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11 from gingivitis to

  1. 1. From Gingivitis to Periodontitis Prof Dr.Eman Abd - Elsattar Tella Faculty of Dentistry, Umm Al Qurra University,Makka.
  2. 2. <ul><li>Clinical Features of Gingivitis </li></ul><ul><li>Extension of inflammation from the gingiva in the supporting periodontal tissue. </li></ul><ul><li>Chronic periodontitis </li></ul>
  3. 3. Clinical Features of Gingivitis
  4. 4. <ul><li>COURSE AND DURATION </li></ul><ul><li>Acute gingivitis is of sudden onset and short duration and can be painful. </li></ul><ul><li>Recurrent gingivitis reappears after having been eliminated by treatment. </li></ul><ul><li>Chronic gingivitis is slow in onset and of ', long duration, and is painless </li></ul><ul><li>Chronic gingivitis is a fluctuating disease in which inflammation persists or resolves. </li></ul>
  5. 5. <ul><li>DISTRIBUTION </li></ul><ul><li>Localized gingivitis is confined to the gingiva of a sin­gle tooth or group of teeth while generalized gingivitis involves the entire mouth. </li></ul><ul><li>Marginal gingivitis involves the gingival margin and may include a portion of the contiguous attached gingiva. </li></ul><ul><li>Papillary gingivitis involves the interdental papillae and often extends into the adjacent portion of the gingival margin. </li></ul><ul><li>Diffuse gingivitis affects the gingival margin, the attached gingiva, and the interdental papille. </li></ul>
  6. 6. <ul><li>DISTRIBUTION </li></ul><ul><li>Localized marginal gingivitis is confined to one or more areas of the marginal gingiva. </li></ul><ul><li>Localized diffuse gingivitis extends from the margin to the mucobuccal fold but is limited in area. </li></ul><ul><li>Localized papillary gingivitis is confined to one or more interdental spaces in a limited area </li></ul><ul><li>Generalized marginal gingivitis involves the gingi­val margins in relation to all the teeth. </li></ul><ul><li>Generalized diffuse gingivitis involves the entire gingiva. The alveolar mucosa and attached gingiva are affected. </li></ul>
  7. 7. <ul><li>DISTRIBUTION </li></ul><ul><li>Localized gingivitis is confined to the gingiva of a single tooth or group of teeth while generalized gingivitis involves the entire mouth. </li></ul>
  8. 8. <ul><li>DISTRIBUTION </li></ul><ul><li>Marginal gingivitis involves the gingival margin and may include a portion of the contiguous attached gingiva. </li></ul><ul><li>Papillary gingivitis involves the interdental papillae and often extends into the adjacent portion of the gingival margin. </li></ul>
  9. 9. <ul><li>DISTRIBUTION </li></ul><ul><li>Diffuse gingivitis affects the gingival margin, the attached gingiva, and the interdental papille. </li></ul>
  10. 10. <ul><li>Healthy gingiva </li></ul><ul><li>Pale pink & stippled. Narrow distinguishable free gingival margin. No bleeding on probing </li></ul><ul><li>Mild gingivitis </li></ul><ul><li>Localized mild erythema & slight edema. Some stippling is lost. Minimal bleeding after probing. </li></ul>
  11. 11. <ul><li>Moderate gingivitis </li></ul><ul><li>Obvious erythema & edema. No stippling, bleeding on probing </li></ul><ul><li>Severe gingivitis </li></ul><ul><li>Fiery redness, edematous & hyperplastic swelling, complete absence of stippling, bleeding on probing & spontaneous hemorrhage. </li></ul>
  12. 12. Mild gingivitis in anterior area : Mild erythema in maxilla. Slight edematous swelling & erythema. In mandible, slight edematous swelling & erythema. Papilla Bleeding Index : Grade 1 & 2 Stained plaque : Small plaque accumulations arounds the necks of the teeth & in interdental areas.
