PERIODONTICS

Periodontics or periodontology, is the branch of dentistry which studies the

supporting structures of teeth, known as the periodontium, which includes the gingival,
alveolar bone, cementum, and the periodontal ligaments. The word comes from the
Greek words peri meaning around and odons meaning tooth. Literally taken, it means
study of that which is around the tooth.

PERIODONTITIS

Periodontitis is an inflammation of the periodontium, or one of the four tissues

that support the teeth in the mouth:
 the gingiva, or gum tissue
 the cementum, or outer layer of the roots of teeth
 the alveolar bone, or the bony sockets into which the teeth are anchored
 the periodontal ligaments (PDLs), which are the connective tissue fibres that
connect the cementum and the gingiva to the alveolar bone.

If left untreated, periodontitis causes progressive bone loss around teeth, looseness of
the teeth and eventual tooth loss. Periodontitis is thought to occur in people who have
preexisting gingivitis - an inflammation that is limited to the soft tissues surrounding the
tooth and does not cause attachment or bone loss. The cause of gingivitis is the
accumulation of a bacterial matrix at the gum line, called dental plaque. In some people,
gingivitis progresses to periodontitis - the gum tissues separate from the tooth and, with
loss of periodontal ligaments, form a periodontal pocket. Subgingival bacteria that exist
in periodontal pockets can cause further inflammation in the gum tissues and further
loss of attachment and bone.
If left undisturbed, bacterial plaque calcifies to form calculus. Calculus above and below
the gum line must be removed completely by the dental hygienist or dentist to treat
gingivitis and periodontitis. Although the primary cause of both gingivitis and
periodontitis is the bacterial plaque that adheres to the tooth surface, there are many
other modifying factors. One of the most predominant risk factors of periodontal disease
is tobacco use. Another very strong risk factor is one's genetic susceptibility. Several
conditions and diseases, including Down syndrome, diabetes, and other diseases that
affect one's resistance to infection also increase susceptibility to periodontitis.

Signs and Symptoms

Symptoms may include the following:
 occasional redness or bleeding of gums while brushing using dental floss or biting
into hard food (e.g. apples) (though this may occur even in gingivitis, where there is
no attachment loss)
 occasional gum swellings that recurs
 halitosis, or bad breath, and a persistent metallic taste in the mouth
 gingival recession, resulting in apparent lengthening of teeth.
 deep pockets between the teeth and the gums (pockets are sites where the
attachment has been gradually destroyed by collagen-destroying enzymes, known
as collagenases)
 loose teeth, in the later stages

Patients should realize that the gingival inflammation and bone destruction are largely
painless. Hence, people may wrongly assume that painless bleeding after teeth
cleaning is insignificant, although this may be a symptom of progressing periodontitis in
that patient.

Prevention
Daily oral hygiene measures to prevent periodontal disease include:
 brushing properly on a regular basis (at least twice daily), with the patient attempting
to direct the toothbrush bristles underneath the gum-line, so as to help disrupt the
bacterial growth and formation of subgingival plaque and calculus;
 flossing daily and using interdental brushes (if there is a sufficiently large space
between teeth), as well as cleaning behind the last tooth in each quarter;
 using an antiseptic mouthwash. Chlorhexidine gluconate based mouthwash or
hydrogen peroxide in combination with careful oral hygiene may cure gingivitis,
although they cannot reverse any attachment loss due to periodontitis;
 regular dental check-ups and professional teeth cleaning as required. Dental check-
ups serve to monitor the person's oral hygiene methods and levels of attachment
around teeth, identify any early signs of periodontitis, and monitor response to
treatment.

Treatment of established disease

A dental hygienist or a periodontist can use professional scraping instruments,
such as scalers and currettes to remove bacterial plaque and calculus around teeth and
below the gum-line. There are devices that use a powerful ultra-sonic vibration and
irrigation system to break up the bacterial plaque and calculus. Local anaesthetic is
commonly used to prevent discomfort in the patient during this process.
It is difficult to induce the body to repair bone that has been destroyed due to
periodontitis. Much depends on exactly how much bone was lost and the architectural
configuration of the remaining bone. Vertical defects are those instances of bone loss
where the height of the bone remains somewhat constant except in the localized area
where there is a steep, almost vertical drop. Horizontal defects are those instances of
more generalized bone loss, resulting in anywhere from mild to severe loss of initial
bone height. Sometimes bone grafting surgery may be tried, but this has mixed
success. Bone grafts are more reliable in instances of vertical defects, where there
might be a sufficient hole within which to place the added bone. Horizontal defects are
rarely if ever able to be grafted properly, as there is nowhere to secure the bone.
Dentists sometimes attempt to treat patients with periodontitis by placing tiny
wafers dispensing antibiotics underneath the gumline in affected areas. However, the
general scientific consensus is that antibiotic treatment is of minimal value in treating
bone loss due to periodontitis. It may help to recover about one millimeter of bone, but it
is questionable if this is of significant therapeutic value.
Alternatively, regular subgingival flushing with an anti-calculus composition can dissolve
subgingival calculus (tartar) thus facilitating natural healing without surgery. This
process is widely used for supragingival tartar via tartar-control toothpastes. Subgingival
application of an anti-calculus composition requires a subgingival syringe or an oral
irrigator. One such anti-calculus composition (Periogen) contains Sodium Tripolypho-
sphate, Tetrapotassium Pyrophosphate, Sodium Bicarbonate, Citric Acid and Sodium
Fluoride. In the composition, Tetrapotassium Pyrophosphate (TKPP) is a cleaning agent
designed to clear away bio-films in order to facilitate chemical access to calculus.
Sodium Tripolyphosphate (STPP) acts as the anti-calculus agent, activated by Sodium
Fluoride (.04%), providing a chelating action on the structure of the calculus.
Sodium Bicarbonate and Citric Acid are product activators which assist in dissolving the
composition in water for periodontal delivery via a subgingival syringe or oral irrigator
with a periodontal tip.

