14: Periodontics

Periodontics

The vast majority of periodontal needs are related to the treatment of gingivitis and early periodontitis, the prevention of periodontal disease, and the maintenance of periodontal health after therapy. These services are provided by dental hygienists; the demand for these services and the dental hygienists who provide them continues to grow. Understanding of periodontics is critical to the process of dental hygiene care.

Basic Features of the Periodontium

Gingiva

Definition

Part of the oral masticatory mucosa that surrounds the cervical portion of the teeth and covers the alveolar process of the jaws

Components

1. Marginal gingiva (unattached or free gingiva)

a. Unattached cuff-like tissue that surrounds teeth facially, lingually, and interproximally

b. Parts of marginal gingiva

(1) Gingival margin—most coronal portion; surrounds the teeth in a scalloped outline; located at or approximately 0.5 millimeters (mm) coronal to the cemento-enamel junction (CEJ)

(2) Gingival groove—present in only 50% of gingival surfaces; when present, it is located 1 to 1.5 mm apical to the gingival margin at the base of the gingival sulcus

(3) Gingival sulcus—space formed by the tooth and the sulcular epithelium laterally and by the coronal end of the junctional epithelium (base of the sulcus) apically; in periodontal health, almost no gingival sulcus exists; a sulcular measurement of 1 to 2 mm facially and lingually and 1 to 3 mm interproximally is considered normal

(4) Interdental gingiva—occupies the interdental space coronal to the alveolar crest (clinically, it fills the embrasure space beneath the area of tooth contact)

2. Attached gingiva

3. Changes in the width of attached gingiva result from changes at the coronal end

Histologic Features1,2

See the sections on “Oral histology,” “Oral mucosa,” and “Dento-gingival junction,” in Chapter 2.

Epithelium

1. Sulcular (crevicular) epithelium—stratified squamous, nonkeratinized epithelium that is continuous with the oral epithelium; lines the peripheral surface of the sulcus extending to the coronal border of the junctional epithelium

2. Junctional epithelium—part of the dento-gingival junction; stratified squamous, nonkeratinized epithelium that surrounds and attaches to the tooth on one side and attaches on the other side to the gingival connective tissue; new cells originate from the cells in the apical portion adjacent to the tooth and from the cells in contact with the connective tissue; epithelial cells are shed (desquamation) at the coronal end of the junctional epithelium, which forms the base of the gingival sulcus

3. Epithelial attachment—basal lamina, hemidesmosomes, adhesion proteins (laminins), and anchoring fibrils that connect the junctional epithelium to the tooth surface at or slightly coronal to the CEJ

Connective tissue (or lamina propria)—composed of gingival fibers (connective tissue fibers), intercellular ground substance, cells, and vessels and nerves (see Chapter 2, Figures 2-20 and 2-27)

1. Gingival fibers—composed of collagen fibers (60% of connective tissue volume) and an elastic fiber system composed of oxytalan, elaunin, and elastin fibers; fiber bundle groups provide support for marginal gingiva, including the interdental papilla (see also Chapter 2, Figure 2-28, B, and the section on “Oral histology, periodontal ligament for gingival fiber groups”)

2. Intercellular ground substance (or matrix)–similar to connective tissue in periodontal ligament

3. Cells

4. Vessels and nerves (see the section on “Blood supply to the periodontium”)

Normal Clinical Features

See Figure 14-2.

Color—in light-skinned individuals, pale or coral pink; in dark-skinned individuals, coral pink to brown; color varies, depending on the degree of vascularity, amount of melanin, epithelial keratinization, and thickness of epithelium

Texture

Consistency

Contour and shape

Periodontal Ligament

See the section on “Periodontal ligament” and Figure 2-27 in Chapter 2.

Alveolar Process

See the section on “Alveolar bone” and Figure 2-26 in Chapter 2.

