by the fbrobbsts Nsnc} e Bosthadt 200649. n “The epi coll evs of Malas we remans of Heng shes; bey occu slos to the cementum a a hater of el tat fora epithe network and seem 0 be mote evident inthe Scton aes. They cou be ivoled in periodontal reprgeneton (Nanci t Boar 20069) “The stm cell or andiforented merenchymal coil ae sociated with peridot regenersion, ining cemestum and bone Stem calls ate sncommited eas capable of both slfreewal and ifeemiation ino mil ell ncages, The are ceria types of em cll popaltions tt ae enol fom embryonic ant posite sues Emyonie stm cells ete rived fom mamalan blstacytes and theoreteally hive the ability 10 aerate diiseatiated cll types ring from th hse pr lyers (mesoderm, ‘stodem and endoderm). Eminonc sem cals ae vitally snort, The immoral ature fesyonic ter li eld ott igh expression ofthe uy flamers, which S inpoan fr minting telomere length and rompromal sabi dering cellar division. I contrast, postal stem cells rc tiougt ob au pi, commite precios capable of evelping ito rested number of ell lineages, ‘Onc danas, the periods hs ted capaci fo regen ‘once pions becomes exablisbed, ony thereat intervention as the seit idee repeneton The comple ser of events asocitd with rider regeneration volves erat of lol derived progenitor esi {othe ste whish ca abeguey diferente no peridonaligumeat- Forming cells, minerabformingcemertblats, or boae-frming ostoblss. Researchers ‘etic at could be clase as mesenchymal tem ells devine fom du peridot gament(perodoml ligament sem cell). The prodotal lige sem cls exited the sapciy to snes canageic adherent cll colonies when plated under the same growth condone as dsxibed fe bone marrow sol el, I appears thse els mann the apa of ier aowt pte Beyond 100 popsiatin dublgs before vw senescence i od nd hey ae considered o ave ite lien. The regulation and the rminennce of quesset sem cells eset contol by lal environmen, peng ofthe host esse (Gros eal 20067). Periodontal fires aes by type I and XM collagen. The vast rmjoy of agen fees the prindonal ligament are aranged indefinite And dist ie bis, and tes are ems a penile. ach bundle resemble plied rope Individual strands canbe conti remodeled wile the overall fine mine Ws architetre an fiction, In this way te ee ade ar blot at the contin stres placed on thom. The execs of olgen fie bundles ae embeded in emetum or bone, andthe embeded orton refered to a Sharpey's les. Sharpes Sle i primary cellular ern fly ioral (Nani et Bosshard 2005). hate fires are potent within te period igaent, Ota Hes tetany of mois tt run more o ss verily ftom the emer ie, fring & thoe-inensonsl trancing network that suroun he root terminates inthe ail complex of arteries, eas and Iympaties (Nane et Bossa 200645). ‘The ground sobtnce at significant eft on the oaths bi to withstand eso 17AWeo ‘Theabeolar proses defined athe parts ofthe maxilla nthe marble tha fom an support the sockets ofthe teh, The aol proces develo ia conjunction withthe deslpment and erntion ofthe teu The wal of the seeker ina hy cota one the ste betes the Soke and betwen the compet aw one wal is ecupd by cancellous bone The evel of aol tone sit 1 a ply to CES, The coro, an he eosin pa ofthe locolarboe ical alveolar eet (Linde e12003(1) ‘Te compact bone (alveolar bone prop) which lines the tooth socket appecs in aiogzph os amin dri petted by numerous Votan’ ‘aa trough which bbod vesels,Imphtis, and nerve fre pass om the loco bone to he periodontal ligament. This layer of bone ito which the ini es are ins (Sharpey' ies is sree alle bade one ‘The nde Hone as many ature in common wi te cement ye (Linde 2003, a PERES kage Ae M Anny of te pei, ene ‘ee Lan NPs Cipro sed apo enn so ao Miah 935 ESM Wie i amy dl sy el ts Goes Sr inn MA The gga uc he acc of pein escent Tash “pe Sh Pe ini oi of ee wink tl A Pome ping: wk StH wi? Cit nt an. 0, Nang CY, See mare su in ei ‘nner Pring nea ES ascuarren2 SURGINGIVAL DENTAL PLAQUE Edacatonlebectves Keosledge of subgingival coloiztion