Assessment and prognosis

Dentists or dental hygienists measure periodontal disease using a device called
a periodontal probe. This is a thin measuring stick that is gently placed into the space
between the gums and the teeth, and slipped below the gum-line. If the probe can slip
more than 3 millimetres length below the gum-line, the patient is said to have a gingival
pocket around that tooth. This is somewhat of a misnomer, as any depth is in essence a
pocket, which in turn is defined by its depth, i.e., a 2 mm pocket or a 6 mm pocket.
However, it is generally accepted that pockets are self-cleansable if they are 3 mm or
less in depth. This is important because if there is a pocket which is deeper than 3 mm
around the tooth, at-home care will not be sufficient to cleanse the pocket, and
professional care should be sought. When the pocket depths reach 5, 6 and 7 mm in
depth, even the hand instruments and cavitrons used by the dental professionals cannot
reach deeply enough into the pocket to clean out the bacterial plaque that cause
gingival inflammation. In such a situation the pocket or the gums around that tooth will
always have inflammation which will likely result in bone loss around that tooth. The
only way to stop the inflammation would be for the patient to undergo some form of
gingival surgery to access the depths of the pockets and perhaps even change the
pocket depths so that they become 3 or less mm in depth and can once again be
properly cleaned by the patient at home with his or her toothbrush.
If a patient has 5 mm or deeper pockets around their teeth, then he would risk
eventual tooth loss over the years. If this periodontal condition is not identified and the
patient remains unaware of the progressive nature of the disease then, years later, he
may be surprised that some teeth will gradually become loose and may need to be
extracted, sometimes due to a severe infection or even pain.
EXERCISES

I Answer the following questions:

1. What is periodontics?
2. What is periodontitis?
3. What does periodontitis cause if left untreated?
4. What is periodontitis preceded by?
5. What do symptoms of periodontitis include?
6. What does prevention include?
7. How is treatment of periodontitis carried out?
8. How do dentists measure periodontal disease?
9. What happens if a patient has 5 mm or deeper pockets?

II The following definitions apply to the listed words. Match them:

tartar, pulpitis, periodontitis, periodontics, syringe, periodontal pocket, dental plaque

1. a pathologically, deepened gingival sulcus;

2. a calcifed deposit that forms on the surfaces of teeth;
3. the prevention and treatment of diseases of the bone and soft tissues surrounding
the teeth;
4. an instrument consisting of a piston in a tight-fitting tube that is attached to a hollow
needle or thin tube;
5. inflammation of the dental pulp;
6. a layer that forms on the surface of a tooth, composed of bacteria in an organic
matrix;
7. inflammation of the tissues surrounding a tooth

III Make WH questions referring to the underlined words:

1. Poor hygiene is often the cause for gingivitis.
2. Progressive proliferation and ulceration of epithelium results in continued deepening
of the pocket.
3. The absence of chewing exercise leads to soft, bleeding gums and poor bone
support.
4. The pulp is able to recover from an injury caused by the caries.
5. The patient is complaining of a mandibular joint pain.
6. The mandible is a movable bone which looks like a horseshoe.
7. Enamel can be compared in degree of hardness to topaz.

IV Choose one of the negative prefixes (un, in, im) to form a word with the
opposite meaning:
measurable, active, mobile, direct, proper, important, possible, favourable, able,
comparable

V Translate the following sentences into English using the appropriate type of IF
CLAUSES:
1. Ako se gingivitis ne leči adekvatno u početnoj fazi, dovešće do periodontitisa.
2. Kada bi zub bio otvoren na vreme, pacijent ne bi osećao oštar bol.
3. Mikroorganizmi bi bili uklonjeni da je stomatolog stavio kalcijum hidroksid na karije-
snu leziju.
4. Ukoliko se uništi periodontalni ligament, zub će postati klimav.
5. Kada se ne bi eliminisali uzročni faktori, progresivna proliferacija i ulceracija epitela
bi dovela do produbljivanja džepa.