Periodontal diseases are one of the most common diseases in adults. Signs of mild periodontal inflammation are usually present in adults, and 10 to 60% of middle-aged adults have severe enough periodontal disease that requires treatment.
For diagnosis, it is helpful to understand the appearance of healthy periodontal tissues. This chapter begins with a description of periodontal health and reviews the contribution of microbes and immune system to the cellular changes that lead to the signs and symptoms of periodontal diseases. This is followed by reviews of periodontal wound healing and tooth development, and their influences on periodontal disease and treatment.
A 25-year old healthy female dental student is seen for a periodontal exam as part of a clinical peer-to-peer exercise. See Fig. 1.1 for clinical presentation and Fig. 1.2 for radiographic presentation. She is currently satisfied with her dental condition, but had minor restorative treatment in the past and receives routine preventive dental care. She brushes and flosses regularly at least twice a day. These are the findings:
Periodontal measurements: Probing depths less than 5 mm, no bleeding on probing, no clinical attachment loss, furcation involvement, tooth mobility, and gingival recession. The gingiva is coral pink with patches of light pink on the maxilla, firmly attached to underlying hard tissue and stippled. The gingival margin follows the contours of the teeth in a scalloped fashion, and no plaque or calculus is present.
This dental student displays a good example of periodontal health. The description of the gingiva matches characteristics of periodontal health. Periodontal health is most commonly seen in young, healthy adults who receive frequent preventive care and practice effective oral hygiene.
As seen in the previous case, periodontal health means absence of signs and symptoms of periodontal disease. No signs of inflammation are present in any area of the gingiva (see Fig. 1.1), and all gingival landmarks are easily visible and in normal proportion to each other. Landmarks and areas of gingiva and mucosa are named as shown in Fig. 1.3.
Fig. 1.3 (a) Oblique facial view of gingiva in patient seen in the preceding case with the different gingival landmarks and areas labeled. (b) Diagram of gingival landmarks. Healthy gingiva usually contains patches of stippling in the attached gingiva zone. (c) Diagram of a cross-section of healthy gingiva and periodontium attaching up to the cemento-enamel junction (CEJ). E = epithelium, CT = connective tissue. (d) Atraumatic extraction of a periodontally involved tooth reveals a depression in the interdental papilla called a “col,” which forms around wide interproximal contact points. Periodontal disease also produced the rough, pebbly epithelial surface that lined the extracted tooth. This is the sulcular epithelium that normally adapts tightly to the tooth surface inside the periodontal sulcus.
The case illustrates what periodontal health looks like, and clinical data matches many elements of periodontal health as shown in Table 1.2.
Most patients’ periodontal disease experience will fall somewhere on a spectrum of periodontal disease between perfect periodontal health and severe disease, matching all characteristics listed in Table 1.2. The challenge for a clinician is to decide whether a patient has sufficient signs and symptoms of the disease to warrant treatment.