and of he vesiy of eel fora would fur the undersaning ofthe etiology of eridon an woul ay te schedule feces heat phases 21.Genera aspects Curent evidence demonstrated thatthe bacteria fring del plague ae the pinay tigi for fperodotldcase, lai experinents hve eons ta accunlation of bacterial plaque on teeth epoducly induces tn indammtory respons in asocitd gingival tissues. Removal of plague lends to the disappearance of the clinical signe of sings iflanmation (Lae et 311965). ‘Te ra rbil community is very complex. About 500600 bacterial taxa fave hoes deleted in samples om the ol ai. a ay given plague sample, 30 or mae bacterl pecis could be detected. Periodontist infection, Periodontal cae ar polymiobi in stare and threo evidence that thy ae owinsos. Te puthogss 15 pur ofa bacterial consorium. The majority of soingval bacterin are ‘omnon colonies However, thre ae ome baci specie hat are fund seldom andor in very low proportion in ek inv and tei ub-ingia resene was sronly cored t periodontal est, ‘As inva ae not equly saceptble to the deste effets of einen eft, iis lta thee ae sme kfc tht modal tbe st response of the pedsposton to pion diese (gents, ses, smoking, es) (Mikel et a.2002)2)- ”(nthe oer hand, an wired periodontal disease increases te rik of veloping some systemic conditions (caroesclar and respiatony disease, emt), The rik fictore inoence the ont and the popession of tions nd mast be ken ito account when herpy approaches ae chosen (Oicbel a. 200232), ‘Actual evidence susie the primary cole of bacteria he etiology of idol eat (Line 1983) 1) Acute periodontal infections, Some eases of wlero-scrtic gingivitis were sucess tried with anibbeapy,wlero-necroispriodonis in Ips was contol wih atisepis orstemi anibiothapy. 2) The relationship Between the plage dass and wings A. postive conelton ws fund between the guuay of plque on dental surfies and plque-indiced gingivitis rm conic igi. 3) The fica of ambos in the trexment of periodontitis, Some sntiiise wore scsi sed the ueatment of LAP (formerly Ielized juvenile peviadonsi, rectory periodontitis or in some CP eases (rmtly ah peridot). 4) Host tome response, Some pions patiets harbour elevated toch ers gaint some priodopahic cei 5) Pathogenicity of deal plague. Pagee bacteria had a puogenic sel when incase in ext-ora s,in animal ©) Animal ses showed the posibiliy of aminsion of perndonopthic bata rom infced nal they one 22.0raL habitat ‘The human Hoy i formed by 10000 bon cells om which 90% ae ‘ctr cls (Daren eal 997K), Some of thse tater colonize the oa vy. Time fsa antomy od el psi eoodions eosbe the development of ferent habia inthe era eavty (Charon & Moston 2005)5). Temporal 28 ‘moieaions, such as exactions, dental erin, dental cares, peidonal Aizome, ee, diy orl contions, vowing the rearangenent a coneraity ctrl composition Difzet ol sies ofr dient copdtins wo bacteria 12 velop. pel desquation cts bacterial elimination; i coma, the sll pits at Sass poet bacteria agsnt removing mechanical forces, thas favouring thei growth. The ifn of phic for sch the, temperature, oxygen oF carbon dixie composion der the bal habitat and repose tthe development of erin bacterial spies, “The prope of te ol bait determine which xpi coli, ‘ow aod prodominte, and retin biome (plaques) with dine species ‘somos in varios habitats ofthe oral ai (rol ries, supa nd sbegngal dental src). Aa ere of « dame hlane imposed by ‘mumeous mobil inact, componest species at + colonization st can ers eave stable over ie, Eaves changes ay led to eurangemen in community struct nl compostin and hereby predispose the host eo dese. 2.2.Dental plague formation. “The del plague bas ben defied ste comsmuny of mio-orgaisns| ‘ound onthe tooth suetice as a biofilm, embed in x max of polymers of salary and tater origin, (ver 300 yeus ago, van Lecuwenbosk observed a vas amy of -ssimacues inhuman det plaque osng is mirscope, Since thes, the ‘ctrlogy ene began to develop (Doel 1958). The microbilogiss have