PERIODONTAL DISEASES

Periodontal disease and dental caries are the

commonest of all diseases.
Periodontal disease has been defined as any
pathological process affecting the periodontal
tissues but almost always refer to inflammatory
diseases, gingivitis and periodontitis.
Periodontitis is characterised by destruction of
perioidontal membrane and alveolar bone and
leads ultimately to loosening and loss of tooth.
• Parts of gingiva are:
• Free gingiva
• Attached gingiva
• Alveolar mucosa
• Normally tip of the gingival margin and enamel
surface of the tooth form an angle known as
gingival sulcus.
• Classification of periodontal disease
• Periodontal disease should be used to refer only
to inflammatory disease of the supporting tissues
alone.
• Chronic gingivitis is mostly the preliminary stage
to the development of periodontal disease.
• The distinction between the two is gingivitis can
be cured but effect of chronic periodontitis are
irreversible because ………part of periodontal
membrane and alveolar bone have been
• Destroyed and cannot be normally restored.

• Classification

• There is no definitive classification of periodontal

disease. The following are main clinical types of
periodontal disease grouped together on basis
of non specific inflammatory process.
• Inflammatory periodontal disease

Gingivitis
i) Acute gingivitis
Acute ulceromembranous gingivitis (Acute
necrotizing ulcerative gingivitis, Vincent’s
gingivitis
Acute non-specific gingivitis
ii) Chronic gingivitis
Periodontitis
• i) Acute periodontitis
• ii) Chronic simple periodontitis
• (Periodontitis simplex, horizontal bone loss
periiodontitis)
• iii) Chronic complex periodontitis
(Periodontitis complex, vertical bone loss
periodontitis)
Dystrophic disease
Hyperplasia
Gingival hyperplasia
Atrophic
Gingival recession
Disuse atrophy
Degenerative
Periodontosis (Juvenile periodontitis)
• Gingivitis is the forerunner of periodontitis and no
sharp dividing line can be drawn between them in
the transition from one to other.

