PERIODONTAL DISEASES

03/20/2024 Dr. Meti

Periodontum:
• It is supporting apparatus of the teeth.
• Attach the tooth to the bone of jaw firmly.
• It includes the gum, alveolar bone, various tissue components
of the gingiva, ligaments, blood vessels, periodontal space,
root and cementum.

03/20/2024 Dr. Meti

 Anatomy of the periodontium

The periodontium
Peri= around
Odontos= tooth
Periodontium means tissues around
the tooth

03/20/2024 Dr. Meti

 Components of periodontium

1. Gingiva
2. Periodontal Ligament
3. Root cement (cementum)
4. Alveolar Bone

03/20/2024 Dr. Meti

1. GINGIVA
• Part of masticatory mucosa, which covers the alveolar bone
process and surround the neck/cervical portion of the teeth.

Types of Gingiva
• Free: Gingiva that is directly next to the crown of the tooth.
There is space between the free Gingiva and the teeth, called
the gingival sulcus.
• Attached: joins the free Gingiva to the rest of the mouth and
is fixed to the bone
• Papillary: Gingiva that lies between the teeth (INTERDENTAL)
03/20/2024 Dr. Meti
 PERIODONTAL DISEASES

03/20/2024 Dr. Meti

Features of Healthy Gingiva
• Color- pink
• Contour- stippled, due to the pull of periodontal ligament
fibers on the Gingiva.
• Consistency- firm
• No bleeding on probing

03/20/2024 Dr. Meti

2.PERIODONTAL LIGAMENT
• Group of specialized connective tissue fibers which attach the
tooth to the bony Socket.

Functions:
• Hold the tooth in the alveolar bone
• Help the tooth withstand the force of mastication
• Has a sensory nerves that sensitize amount of the force
(sense of Pressure and tension)
• Protective function (from foreign body)

03/20/2024 Dr. Meti

3.ROOT CEMENT (CEMENTUM)
• Specialized and mineralized connective tissue which covers
the dentine of the root.
• It has similar property with bone.

Functions:
 Attach the fibers to the root
 Contributes to the deposition of damage

4. ALVEOLAR BONE
Part of maxilla and mandible that forms support of tooth.
03/20/2024 Dr. Meti
Teeth and Supporting Structures

Schematic representation
of the normal dental
anatomy and surrounding
supporting structures

03/20/2024 Dr. Meti

 PERIODONTAL DISEASES
Periodontal Diseases
• Periodontal disease is a disease of the supporting structure of
the teeth.(periodontal ligament, cementum, alveolar bone and
the various tissue components of the gingiva).

• Periodontal disease, also called gum disease, is mainly caused

by bacteria from plaque and tartar build up.

03/20/2024 Dr. Meti

Prevalence of Periodontal Disease
• Periodontal diseases are the leading cause of tooth loss in
adults.
• Almost all adults and many children have calculus on their
teeth.
• Fortunately, with the early detection and treatment of
periodontal disease, most people can keep their teeth for life.

03/20/2024 Dr. Meti

Etiology

Plaque
• Biofilm which is firmly adherent mass of bacteria in a muco-
polysaccharide matrix.
• Can’t be rinsed off, but can be removed by brushing.
• The principal etiological factor in virtually all forms of periodontal
diseases.
• The etiological bacteria are anaerobic and facultative anaerobes.
*Plaque is the root of most dental diseases.

03/20/2024 Dr. Meti

Calculus
• Also called tartar, is a calcified deposit found on teeth
• It is formed by mineralization of plaque deposits.
• Persistent plaque accumulation for more than 2 weeks, leads
to formation of calculus (tartar),
• Newly formed calculus is light yellow. It is easily stained dark
by foods, coffee, tea and tobacco.

• Calculus cannot be removed by tooth brushing. However, its

presence can make cleaning the teeth more difficult.

03/20/2024 Dr. Meti

• It can be subdivided in to two.
Supra-gingival – above the gingival margin
– it is visible on tooth surface.
Sub-gingival – Underneath the gingival margin
– it is not visible on tooth surface.

03/20/2024 Dr. Meti

Risk Factors:
Systemic factors: Immune status
Stress
Endocrine factors (e.g. DM)
Smoking
Drugs
Age
Nutrition
Local factors: Calculus
Appliances
Muco-gingival state

03/20/2024 Dr. Meti

 • The initiation and progression of periodontal tissue
destruction is a complex process, involving:
• Bacterial accumulation
• Invasion of gingival or periodontal tissue
• Release of bacterial substance
• Host inflammatory response

 It results from an imbalance between potentially pathogenic

microbes and local and systemic host responses. In other
words, bacteria is necessary but not sufficient to cause
disease.
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 Buildup of bacterial plaque on the teeth affects the gingival tissues

03/20/2024 Dr. Meti

• PERIODONTAL DISEASES

• Periodontal disease is an inclusive term describing any disease

of the periodontium.
• Gingival diseases and periodontitis are the two basic forms of
periodontal disease, and each has a variety of forms.