amenpted 1 isolate and carcterize the species ofthe oa avy. The eal Pague is a disint srucure composed by a lnge diversity of bacterial rmorpospes. The dental plague develops on coronal or rook srics of the tual eth on postive“The development of deal plague can be divided ito several arbirary sings The fit tage he asortion of salvar lyme the tooth form the cqred pelle (Charon et Mouton 20034). Within the fin ew Bours 2 pellicle forms on the clan tooth suice, which consiss of poi and fpcoprocns (98%) found inthe sv andcevcuer fi. The thickness ofthe equa pelle is 1p, elite formation provides sures for bacterial sacs ‘The flowing age ite wansport of mis-arganiss to the polymer contd tooth saris. The micoba coaing of fehl cleaned tooth rice occts rpily, The long-range plyico-chemial intracions tetween the nicrobial el sic a the plislecoate tooth ake place. The iaepay of ‘Van der Waal trative frees an ketone repulsion du othe iteration charg moles om the bacterial el and inthe peice produces» wesk wea oft train tht file reversible adhesion. Shortage intrstons ‘volving specie nation between adhesin the mobil sri an the receptor in the squire pels emit in ineversble adhesion (Koknbanier 1991. “The erst clonizers re overwelminglyseeoonel (ost eguemly Siprococens mi, Sospococas oral, Speptocceus goroni), which ‘consttte 47% to 45% of else cells fun daring the Sst 4 ours afer profesional letng Actnompes mp ar sk 2 ety coli. They form tbe loner communi, Many of the eal colonizers are known 10 recognize ‘components of he segue plc, Soptocceus gordon one ofthe carly ‘oonzers ofthe del bifi@ binds 1 ce elineeh proteins forming the soqited pellicle Srepococcas sain nots xy clan Conran is 4 specific cello-ell rectioadhrence hat occurs ecwesn dist bacteria els ad i on of the mst important mechanisms ‘dying ral bate colenizatoa aad desl boi formation. Cell recognition isnot random bt ech xin has « defied st of coggreation ues Fancy, imi esis found on bacteria fifizet gee my recogni the same receptors on other tater. The pincer hacer provide rie reepors fr itn ater atacmest. Congregation may be ina, ner. rm ener (Charo et Mouton 20008). “Tae flowing pase in plage fomition the irene of misrobil pase ives. A complex microbial comma develops within he space of ely fo days andthe secondary colons el 1 be te more pathogenic pies such as Porpromonas ginal, Tamereia forgtha, Treponema denial Prsobrtrn mucosa aod A.ctinompctomcomitas. These later colors crores mumous sitesi that enable atachment to the ater bacterial intabiats of the region, often choosing” panes tht are metahoilly compte (Koni Lamont 201019) “Te coparezation of micr-ceaisns to okendyaacbed bacteria res in an inceseddiversty of the plague micofars. Ina and inte bea ‘oagereption plays an important le plage formation, Many te colonizers, sch a obligate aerobic bee, do sot bind the ooquie pic but ey tached psi ich a Actinomcer Fp aon pp coud ma sore deely on dental suies but tey co erepte with previous colonizing ber sich as Actinompesr icon, Sreprococis mutant, Nesria sp. Siptooccs songs (McBee an der Hoeven 1981X10) ‘Sinpacocens gordon co-agreaes wih eter ar sreptocae! such Sreprooceus orale at can ako etabish itegeericelaonships with “Actinomyces viscous ot Pasoacterum sp. Porporomonar gina adheres 1e Aatnomyees sos, Sepococes gordonii or Treponema denticola (Kokenbrander London 1983)1).Some ol cei sch 8 Sreptacccs salvar, Seproocews mits Prevotlle interme, Actnampces maendi, Porpyromonar gigas possess inbrine (Scrasky et Hfijee 200212), which are ike” sopendi, 28m in deter, playing an ptt le in ace aero Aatnomsces vsconus, one of the most imporantconsitvet of dental gu, possess fimbrite which enbi atra elt ae to Bad su and to other cll, sck as PMN, heatoaeytes and sreoonee (Sorasky et aes 200212. Porploromonas gle can bind to ety coloizrs. The lows five of Popyromona ngs could bind to the surtace of Srprococes oral Fobacterim mcleatum can co-agregt wi many oral bacteriocins