• ACUTE ULCEROMEMBRANOUS GINGIVITIS

• (Acute ulcerative gingivitis, Acute necrotising
ulcerative gingivitis, Vincent’s gingivitis)
• Acute ulceromembranous gingivitis is a diffuse,
specific condition characterised by rapidly
progressive ulceration starting at tip of
• Interdental papillae, spreading along gingival
margins and on to acute destruction of
periodontal tissues. There is no persistent
infection only one or two episodes with localised
damage to gilngival tissue.
• Microbiological aspect
• The disease is infective and responds rapidly to
antimicrobials including metronidazole which is
effective against anaerobes.
• Aetiology
• The causative microorganisms appear to be
Gram negative anaerobes particularly spindle
shaped Fusobacterium fusforme and spirochaete
Borrelia vincenti. Bacteroides melaninogences
regarded as causative agent induces abscess
formation.
• Host factor
• Affect young adults usually with neglected
mouths
• Predisposing factors
• Smoking, anxiety, upper respiratory infection
• Clinical features
• General sign of infection – slight or absent
• Mostly no fever, not unwell, lymph nodes not
enlarged
• Oral features
• Main component- sorenesss of mouth, eating
difficulty
• Bleeding from gums after trauma
• Excessive salivation
• Halitosis
• Local lesion
• Crater shaped or punched out ulcers form at tip
of interdental papillae, edges sharply defined by
erythema and oedema of margins and surface of
ulcer covered by greyish or yellowish slough
removal of which causes bleeding.
• Treatment
• Main aspects
a. Physical (oral hygiene) measures to reduce the acute
infection – surgical debridement
This is the most important aspect of treatment. Plaque
and calculus removal by thorough scaling and irrigation
which should be adequate.
b. Use of oxidising antilseptics
Oxidising antiseptics such as hydrogen peroxide or
sodium hypochlorite applied to isolated and dried gingiva
• Use of systemically acting antimicrobials
• -spectrum of antibacterial activity against obligate
anaerobes
• Hypersensitivity absent
• Other side effects- minimal nausea or metallic
taste
• ACUTE NON-SPECIFIC GINGIVITIS
• Acute gingivitis associated with herpetic
stomatitis or acute streptococcal sore throat
• Gingiva light red and oedematous
• Swelling causes surface to lose stippling
and appear glossy. There may be slight
soreness
• CHRONIC GINGIVITIS
• Chronic gingivitis is due to persistent low grade infection
from accumulation of bacterial plaque round necks of
teeth. Adequate toothbrushing will remove deposits
from teeth and eliminate chronic gingivitis. Failure to
prevent accumulation of deposits is followed by spread
of infection and inflammatiion together with increasing
damage to periodontal membrane and alveolar bone.
Chronic periodontitis with progressive destruction of
supporting tissues becomes established.
• Aetiology
• The most common cause of gingivitis is accumulation
of bacterial plaque between and around teeth. Plaque
triggers an immune response which in turn can lead to
destruction of gingival tissue. It may also eventually
lead to further complications including loss of teeth.
• Dental plaque is a biofilm that accumulates naturally
on the teeth. It is formed by colonising bacteria
attached to smooth surface of tooth.
• These bacteria might help protect the mouth from
colonization of harmful microorganisms but dental
plaque can also cause tooth decay and gingivitis as
well as chronic periodontitis. When plaque is not
removed adequately, it can harden into calculus.
Plaque and calculus eventually irritate the gingiva
causing gingival inflammation.
• Risk factors:
• Changes in hormone- This may occur during puberty,
menopause, menstrual cycle, pregnancy. Gingiva
become more
• risk of inflammation
Some diseases- caries, diabetes and HIV are limited to
higher risk of gingivitis
Drugs- oral health may be affected by some medications
especially if saliva flow is reduced. Dilantin, an
anticonvulsant, and some anti-angina medications can
cause abnormal growth of gum tissues
Smoking-regular smokers more commonly develop
gingivitis compared with non-smokers
Age-The risk of gingivitis increases with age
Poor diet- Vit C deficiency is limited to gum disease
• Family history- Those with parents having
gingivitis have a higher risk of developing it too
due to the type of bacteria acquired during early
life.
• Clinical features
Gingivitis often starts in childhood and early signs
seen at adolescence
There may be bleeding from gums
Earliest visible change is darkening in colour of
gingival margin from normal pale pink to red
• Purplish
• Plaque is visible along the gingival margins
• Gingivae are slightly swollen, soft, smooth and
glazed and normal surface pattern is lost
• Slight pressure on the gingiva which are not
tender causes bleeding
• Chronic oedematous ( ‘hyperplastic’ ) gingivitis
• In young patients especially in mouth-breathers and
with dirty mouths, gingival margins are swollen and
interdental papillae become bulbous. Stagnation
areas (false pockets) are formed between gingival
margin and teeth and this inflammatory condition is
known as Chronic hyperplastic gingivitis. This
differs from Chronic simple gingivitis mainly in
degree of inflammatory changes rather than in its
essential nature.
• However, there is distinction between gingival swelling
due to inflammatory oedema (Chronic hyperplastic
gingivitis) and true gingival hyperplasia in which there is
fibrous overgrowth but minor inflammatory changes
secondary to false pocketing
• Progress of gingivitis
• Without adequate treatment or care Chronic gingivitis
progresses to Chronic periodontitis,ie, destruction of
supporting tissues and true pocket formation. There is no
dividing line between the two but clinically periodontitis is
present when pocket extends to cementum.
• ACUTE PERIODONTITIS
• Is uncommon and of short duration
• a. Traumatic periodontitis
• Biting suddenly on hard objects or high restoration
causes minor damage to periodontal fibers and
localised inflammation with tenderness of teeth.
Removal of cause followed by resolution
• b. Periodontal abscess
• There is localised acute complication of periodontal
disease with rapid deepening of pockets and abscess
formation.
• C. Ulceromembranous gingivitis
• If untreated, rapidly and progressively destroys
gingivae, alveolar margin and periodontal fibres
especially intradentally.