  13. 13. <ul><li>Gingival Bleeding on Probing </li></ul><ul><li>The two earliest symptoms of gingival inflammation preceding established gingivitis are: </li></ul><ul><li>increased gingival crevicular fluid production rate and </li></ul><ul><li>bleeding from the gingival sulcus on gentle probing </li></ul><ul><li>shown that bleeding on probing appears earlier than a change in color or other visual signs of inflammation. </li></ul>
  14. 14. Moderate gingivitis in anterior teeth :Erythema & enlargement of gingiva pronounced in mand than in maxilla. Papilla Bleeding Index : grade 3 & 4 Stained plaque : Moderate plaque accumulation in maxilla. Heavier plaque in mandible. Radiographically, no destruction of interdental bony septa.
  15. 15. <ul><li>Gingival Bleeding Caused by Local Factors </li></ul><ul><li>Chronic and Recurrent Bleeding </li></ul><ul><li>The most common cause of abnormal gingival bleeding on probing is chronic inflammation. The bleeding is chronic or recurrent and is provoked by mechanical trauma (e.g., from toothbrushing, toothpicks, or food impaction) or by biting into solid foods such as apples. </li></ul><ul><li>In cases of moderate or advanced periodontitis, the presence of bleeding on probing is considered a sign of active tissue destruction. </li></ul>
  16. 16. <ul><li>Acute bleeding. </li></ul><ul><li>Acute episodes of gingival bleeding are caused by injury or occur spontaneously in acute gingival disease. </li></ul><ul><li>Spontaneous bleeding or bleeding on slight provocation can occur in acute necrotizing ulcerative gingivitis. In this condition, engorged blood vessels in the inflamed connective tissue arc exposed by ulceration of the necrotic surface epithelium. </li></ul>
  17. 17. <ul><li>Gingival bleeding Associated with Systemic Changes </li></ul><ul><li>In some systemic disorders, gingival hem­orrhage occurs spontaneously or after irritation and is excessive and difficult to control. </li></ul><ul><li>A hemostatic mechanism failure and result in abnormal bleeding (vitamin C deficiency or allergy such as Schonlein-Hchoch purpura) , platelet disorders (thrombocytopcnic purpura) , hypopro-thrombincmia (vitamin K deficiency) , other coagulation defects (hemophilia, leukemia, Christmas disease) </li></ul>
  18. 18. <ul><li>Color Changes in the Gingiva </li></ul><ul><li>Color Changes in Chronic Gingivitis. </li></ul><ul><li>The normal gingival color is &quot;coral pink&quot; . </li></ul><ul><li>Thus chronic inflammation intensifies the red or bluish red color, because of vascular proliferation and reduction of keratinization. </li></ul><ul><li>Color Changes in Acute Gingivitis. </li></ul><ul><li>The color changes may be marginal, diffuse, or patchlike, depending on the underlying acute condition. </li></ul><ul><li>In acute necrotizing ulcerative gingivitis the involvement is marginal; in herpetic gingivostomatitis, it is diffuse. </li></ul><ul><li>Color changes vary with the intensity of the inflammation. Initially, there is an increasingly red erythema. </li></ul>
  19. 19. <ul><li>Metallic Pigmentation </li></ul><ul><li>Heavy metals (bismuth, arsenic, mercury, lead, silver) absorbed systemically from therapeutic use or occupational or household environments may discolor the gingiva and other areas of the oral mucosa. </li></ul>
  20. 20. <ul><li>Color Changes Associated with Systemic Factors </li></ul><ul><li>Addison's disease </li></ul><ul><li>caused by adrenal dysfunction and pro­duces isolated patches of discoloration varying from bluish black to brown </li></ul>
  21. 21. <ul><li>Changes in the Consistency of the Gingiva </li></ul><ul><li>Both chronic and acute inflammation produce changes in the normal firm, resilient consistency of the gingiva. </li></ul><ul><li>As noted in the preceding discussion, in chronic gingivitis, both destructive (edematous) and reparative (fibrotic) changes coexist and the consistency of the gingiva is determined. </li></ul><ul><li>Changes in the Surface Texture of the Cingiva </li></ul><ul><li>Loss of surface stippling is tin early sign of gingivitis. In chronic inflammation the surface is either smooth and shiny or firm and nodular, depending on whether the dominant changes are exudative or fibrotic. </li></ul>