03/20/2024 Dr. Meti

Gingivitis
• It is an inflammatory lesion confined to the tissue of the
marginal gingiva.
• Gingivitis is beginning stage of gum disease and is often
undetected.
• This stage of the disease is reversible.

• Gingivitis is limited to the epithelium and gingival

connective tissues.
– It is important to note that there is no tissue recession
or loss of connective tissue or bone.
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 Cause: accumulation of bacterial plaque at or near the gingival
margin.
• The bacterial component of plaque produces and releases variety of
enzymes and toxins (e.g. lipopolysacchardies and lipotechoic acid)
which diffuse through the junctional epithelium and initiate
inflammatory changes in the gingival connective tissues.

Other factors that have the potential to cause gum disease may
include:
• Tobacco use
• Systemic diseases
• Certain medications
• Genetics

03/20/2024 Dr. Meti

Clinical feature
• Redness of the gum
• Gum bleeding
• Oedema of the gum
• Painful gum
• swollen gums
• Halitosis /Bad breath/
• Bleedin on probing

03/20/2024 Dr. Meti

• Subdivision of Gingivitis

1. Plaque associated Gingivitis (Chronic Gingivitis)

Caused by accumulation of plaque/ calculus on tooth surface.
C.F.- Gingival Redness
- Edema
- Bleeding on probing
- Tenderness

03/20/2024 Dr. Meti

2. Acute Necrotizing Ulcerative Gingivitis (ANUG )
• Definition: is an inflammatory destructive gingival condition
which exhibits characteristics clinical signs and symptoms.
• The other names for ANUG are "Vincent's gingivitis" or
"Vincents gingivostomatitis", 'Trench mouth''

03/20/2024 Dr. Meti

Cause: -
• Fusiform bacteria
• Treponema vincenti
• Fusobacterium nucleatum
• Porphymonas gingivalis

NB. These bacteria are found in large numbers in the

slough and necrotic tissues at the surface of the ulcer.

03/20/2024 Dr. Meti

 Clinical features
• Interproximal ulcers covered with a yellowish-white or grayish
debris
• Easily bleeding
• Necrosis develops rapidly
• Linear erythema
• Bleeding
• Pain
• Halitosis
• Lymphadenitis
• Fever and malaise

03/20/2024 Dr. Meti

Treatment aim
• Control of the acute phase
• Management of the residual condition
Control of the acute phase
• Antibacterial cleaning/2% Chlorhexeidine mouth wash
• Irrigation of the wound with 3% hydrogen peroxide solution
• Scaling of the affected teeth
• Antibiotics: Metronidazole

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Management of the residual condition
– Supra and subgingival scaling
– Regular follow up for maintenance of oral health
NB .Patients with recurrence should undergo medical
examination and screening for predisposing factors.

03/20/2024 Dr. Meti

 3. Gingivitis associated with systemic conditions

A. Hormone induced gingivitis

• Changes in the levels of circulating estrogen and progesterone
can cause gingival hyperplasia,
• It can occur at puberty or pregnancy.
C.F. –Gingival redness
- Edema
- Bleeding on probing
- Enlargement and tenderness

03/20/2024 Dr. Meti

B. Drug induced gingivitis
Medication such as
• phenytoin
• cyclosporine
• calcim channel bloker (nifedipine, diltiazem, amilodipine)
can cause gingival overgrowth/hyperplasia

C.F. - bleeding
- discomfort during chewing
- Pseudopocket
-BOP
• If medically possible the drug responsible for gingival over
growth should be discontinued
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C. Vitamin B and C deficiency gingivitis
C.F. - Redness
- BOP

D. Bacterial, Viral or Fungal

Patients with acute herpetic gingivostomatitis, Candida
albicans and others can sometimes cause gingivitis with
thrush.

03/20/2024 Dr. Meti

Treatment
- Maintenance of good oral hygiene
- Treatment of underlying systemic problem
- Elimination of local irritant
- Antiseptic mouth rinses
- Antibiotics

03/20/2024 Dr. Meti

Periodontitis
• Periodontitis means inflammation of the supporting tissues of the
teeth.
• it is host inflammatory response.