• CHRONIC PERIODONTITIS
• Chronic simple periodontitis is the commonest
and most important type of periodontal disease
and is the main cause of tooth loss in adults
• Aetiology and pathology
• Chronic periodontitis is mainly regarded as
continuation of process chronic gingivitis.
• Persistence of inflammation at the gingival
margins leads to progressive inflammation and
destruction of supporting tissues of teeth.
Disease may progress most rapidly in patients
with poor resistance and local factors are most
important in development of chronic
periodontitis.
• Main features of pathology of chronic periodontitis
• 1. Destruction of periodontal membrane fibres
• 2. Resorption of alveolar bone
• 3. Migration of epithelial attachment along the roots
towards the apex
• 4. Formation of pocket and teeth
• Prognosis of Chronic periodontitis
• Once established it is self-perpetuating
• Pockets cannot drain effectively and encourages
proliferation of bacteria.
• Epithelial lining, plaque and subgingival calculus
• Prevent healing and further destruction of periodontal
membrane and alveolar bone causes pockets to deepen.
Termination of process is loosening and exfoliation of teeth
• Clinical features
Further completion of bleeding from gums and unpleasant
taste
In late stage – completion of recession of gingiva or loosening
of teeth. Also may cause foul smelling breath or halitosis
There is chronic gingivitis and congested gingival margins
become purplish red, flabby and smooth. Interdental papillae
split and detach from teeth.
• Later papilla destroyed and gingival margins become
straight with swollen rounded edge. Pressure on
gingival margins cause bleeding and sometimes pus
extruded from neck of teeth. Bacterial plaque and
calculus widespread. Loss of attachment leads to
pocketing
• In later stage teeth become loose and dull to
percussion.
• Radiological change
• Early stage- loss of definition and blunting of alveolar
cover tips. The characteristic radiographic
• feature of simple periodontal disease is
progressive bone resorption at same level along
row of teeth and horizontal bone loss.
• General principles of management of Chronic
Gingivitis and Periodontitis
• Management comprises of two main components:
• 1. Control of bacterial plaque by oral hygiene
measures
• Control of plaque is mainly by toothbrushing
together with scaling and polishing
• 2. Corrective treatment of established disease mainly by
surgery
• Type of operation a. Subgingival currettage
• b. Gingivectomy c. Gingivoplasty d. Reverse bevel replaced
flaps

PERIODONTITIS COMPLEX
Is less common. Main features are chronic inflammatory
changes with deep, irregular pocketing and destruction of
alveolar bone. This may be due to systemic failure or infection
and inflammation superimposed upon periodontosis but
underlying
• cause is unknown. Periodontitis complex is also
regarded as simple periodontitis complicated by
abnormal local factors such as occlusal trauma.
• Clinically diagnosis is made where there is gingivitis
with deep, irregular pockets around teeth. Patients
are relatively young and oral care relatively good.
• Radiographically, bone destruction is deep and
irregularly distributed
• Bone-loss is in vertical direction in contrast to
horizontal bone loss of periodontitis simplex.
• Treatment
Treatment is by conventional means.
Source of trauma to supporting tissues looked for, gingival
infection dealt with and pockets removed surgically.
Prognosis is poor. Severely affected teeth are extracted.