  22. 23. <ul><li>Changes in the Position of the Gingiva </li></ul><ul><li>Actual and Apparent Positions of the Gingiva. Recession is exposure of the root surface by an apical shift in the position of the gingiva. </li></ul><ul><li>The actual position is the level of the epithelial attachment on the tooth, whereas the apparent position . </li></ul><ul><li>The severity of recession is determined by the actual position of the gingiva, not its apparent position. </li></ul>
  23. 25. <ul><li>Changes in Gingival Contour </li></ul><ul><li>Changes in gingival contour are for the most part associated with gingival enlargement </li></ul>
  24. 26. II- Extension of inflammation from the gingiva in the supporting periodontal tissue
  25. 27. <ul><li>Histologically </li></ul><ul><li>Interproximally, inflammation spreads to the loose connective tissue around the blood vessels, through the fibers, and then into the bone through vessel channels that perforate the crest of the interdental septum at the center of the crest toward the side of the crest or at the angle of the septum and it may enter the bone through more than one channel. </li></ul><ul><li>Less frequently, the inflammation spreads from the gingiva directly into the periodontal ligament and from there into the interdental septum. </li></ul><ul><li>Facially and lingually, inflammation from the gingiva spreads along the outer periosteal surface of the bone and penetrates into the marrow spaces through vessel channels in the outer cortex. </li></ul>
  26. 29. III- Chronic periodontitis
  27. 30. <ul><li>Chronic periodontitis is most frequently observed in adults, it i an occur in children and adolescents in response to chronic plaque and calculus accumulation. </li></ul><ul><li>Chronic periodontitis has recently been defined as &quot;an infectious disease resulting in inflammation within the supposing tissues of the teeth, progressive attachment loss and bone loss. </li></ul><ul><li>Microbial plaque formation, periodontal inflammation, and loss of attachment and alveolar bone. </li></ul>
  28. 31. <ul><li>CLINICAL FEATURES </li></ul><ul><li>General Characteristics </li></ul><ul><li>Characteristic clinical findings in patients with chroni periodontitis include supragingival and subgingiva plaque accumulation that is frequently associated with calculus formation, gingival inflammation, pocket formation, loss of periodontal attachment and loss of alveolar bone. </li></ul><ul><li>The gingiva ordinarily is slightly to moderately swollen and exhibits alterations in color ranging from pale red to magenta. </li></ul>
  29. 32. <ul><li>General Characteristics </li></ul><ul><li>Loss of gingival stip pling and changes in the surface topography may in elude blunted or rolled gingival margins and flattened of cratcred papillae. </li></ul><ul><li>Gingival bleeding, either spontaneous or in response to probing, is frequent and inflammation-related exudates of cervicular fluid and suppuration from the pocket also may be found. </li></ul><ul><li>Pocket depths are variable, and both horizontal and vertical bone loss can be found. Tooth mobility often appears in advanced cases when bone loss has been considerable. </li></ul>
  30. 33. <ul><li>General Characteristics </li></ul><ul><li>Chronic periodontitis can be clinically diagnosed by the detection of chronic inflammatory changes in the marginal gingiva, presence of periodontal pockets, and loss of clinical attachment. </li></ul><ul><li>It is diagnosed radiographically by evidence of bone loss. </li></ul>
  31. 34. Chronic Periodontitis General Clinical Features: (cont.’) • Periodontal pocket formation with variable depth. • Bleeding upon probing (BOP)
  32. 38. <ul><li>Disease Distribution </li></ul><ul><li>Chronic periodontitis is considered a site-specific disease. </li></ul><ul><li>Localized periodontitis : </li></ul><ul><li>Periodontitis is considered localized when <30% of the sites assessed in the mouth demonstrate attachment loss and bone loss. </li></ul><ul><li>Generalized periodontitis : </li></ul><ul><li>Periodontitis is considered generalized when >30% of the sites assessed In the mouth demonstrate attachment loss and bone loss. </li></ul>
