“Periodontology” is the study of the tooth-supporting tissues, the “periodontium.” The periodontium is made up of those tissues that surround each tooth and which anchor each tooth into the alveolar process (Greek: para = adjacent, odus = tooth).
The following soft and hard tissues constitute the structure of the periodontium:
• Gingiva
• Periodontal Ligament
• Root Cementum
• Alveolar Bone
The structure and function of these periodontal tissues have been extensively researched (Schroeder 1992). Knowledge of the interplay between and among the cellular and molecular components of the periodontium leads to optimum therapy, and also helps to establish the goals for future intensive research.
Periodontal Diseases
Gingivitis – Periodontitis
There are numerous diseases that affect the periodontium. By far the most important of these are plaque-associated gingivitis (gingival inflammation without attachment loss) and periodontitis (inflammation-associated loss of periodontal supporting tissues).
Gingivitis is limited to the marginal, supracrestal soft tissues. It is manifested clinically by bleeding upon probing of the gingival sulcus, and in more severe cases by erythema and swelling, especially of the interdental papillae (Fig. 3).
Periodontitis can develop from a pre-existing gingivitis in patients with compromised immune status, the presence of risk factors and pro-inflammatory mediators, as well as the presence of a predominately periodontopathic microbial flora. The inflammation of the gingiva may then extend into the deeper structures of the tooth-supporting apparatus. The consequences include destruction of collagen and loss of alveolar bone (attachment loss). The junctional epithelium degenerates into a “pocket” epithelium, which proliferates apically and laterally. A true periodontal pocket forms. Such a pocket is a predilection site and a reservoir for opportunistic, pathogenic bacteria; these bacteria sustain periodontitis and enhance the progression of the disease processes (Fig. 4).
Gingival Recession
Gingival recession is not actually a “disease,” but rather an anatomic alteration that is elicited by morphology, improper oral hygiene (aggressive scrubbing), and possibly functional overloading.
Teeth are not lost due to classical gingival recession, but patients may experience cervical hypersensitivity and esthetic complications. If gingival recession extends to the mobile oral mucosa, adequate oral hygiene is often no longer possible. Secondary inflammation is the consequence.
In addition to classical gingival recession, apical migration of the gingiva is often observed in patients with long-standing, untreated periodontitis, and it may be a consequence of periodontitis therapy in elderly patients (“involution”; Fig. 2).
These three periodontal disorders – gingivitis, periodontitis, gingival recession – are observed world-wide; they affect almost the entire population of the earth to greater or lesser degree. In addition to these common forms of oral pathology, there are many less frequently encountered diseases and defects of the periodontal tissues. All of these diseases were comprehensively classified at an international World Work-shop in 1999 (see Appendix, p. 327).
1Healthy PeriodontiumThe most important characteristic of the periodontium is the special connection between soft and hard tissues:• In the marginal region, one observes inflammation-free gingiva, which provides the epithelial attachment to the tooth by means of its junctional epithelium (pink collar). This connection protects the deeper-lying components of the periodontium from mechanical and microbiologic insult.• Subjacent to the junctional epithelium, one observes the supracrestal fibers, which serve to connect the tooth with the gingiva, and also the periodontal ligament fibers in the region of the alveolar bone, which insert into the bone and the cementum of the root surface.Prevention of disease: Maintaining the health of the periodontium is the highest goal in periodontics, and should also be the patient’s goal. It is achieved by optimum, purely mechanical oral hygiene. Disinfectant mouthwashes may enhance mechanical hygiene.2Gingival RecessionThe main characteristic of this condition, which is often esthetically objectionable to patients, is an inflammation-free apical migration of the gingival margin. A morphological prerequisite is generally a facial bony lamella that is either extremely thin or entirely lacking. Gingival recession can be initiated and propagated by improper traumatic tooth brushing (horizontal scrubbing), and functional overloading may also play a role (?). Thus gingival recession cannot be classified as a true periodontal disease.The best way for a patient to prevent gingival recession is by using an adequate but gentle oral hygiene technique (vertical-rotatory brushing or use of a sonic toothbrush).Treatment: Incipient or progressing gingival recession can be halted by altering the patient’s oral hygiene techniques; in severe cases, mucogingival surgery may be employed to stop the progression or re-cover the exposed root surfaces.3GingivitisGingivitis is characterized by plaque-induced inflammation of the papillary and marginal gingivae. Clinical symptoms include bleeding on probing, erythema, and eventual swelling. Gingivitis may be more or less pronounced depending upon the plaque—a biofilm—(quantity/quality) and the host response. Deeper lying structures (alveolar bone, periodontal ligament) are not involved. Gingivitis may be a precursor to periodontitis, but this does not always occur.Treatment: Gingivitis can be completely controlled simply through adequate plaque control. Following initiation or improvement of oral hygiene procedures, coupled with professional plaque and calculus removal, complete healing can be expected. Nevertheless, freedom from inflammation, e.g., absence of bleeding on probing, will be impossible to achieve if the patient is not capable of maintaining a high standard of oral hygiene over the long term, or is not willing to do so (compliance!).4PeriodontitisAt the gingival margin, the characteristics of periodontitis are similar to those of gingivitis, but the inflammatory processes extend further, into the deeper-lying periodontal structures (alveolar bone and periodontal ligament). True periodontal pockets are formed and connective tissue attachment is lost. Loss of hard and soft tissues is usually localized and not generalized.Periodontitis may be classified as chronic (Type II) or aggressive (Type III), with varying degrees of severity. Approximately 90% of all cases are characterized as “chronic periodontitis” (p. 108, 327).Treatment: Most cases of periodontitis can be treated successfully. However, the required therapeutic endeavor can vary enormously from case to case. The treatment effort may be relatively small in early stages of periodontitis. Mechanical treatment remains today in the foreground. In special cases, topical and systemic medications may be used as supportive therapy.
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