Shape, Thickness, and Location

The contour of the alveolar bone follows the contour of the CEJ and the arrangement of the dentition

The shape of the alveolar crest is generally parallel to the CEJ of adjacent teeth; is approximately 1.5 to 2 mm apical to the CEJ

Cortical plates generally are thicker in the mandible than in the maxilla

Posterior areas—bone generally is thick, and cancellous bone separates the cortical plate from the alveolar bone proper

Anterior areas—bone is thin, with little or no cancellous bone separating the cortical plate from the alveolar bone proper

Dehiscence—situation in which the marginal alveolar bone is denuded, forming a defect extending apical to the normal level, exposing an abnormal amount of root surface

Fenestration—situation in which the margin of alveolar bone is intact; an isolated lack of alveolar bone on the root surface leaves it covered only by the periosteum and overlying gingiva

Radiographic Features of the Normal Periodontium

See Figure 14-3.

Alveolar crest—thin, radiopaque line continuous with the lamina dura; the shape is dependent on the following:

Interdental septum—proximal alveolar bone bordered by the alveolar crest

Lamina dura—radiographic image of the alveolar bone proper; may or may not be present as a thin radiopaque line surrounding the bone adjacent to the periodontal ligament

Periodontal ligament space—thin radiolucent line surrounding each tooth between the root and adjacent alveolar bone

Supporting bone—radiopacity of the trabecular pattern varies, depending on the amount, pattern, and presence of cancellous and cortical bone

Limitations of radiographs—radiographs:

Diseases of the Periodontium

Classification of Periodontal Diseases1–3

See the section on “Periodontal diseases” in Chapter 9.

Importance of disease classification

Current classifications of periodontal diseases3

1. Gingival diseases

2. Chronic periodontitis—localized or generalized

3. Aggressive periodontitis—localized or generalized

4. Periodontitis as a manifestation of systemic diseases (i.e., hematologic or genetic)

5. Necrotizing periodontal diseases

6. Abscesses of the periodontium

7. Periodontitis associated with endodontic lesions

8. Developmental or acquired deformities and conditions

Gingival Diseases1,3

Common characteristics

Dental plaque–induced gingivitis

1. Inflammation of the gingiva resulting from bacterial plaque biofilm at the gingival margin

2. Most common form of periodontal disease; prevalent in all age groups

3. Change in gingival color and contour (redness, swelling, enlargement); increased sulcular temperature and gingival exudate; bleeding on provocation; reversible with plaque removal

4. Sensitivity or tenderness can occur, although not necessarily present in all clients

5. Absence of attachment loss and bone loss is characteristic; after active periodontal treatment and resolution of inflammation in periodontitis, tissue becomes healthy, but attachment loss remains; dental plaque–induced gingivitis on a reduced periodontium can occur in these cases if gingival inflammation arises without evidence of progressive attachment loss

Gingival diseases associated with endocrine changes or endogenous sex hormones

1. Periodontal tissues are modulated by androgens, estrogens, and progestin

2. Most information exists about sex hormone–induced effects in women: menstruation, pregnancy, and puberty

3. Gingival response requires bacterial plaque in conjunction with steroid hormones

a. Puberty-associated gingivitis—occurs in adolescents during puberty in both genders when the dramatic rise in hormone levels has a transient effect on gingival inflammation; signs of gingivitis exist in the presence of relatively sparse deposits

b. Menstrual cycle–associated gingivitis—significant and observable inflammatory changes occur most frequently during ovulation

c. Pregnancy-associated gingivitis—some of the most remarkable endocrine changes occur during pregnancy owing to increased plasma hormone levels; features are similar to plaque-induced gingivitis, but relatively little bacterial plaque may be present

d. Pregnancy-associated pyogenic granuloma (pregnancy tumor)—pronounced response of gingiva to bacterial plaque at gingival margin in the form of a sessile or pedunculated protuberant mass; more common interproximally; regresses after parturition

Gingival diseases associated with medications (drug-influenced gingival diseases)2–4

1. Drug-influenced gingival enlargement—overgrowth of the gingiva most commonly associated with the following:

2. Occurs most frequently in the anterior gingiva, especially in children; onset within 3 months of drug regimen

3. Changes in gingival contour, size, and color all because of enlargement; increased gingival exudate and bleeding on provocation can coexist; first occurs interproximally

4. Found in the gingiva, with or without bone loss; not associated with attachment loss

5. Plaque control can limit the severity of the pronounced inflammatory response of the gingiva

6. Oral contraceptive–associated gingivitis—also can occur in the presence of marginal plaque because of the pronounced inflammatory response of the gingiva in women using certain oral contraceptive agents; inflammation and enlargement are reversible when the drug is discontinued