• Periodontitis is the extension of the inflammatory process from

the Gingiva into the connective tissue and alveolar bone that
supports the teeth.
• The progression of periodontitis involves the destruction of
connective tissue attachment at the most apical portion of a
periodontal pocket.
03/20/2024 Dr. Meti
• With complicated periodontitis, the common outcome is
chronic inflammatory response
a condition when the body breaks down the bone and
tissue in the infected area of the mouth
ultimately resulting in tooth and bone loss.

03/20/2024 Dr. Meti

CHRONIC PERIODONTITIS
 Chronic periodontitis formerly known as adult periodontitis or
chronic adult periodontitis it is the most prevalent form of
periodontitis.

 Chronic periodontitis has been defined as “an infectious

disease resulting in inflammation with in supporting tissues of
the teeth, progressive attachment loss and bone loss”.
 More common in males

03/20/2024 Dr. Meti

 Causes – actinobacillus actinomycetumcomitans , bacteriodes
forythus ,porphyromonus gingivalis & prevotella intermdia
 Predisposing factors-smoking ,DM, increasing age

 localized periodontitis: when less than 30% of sites assessed

in the mouth demonstrate attachment and bone loss

 •Generalized: when 30% or more of the sites in the mouth

demonstrate attachment and bone loss

03/20/2024 Dr. Meti

• Risk factors for chronic periodontitis
• The risk factors for chronic periodontitis include
Behavioral risk factors
• Smoking
• Stress
Systemic risk factors.
• •Diabetes
• •Osteoporosis
• •HIV
• •Age
• •Microbiological Factors
• •Familial &Genetic Factors
03/20/2024 Dr. Meti
Signs and symptoms of chronic periodontitis

Symptoms:

• Gingival bleeding when brushing or eating

• Spaces between teeth as a result of tooth movement
• Teeth have become loose or mobile
• Usually painless but occasionally ,
pain may be present in the absence of caries caused by exposed
roots that are sensitive to cold, heat or both.
• Areas of localized dull pain, sometimes radiating deep into,
the jaw
• The presence of areas of food impaction
• Gingival tenderness or itchiness may also be found.
• Halitosis

03/20/2024 Dr. Meti

Chronic periodontitis is a common disease of the oral cavity
consisting of chronic inflammation of the periodontal tissues
that is caused by accumulation of profuse amounts of dental
plaque.

03/20/2024 Dr. Meti

Signs:
• Supragingival and
subgingivalplaque
•Gingival inflammation
•Spontaneous bleeding of Gingiva or
bleeding on probing
•Slightly to moderately swollen
gingiva.
•Loss of gingival stippling
•gingival recession resulting from
loss of attachment &alveolar bone.
•Pocket formation
•Loss of periodontal attachment
•Loss of alveolar bone
•Root fraction exposure.
•Tooth mobility in advanced cases of
bone destruction
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Radiological appearance chronic periodontal disease

03/20/2024 Dr. Meti

• Diagnosis
• Chronic periodontitis can be clinically diagnosed by
• -Detection of chronic inflammatory changes in the marginal
gingival
• -Presence of periodontal pocket
• -Loss of clinical attachment
• It is diagnosed radio graphically by evidence of bone loss
• X-ray result shows widening of the periodontal space in
chronic cases.

.
03/20/2024 Dr. Meti
• These findings may be similar to those seen in aggressive
periodontitis
• A differential diagnosis is based on
Age of the patient
Rate of diseases progression over time
Familial nature of aggressive periodontitis
• Relative absence of local factors in aggressive periodontitis
compared with the presence of abundant plaque and calculus
in chronic periodontitis

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 ….cont.

03/20/2024 Dr. Meti

TREATMENT

•Improvement In Oral
Hygeine
•Scaling And Root Planning
•Sometimes Curettage
•Occlusal evaluation and
therapy
•Reconstructive periodontal
surgery
•Furcation treatment

03/20/2024 Dr. Meti

AGGRESSIVE PERIODONTITIS

“Comprises of a group of rare, often severe, rapidly

progressive forms of periodontitis often characterized
by an early age of clinical manifestation and a
distinctive tendency for cases to aggregate in families.”