replocnsi and amrobic bacteria. Fusobactrin clean is a key ponent of etl bois and eves corr tt ies the te ant ‘ery colonize. Fesabacterimnuclenum o-egreaes with any orl ceria sch as Porphyromanar ginal, Treponema denicla, etnomyes spp, Pinterms,Exboocteriam sp, Selnomona 2p, ‘Aspect beri configuration in det plage cor oh, was dxerbed by Lisgnten (1973913, in which a cena acts (Cornebctrm) is secrounded by many cocci el Srprocces ert). Rosset” anther special bcterilaangement” dere in dental gue, ia which a cent cossur is suraunded by supe rod cells (Fusohacerm mcletim., Resets” fom when the proportion between the ‘intergenic coggrestion pres is more thin 101 in fvour of rods (Kolenbrander et Andersen 19884), Rel networks ste fred when third are fciaes the inks baween graseles™. dtinompees nae could create sich links between rower” formed by Baceoer betcha sa Siptococes sangos(Kolenbrandr 1989). These sangeet re formed inthe periphery ofthe deta plague (Koka 1991), 2.4.Dena plague: elascaton and composition ‘The dental plague takes he for of pone communis tached to i or abit race (Daren 20916), The del plage is & mayer statue which ons allowing reise pases (Sore Hae 1990K17). ‘There ae 0 diferent pes of dental plague biflins. Sypre-inghel| plague fos above he igi magi nsdn plage fons below ths ot, Tr bacterial compositions are tity deren ‘Sspro-gina plague row, being lcte in conta 1 theo ay, subject to mach more irom abrasion, which sits is met aceon. In don, this fi is subject to the flow characteris of svat ost ese componens, Saliva conti secretory IgA, tein, Izoayme and roxas that diy wide spectrum of atimiobi it bith colniziton and spread of the spring Batra. In 8 vies and sen thick lier, spr ingial en plage ibis on clinical examizaon, Supa plague develops prefrestilyin the eri or appro ssa ad in ech sures(Chaon et Motion 203XS) In conta, subngialplague, riding i 2 more poet location, | ot sujet to the sane degree of inraoral season or salary Bost dee cnpovent, The main determinants ining i arowth ae the ysl sac nd the imate dens tem of th bos The gigi erevclar fi abnaph rich source of sues, conan 2 ptet aay of anil substances. The subgingival ge may are anaerobic conditions fr bacterial developmen ‘The eubingial plague may be unig as tere may be two Binns in| opposition o cach tr: one tached othe toh sericea the ther ata ‘othe citi ols ning he periodontal pocketing ues. These bins may be ridged by a one of os tached or untae species (Soran et Hates 200212) »2.5.Component of data plague “The exrceluor substance consis of polsaecharies, pte, pis, lee acids, Ig and other lemeats (wate, Ce, oigo-clemens). The cael substance Bp baeia to adhere tthe eal sure, aswel ato er blr el, Colle Many bacterial morpotypes ae found the deal plague The emalplage consins 1010" bacteaing (Charon et Mouton 2000X8), but orn sch at views, mycoplasna ad leurs may be pres About 50-60 haters ta ave eon etc i plage srpes fom oval cavity (Sacransy et Hathjee 20212), om which only 50-40% were ole taxa (Armitage 201018). Other bacteria ae .ot-yetuvatd” nd ave en iti sing molecular techique Sera et Hate 2002\12, Dental plage composition les i hall ad dss. The batrl oad soci with gingival hah is eativly How (10-10 nd the cabin is oly Grane postive, formed hy stopococe! and scinmyces, with about 13% Crans-opnive rod mies having bee determined (Durvea &aL.1997)). An individual more Hely to niet Grum-neaive batra and periodontal topes in Hey ses with increasing ae. Srpococcus spp are important onsen of denial plague ia perndonally bekhy sites. The presence of| ello comples, which Is formed by Stepocorusgp was demonstrated in eridooally hey ind. As reveled eae, Gram-negative baci, ‘chs Fosobcterionmicleat, at contin of sab ingival plague in ater stages of plaque development (Soranky &t Hae 2002K12). Actnobuis ectramyectoncontins (A.actinomyetencomion), Tamera orsthia ani Preotele iermecia may be preset ia low murs in peodontallybeainy ‘adits (Gur