  33. 39. <ul><li>Disease Severity </li></ul><ul><li>Slight (mild) Periodontitis : </li></ul><ul><li>Periodontal destruction is generally considered slight when no more than 1 to 2 mm of clinical attachment loss has occurred. </li></ul><ul><li>Moderate Periodontitis : </li></ul><ul><li>Periodontal destruction is generally considered moderate when 3 to 4 mm of clinical attachment loss has occurred. </li></ul><ul><li>Severe Periodontitis : </li></ul><ul><li>Periodontal destruction is considered severe when 5 mm or more of clinical attachment loss has occurred. </li></ul>
  34. 40. <ul><li>Symptoms </li></ul><ul><li>Because chronic periodontitis is usually painless, patients may be less likely to seek treatment and accept treatment recommendations. </li></ul><ul><li>Occasionally, pain may be present in the absence of caries due to exposed roots that an sensitive to heat, cold, or both. </li></ul><ul><li>The presence of areas of food impaction may add to the patient's discomfort. </li></ul>
  35. 41. <ul><li>Disease Progression </li></ul><ul><li>The rate of disease progression is usually slow but may be modified by systemic and/or environmental and behavioral factors. </li></ul><ul><li>Onset of chronic periodontitis can occur at any time, and the first signs may be detected during adolescence in the presence of chronic plaque and calculus accumulation. </li></ul><ul><li>Chronic periodontitis does not progress at an equal rate in all affected sites throughout the mouth. Some involved areas may remain static for long periods of time/ whereas others may progress more rapidly. </li></ul><ul><li>More rapidly progressive lesions occur most frequently in interproximal areas and are usually associated with areas of greater plaque accumulation and inaccessibility to plaque control measures </li></ul>
  36. 42. <ul><li>Prevalence </li></ul><ul><li>Chronic periodontitis increases in prevalence and severity with age, generally affecting both sexes equally. </li></ul>
  37. 43. <ul><li>RISK FACTORS FOR DISEASE </li></ul><ul><li>Prior History of Periodontitis </li></ul><ul><li>Local Factors </li></ul><ul><li>Claque accumulation on tooth and gingival surfaces at the dentogingival junction is considered the primary initiating agent in the etiology of chronic periodontitis. </li></ul><ul><li>Attachment and bone loss are associated with an increase i n the proportion of gram-negative organisms in the sub­gingival plaque biofilm. </li></ul><ul><li>Bacteroides gingivals, Bacteroids forsythus and Teponema denticola. </li></ul>
  38. 44. <ul><li>These microorganims and their virulence factors. </li></ul><ul><li>But these bacteria may impart a local effect on the cells of the inflammatory response and the cells and tissues of the host, resulting in a local, site-specific disease process. </li></ul><ul><li>Calculus is considered the most important plaque retentive factor, because of its ability to retain and harbor plaque bacteria on its rough surface </li></ul>
  39. 45. <ul><li>Other factors </li></ul><ul><li>Overhanging margins of restorations. </li></ul><ul><li>carious legions. </li></ul><ul><li>Furcations. </li></ul><ul><li>crowded and malaligned teeth. </li></ul><ul><li>root grooves and concavities </li></ul>
  40. 46. <ul><li>Systemic Factors </li></ul><ul><li>The rate of periodontal destruction may be significantly increased. Diabetes is a systemic condition that can increase the severity and extent if periodontal disease in an affected patient. </li></ul>
  41. 47. <ul><li>Environmental and Behavioral Factors </li></ul><ul><li>Smoking has been shown to increase the severity and extent of periodontal disease. </li></ul><ul><li>When combined with plaque-induced chronic periodontitis, an increased in the rate of periodontal destruction. </li></ul><ul><li>Emotional stress. </li></ul><ul><li>Suggests that emotional stress also may influence the extent and severity of chronic periodontitis. </li></ul>
  42. 48. <ul><li>Genetic Factors </li></ul><ul><li>Periodontal destruction is frequently seen among family members and across different generations within a family, suggesting the possibility of a genetic basis to the susceptibility to periodontal disease. </li></ul><ul><li>Recurrent studies have demonstrated a familial aggregation of localized and generalized aggressive periodonlitis. </li></ul>