03/20/2024 Dr. Meti

 CLASSIFICATION

EARLY ONSET
PERIODONTITIS

AGGRESSIVE
PREPUBERTAL (JUVENILE)
PERIODONTITIS RAPIDLY
PERIODONTITIS PROGRESSIVE
 GENERALIZED PERIODONTITIS
 LOCALIZED  GENERALIZED
 LOCALIZED

03/20/2024 Dr. Meti

• CLINICAL FEATURES
 Onset around the time of puberty .
 Occur in an otherwise healthy individual, clinical
inflammation may not be obvious.
 Localized almost exclusively to the incisors & first molars,
less than 30% of sites are involved.
 Females are affected more than males
 Blacks affected more than whites
 Abnormality in the phagocyte function.
 Self arresting disease progression.

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 Earliest Sign Drifting of teeth in a patient having a good oral
hygiene
 Affected teeth becomes mobile followed by pocket formation.
 Progression of bone loss is 3-5 times faster than adult
periodontitis.
 Maxillary incisors migrate in distolabial direction 
diastema.
 Sensitive root surfaces
 Deep,dull,radiating pain may occur with mastication
(irritation of the supporting tissues)
 Periodontal abscess formation

03/20/2024 Dr. Meti

RADIOGRAPHIC FINDINGS

a. Classic diagnostic sign:

b. Vertical loss of alveolar bone
c. Beginning around puberty in an
otherwise healthy teenagers
d. “Arc shaped loss of alveolar bone

03/20/2024 Dr. Meti

TREATMENT

• Patient education
• Oral hygiene instructions in plaque control & reinforcement
• Selective extraction & replacement
• scaling & root planning of teeth
• Surgical curretement of periodontal pocket
• Systemic administration of antibiotic

03/20/2024 Dr. Meti

Gingival Abscess

• A localized purulent infection that involves the marginal gingival or

interdental papilla

Etiology
• Acute inflammatory response to foreign substances forced into
the gingiva

03/20/2024 Dr. Meti

Clinical Features

Localized swelling of marginal gingiva or

papilla
A red, smooth, shiny surface
May be painful and appear pointed
Purulent exudates may be present
No previous periodontal disease

Treatment

Elimination of foreign object

Drainage through sulcus with probe or light
scaling
Follow-up after 24-48 hours

03/20/2024 Dr. Meti

• Periodontal Abscess
• A localized purulent infection within the tissues adjacent to
the periodontal pocket that may lead to the destruction of
periodontal ligament and alveolar bone
• Usually pre-existing chronic periodontitis present!!!

03/20/2024 Dr. Meti

• Factors associated with abscess development
• Occlusion of pocket orifice (by healing of marginal gingiva
following supragingival scaling)
 Furcation involvement
 Systemic antibiotic therapy (allowing overgrowth of
resistant bacteria)
 Diabetes Mellitus

03/20/2024 Dr. Meti

Clinical Features

• Smooth, shiny swelling of the

gingiva
• Painful, tender to palpation
• Purulent exudates
• Increased probing depth
• Mobile and/or percussion sensitive
• Tooth usually vital

• Treatment
• Drainage
• Antibiotics

03/20/2024 Dr. Meti

 Periodontal Vs. Periapical Abscess

• Periodontal Abscess • Periapical Abscess

– Vital tooth – Non-vital tooth
– No caries – Caries
– Pocket – No pocket
– Lateral radiolucency
– Apical radiolucency
– Mobility
– No or minimal mobility
– Percussion sensitivity
variable – Percussion sensitivity
– Sinus tract opens via – Sinus tract opens via
keratinized gingiva alveolar mucosa

03/20/2024 Dr. Meti

Pericoronal Abscess

A localized purulent infection within the tissue surrounding the

crown of a partially erupted tooth.

Most common adjacent to mandibular third molars in young adults;

usually caused by impaction of debris under the soft tissue flap

03/20/2024 Dr. Meti

 PERIODONTAL DISEASES
• Clinical Features
• Operculum (soft tissue flap)
• Localized red, swollen tissue
• Area painful to touch
• Tissue trauma from opposing tooth common
• Purulent exudate, trismus, lymphadenopathy, fever, and
malaise may be present

03/20/2024 Dr. Meti

• Treatment Options
• Debride/irrigate under Pericoronal flap
• Tissue recontouring (removing tissue flap)
• Extraction of involved and/or opposing tooth
• Antimicrobials ( as needed)

03/20/2024 Dr. Meti

Necrotizing Ulcerative Periodontitis(NUP)
An infection characterized by necrosis of
gingival tissues, periodontal ligament, and
alveolar bone
Clinical Features
Severe deep aching pain
Very rapid rate of bone destruction
Treatment
 Local debridement
 Oral hygiene instructions
 Oral rinses
 Antibiotics and analgesic
 Modify predisposing factors

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