et Guggenbcin 1998X19), Gingivitis ie ascited with an increased mirobial load ( swf orgnis) and en increase ofthe pongo of Gram-aegate organisms. In recon, ot only here is aires he fol Haters (10°10 ricoornisms), but here is ao an ners in the proportion af Gram-negative ‘ters (15-50%) (Daren et 1997X4).Pesodotl disease isnt asad with single onanism, and its key hat conor of bacterially ssi inthe css. Some of he Gram-negative tater ting aso ‘with periodontal dese ae: Tanne forshia,Porpromonas singhl, ‘Treponema doticol and Preoela interme (Soca aL 1998N20), 26, Acceptance eter for periodontal pathogen Koch proposed some ertera for decrbing pvidonal patbogen ‘Secraky (1979)21) pine ou tht the 2d and 3d Koch's poste cannot be ffi inthe ete of prion: tbe 2nd pose apes ht the Dathoge cn be gown in nbrtory om artificial mali, wich, fe pions pathogens, at alvays tus, Phe 3d postulate sates tat ioclton of pure ‘ale into exprinetl anima case condtion similar ote human dizase ‘om whic he rg Was ail outed (Wc is ot ue ifthe ateism canot be cutive). The following fv yes of rein or nes of evidence an be usd o spor an etl le fr ceria microorgnis a peridontal ‘afin (Sacrasky 1979, Armiage 201021, Pydsoction with das his rtevon nates tt th patie pathogen soul! bea higher levels diese sits than a hy aes. Thi docs nat sme tat the pathogen needs tobe a predominant member of he peidonat rncobiota; many specedpthoges only erent 15% ofthe olny foing uns ata duetd ste Thier ilo applied to micoorgansns tha aren ate” category, 1»2)Elinination oF suppression of the orgniom specifies tthe progreion of periodontitis is areted ifthe suspected bacterium is suppressed or lina by an appropriate thrpy. The wordline” mas be ed with ato sine tae i good evidence tht many periodontal esi inidls the om-yetca ascan tatour low levels of peiodowtal pathogen a prt of sce sara sb ng ora I unkaly tht» member of moemal Nora will be peemarethy liminated fom the ol ecosystem (coll be detected by highly sestive molec tsnigues), On the ot han, thapy can eal sede the sub- ingress of periodontal patogens to ew tint of tein (De Soxte 012001122). ot rspone 6 an porn rierion fr enuation,Hacuse most tical destin is believed to Be defo Bot infantry responses 1 the sb-gngva microbial chalege. A lower Ios response muy inte special abiliy ofthe patioge to vo the host srslnce (Armitage 201018). Pnimal pothogancny. wae demonstrated at several periodontal pathogens islted fom fuman cae of peinontis can caus similar Pridonal lxons when noulted ito expert anal. This iceaton ‘fen ot suse, Fastcous organs sacha poche cannot be used for mono-speies planation as they require other bacteria 19 rene a ncroenvironmen ta issuable fr eolnzation PspMechanims of pathogenic: This erterion sige that the nsroorgnim should potest an ary of viene factors tat promote is ily to inate ad perpetrator evens tat rl in peridoatal es At the 1996 Word Workshop in Peridonies 2h recon was de, ‘The 6 ertedoa, dteton ofthe miroorgmnism prior dense progres, was used as an aditnal ine of evidence for pbogenisty (Genco ct 211996423 27.Peviodontl pathogens ia 1996 Ath 1996 Word Workshop n Periodontist of pxodotl pathogens was sali, xing an evidence-based approach The six Socransy's evra vee used fo gener the Ist of ptbogens (1979421). It was conchided tat 36 Tr there is strong. evidence hat Aactnomcetonconilon, Porphyromonas ingot and Tamla forthia ae pogo pathogens when preset in sufiint mbes in sacepible hosts (Genco et 11996)25) Thee was inde evidence to sport the egies role Lor Campylobacter recs Prete termed, Prevoclia nigrescens, bacterium nada, Parvinonas icra omar Micromonos micros and Peptosrepococus micro Siprococeu nome and Treponema deta. There was itil evidence to inclu the flowing bacteria on the Ut of probable periodontal pathogens ikea cords, Prendomonas sp, Stapycoces sp, eerie ads (eee 1 s11996)03), No extmanive atengt wat made Je compare the various periodontal pathogens with piodoal disease