GINGIVAL SWELLING
True hyperplasia ,ie, fibrous overgrowth of gums is
uncommon and swelling of gingivitis is more often
inflammatory in origin, precipitated by local infection at
gingival margins.
• Cause of swelling of gingiva fall into two main groups –
hyperplastic conditions and commoner inflammatory
conditions.
• Cause of gingival swelling are:
• 1. Gingival hyperplasia
– a. Idiopathic or hereditary
– b. Phenytoin induced
2. Inflammatory gingival swelling
a. Chronic hyperplastic gingivitis
b. Pregnancy gingivitis
c. Leukaemic gingivitis
d. Scurvy
• 1. Gingival hyperplasia
• a. Hereditary gingival fibromatosis
• Rare condition characterised by gross fibrous hyperplasia of
gingivae. In minority there is clear family history and is
inherited.
• Onset of gingival enlargement may be in infancy preceding
eruption of teeth or may develop later in childhood. The
gums may be grossly enlarged and completely bury the
teeth and are pale, firm and smooth or stippled in texture.
• Other changes associated are:
• Facial features- coarse and thickened simulating acromegaly
and there may be excessive hairiness
• (hypertrichosis). Excessive gingival tissue can only be
removed by surgical excision but may reform. Oral hygiene
maintenance to prevent effect of infection but in spite of
deep false pocketing inflammation may be absent.
• b. Phenytoin hyperplasia
Some patients taking phenytoin (Epanutin, Dilantin) for
epilepsy develop gingival hyperplasia. Overgrowth involves
interdental papillae which become bulbous and overlap teeth.
Gums are firm and pale and stippled texture exaggerated
producing orange-peel appearance.Inflammatory changes are
absent and similar to idiopathic fibromatosis. Gingival infection
• may result in overgrowth of gingiva which can be controlled by
oral hygiene. Frequently gingivectomy becomes necessary.
• Drug induced gingival hyperplasia include:
• - Anticonvulsants (phenytoin, phenobarbitol etc.)
• -Calcium channel blockers (Antihypertensives such as
nifedipine, amlodipine)
• -Cyclosporine – an immune suppressant
• 2.Inflammatory gingival swelling
• a. Chronic ‘hyperplastic’ gingivitis
• Commonest cause of gingival swelling mainly affects young
people, faulty lip seal often important factor
• Gingival margins – swollen, smooth, oedematous, enlarged
• Management – rigorous oral hygiene to control gingival
infection
• Swelling mostly due to oedema
• b. Gingiva in pregnancy
• During pregnancy gingival margins may sometimes become
swollen. There is redness and swelling restricted to
interdental papillae and gingival margins. Exaggeration of
inflammatory changes at one papilla may produce localised
nodule called pregnancy tumour. Gingival changes are due to
localised infection and neglected oral hygiene
• c. Acute leukaemia
• Acute leukaekia is associated with gingival swelling. Clinically
gingiva are swollen, shiny and pale or purplish in colour.
Ulceration may be present. Pallor, purpura may be secondary.
Swelling can be controlled by topical use of antibiotics.
• d. Scurvy
Grossly swollen and congested gums are classic sign of scurvy.
Gingival swelling due to chronic inflammation and inflammatory
congestion and bleeding due to purpura
When there is dietary deficiency and purpura, treatment is with
Vit C and adequate oral hygiene
• Periodontal atrophy
Atrophy of periodontal tissue causes recession of
gingival margins and gradual exposure of roots
teeth. Mainly due to effect of age and wear on
tissues. Gingiva are quite healthy
Senile gingival recession
In later life gingival margins recede from crown of
teeth and expose roots. After middle age skeletal
tissues gradually atrophy as blood supply
decreases and diminish in bulk. Supporting tissues
• Slowly shrink, continued eruption of teeth, wear
and tear on gingiva due to eating and
toothbrushing
• Receded gingival margins are healthy and
pockets do not form around teeth. Gingiva are
pale in colour, firm in texture but part of roots
exposed.
• Presenile gingival recession
• Rarely gingiva recede at early age in young
adults. Cause unknown.
• Gingival abrasion
• Abrasion by vigorous toothbrushing, cause recession
of gingiva and damage to teeth.
• Gingival margins recede but remain firm, pale and
healthy
• Treatment
• Main consideration is to keep gingival margins clean
especially in enlarged interstitial spaces.
• Prevention of chronic gingivitis is the only useful
measure. Nothing can be done to restore lost tlssue.
– Periodontitis, Juvenile periodontitis
– Rare disease characterised by resorption of
alveolar bone with loosening or drifting of
teeth without inflammatory changes initially.
Infection and inflammation may become
superimposed and periodontosis is seen.
– It affects young patients and is characterised
by rapid, irregular loss of supporting tissues
without apparent local cause.
• Aetiology
• Cause of periodontosis is unknown but causative factor
may be presence of certain specific Gram negative
anaerobic rods in plaque or selected defect of cell
mediated immunity.
• Clinical features
• Periodontosis is common iin women and young people.
Incisors and first molars usually affected. Main factor is
drifting and loosening of anterior teeth which may be tilted
or extruded. There is no pocketing. When inflammatory
changes develop, pockets are deep, irregular as is bone-
loss.
• Radiological features
• Main features are deep, irregular bone-loss and
displacement of anterior teeth
• Treatment
• Since cause is unknown treatment is
symptomatic and limited. Severely affected teeth
should be extracted. Treatment is directed
toward removal of gingival infection and pockets.