Gingival diseases associated with systemic diseases

Gingival diseases associated with malnutrition

Non–plaque-induced gingival lesions3

1. Infectious gingivitis—includes specific bacteria (e.g., Neisseria gonorrhoeae, Treponema pallidum, streptococci), viruses (e.g., herpes simplex types 1 and 2, varicella zoster, and papillomavirus), fungi (e.g., Candida species), or genetic conditions (e.g., hereditary gingival fibromatosis) (see the section on “Periodontal diseases” in Chapter 9); linear gingival erythema occurs in individuals who have acquired immune deficiency syndrome (AIDS) or other immunocompromising diseases

2. Dermatologic diseases, including lichen planus, pemphigoid, pemphigus vulgaris, erythema multiforme, psoriasis, and lupus erythematosus, also may present with gingival manifestations; the diagnosis depends on clinical findings and biopsy specimens (see the sections on “Major aphthous ulcers,” “Skin diseases,” and “White lesions” in Chapter 8)

3. Allergic reactions in the oral mucosa are uncommon but can be caused by dental restorations, dentifrices, mouthwashes, and food allergens; signs and symptoms do not resolve when oral hygiene is instituted

4. Foreign body reactions occur when ulceration of the gingival epithelium allows entry of a substance into the gingival connective tissue; most commonly is an amalgam tattoo

5. Mechanical trauma can be accidental, iatrogenic, or factitious; results in gingival or tooth abrasion, recession, ulceration, inflammation, or laceration

Chronic Periodontitis2,3

Slowly progressive; most common in adults; can also occur in children and adolescents

The disease results from the inflammatory process originating in the gingiva (gingivitis) and extending into the supporting periodontal structures; may have periods of activity and remission; has slow to moderate progression; may have periods of rapid progression

1. Can be further classified on the basis of extent and severity

a. Extent—number of sites involved

b. Severity—clinical attachment loss (CAL)

(1) Early—progression of gingival inflammation into the deeper periodontal structures and alveolar bone crest, with slight bone loss; with normal gingival contour, usual periodontal probing depth is 2 to 3 mm, with slight loss of connective tissue attachment and alveolar bone; average 1 to 2 mm attachment loss

(2) Moderate—a more advanced state of the above condition, with increased destruction of periodontal structures and noticeable loss of bone support, possibly accompanied by an increase in tooth mobility; average probing depth of 4 to 5 mm, with normal gingival contour; average 3 to 4 mm attachment loss

(3) Advanced—further progression of periodontitis, with major loss of alveolar bone support >30%;5 usually accompanied by increased tooth mobility; furcation involvement in multiple-rooted teeth is likely; recession is common; average probing depth 6 mm or more, with normal gingival contour; average ≥5 mm attachment loss

2. Radiographic features (see the section on “Changes in the periodontium associated with disease”)

3. Cause—host response to bacterial plaque biofilm; the amount of destruction is consistent with the presence of local factors; subgingival calculus is frequently seen; is associated with various microbial patterns; can be associated with local predisposing factors; may be modified by systemic diseases and other risk factors

4. Treatment—nonsurgical or surgical periodontal therapy, or both, depending on extent and severity, followed by periodontal maintenance procedures

Chronic periodontitis can be recurrent and refractory (nonresponsive); not all cases of periodontitis have successful treatment outcomes

Aggressive Periodontitis1–3,6

Can occur at any age; may be localized or generalized

Common features

Localized aggressive periodontitis

Generalized aggressive periodontitis

Treatment—same as for chronic periodontitis; systemic antibiotic (tetracycline derivative or metronidazole and amoxicillin therapy) and diligent periodontal maintenance procedures

Periodontitis as a Manifestation of Systemic Diseases2,3

Systemic factors modify all forms of periodontal disease, but some systemic diseases cause periodontitis; the listing is categorized under broad headings; other diseases may be added to the list in the future

Hematologic disorders—see the section on “Blood dyscrasias” in Chapter 8

Genetic disorders1,6 (see the section on “Genetics” in Chapter 7)

Jan 1, 2015 | Posted by in Dental Hygiene | Comments Off on 14: Periodontics
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