entities, The consnses deine tht atnomptoncomitons was moe offen found in agzreive (uty onset) periodoni (AP), and Parpromonar gingivalis ad Tanmerella oroia were oa ore equi ernie pints (CP) (aon). ‘The tadonl conept “one gem, one seu” ie mot salable foe orion disse, The infections are caused by an extremely diverse onsorium of mieroorsnisms tt apa ofthe endogenous micobiasof most ple. Whoa detested in eaty ses, erin anges ae scat i Wery low makers Carag of pute perindowlpaioges at ow levels as part of ‘he commensal ra lr is peobubly benef, sinse i key hat shee presence is mecesary for the development and maturation of the inte and dav immunity of he ost (Arie 20108) 2Ln.Periodonta pathogens today ‘The pathogens it F196 was confine to cea tar cou be own on itil media in abrstary. This now considered a spersimpliied it, since snprosnntly 0% ofthe members of mb-gngival microbiota ae iste -a0 etcukmted™ grup. The esocition of micoorganians fom the Archaea onan wit pardon disese was ouiced, Arche are proaots tathe baci bot hve iffveatmalete sequences in their 165 RNA and are thee ot athe Batra dorsi. Methanoreibacter oral i ‘meth producing torganis adi isthe ost commonly unl Archova tener in pesados cates, Arhawa have never bee ound inthe ub-igia ncobiota of periodontal est inves rs hess in patents with eriodorie (Lapp et 20042, The proton of CP patients who labour Archoca a sugges ranges from approximately 19-73% depending 0m the popultion surveyed, Now-surgcl treatment of Archaea postive CP ses eas abl to rede tbe mieoorganims to aondeectable levels (Lop et 12000129, Methaobrestbacterorls has een cred ia the boro, but i ifeu o ow an is ot solid ding oun scoop assent, I induces pecifc 1 produto by CP patios who harbour this mirorgaisn in tir ub gingival plague Sub-gngal ses of CP patie wit igh eves of | Methonobrevibater ovals tave low level of Treponema spp (Lop et 112004424), Is pone that Archane Inve 90 diet patogsic eet but conti 1 the overalpaogcicy of sub gingival bioin by interactions ith ther robes (Armitage 2010). igh evels of M7 base were ascid with ligt prindotl damage (AL 2-3 om) (Bring @212003)25). Bosra inthe TMT group ae gram stive and none has yet bee cle i he nboratoy thi roup of bacteria as ecealy hee asoited with active inlammatory bowel disease (Armitage 2o10xisy, 2 vot Mende Je Ep eg med EESSGI ZONE. malacAt Pcs ep ptt Mi er cere behin') Roolool oat Eee » ne, Cla! Parl bp ety Mansi 198 Daren PP Tamar Pgs Theol cals pone Pode 00, 197 413 hrc Monte © Puen CaP 2034590 {Babs ¢. te cnowates on etapa nl acon Antony ‘Van Lesinenck sn His ie Anam Ruslan Ral i, New Yor. 56 rs 258. 7 Koliandct PE Conpepnatirece ie the human orl ictal ‘Senytem. 70 ee Dueia M(e. Micbal celled ects ‘Kren Sy of Meloy Wastin 1981 5 Kehoe A amt Saga tin rc. Pin! 20, 10 Metre BC, van der Hoeven. Role of incr ache in the ‘Sloosico thwal air erik asf wih Spas ‘ia nda alone ma 1981 3:46. 11, Roan PE" Londo Ae toa br emerow: erat Rcte 12. Serumiy ute AD. Domi bln: dik heap rg Prsodont 2002008 281285 1a. Ligaen MAL Mayo Aad M, Uric of the achat ‘die Dawes cal apf macecrom it “eros” feminine pag Sees of Ol Bg) 1973886 14. Konner PE, "nan RN inure nae seed ure ‘ops song Taman psn tei pl Emon Mobo 15 Kleirnder PE Saree recgiion among al tai: muigeic ‘Suarepinns tthe mesons Crt Rev nc! WE 72}37 19 16 Barat RP Ol Maral rcs‘ Oat Mei Case's ‘taco whe pool te Se sm I a Cl Bo) 203203938, 17. Seeimly $& Faiee AD. Evsece of tata egy «sel ‘pie Review Pal 2, 985735 1s Renae OC: Comurice of to mcd araes of eons and Sezer prose, Pos! 20 2010557088 19. Gru R Conzete teres sprapagi! pote mua hb of ‘Gime stanton Racer fran, Conbacer ‘peur a Prev nacre Det 5473 20, Scranity 5, Hale AD. Cis MA, Sih C, Kem RL, Mobi ‘Solr nsaagal pga JC Pes 983 25134148 21, Scrum SS Cetra re cto gen eal asd periodontal deste 9 Clr Porto! 136162 22 De Sic Mr Mong, Pair M, Halle A, Soca $8, van Sorbie, Gurynen M Onenuge fllmath enacien Long tm ‘sculpt apd by cas ONADNA han 7