Periodontal Considerations In Dentistry

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Periodontal Considerations
Dr. Dina Zohaia

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●The periodontal status of the involved abutment teeth
should be determined, to allow accurate prognosis of
the restoration.
●Because periodontal disease is the major cause of
tooth loss in adults.
Introduction:

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Anatomy:
●The lining of the oral cavity consists of three types of
mucosa:
1) Masticatory (keratinized) mucosa: covering gingiva
and hard palate.
2) Lining (reflecting) mucosa: covering lips, cheeks,
vestibule, alveoli, floor of mouth, and soft palate.
3) Specialized (sensory) mucosa: covering dorsum of
tongue and taste buds.

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Gingiva:
●Normal gingiva is pink and stippled.
●(1-9 mm) in width.
●Extends from the free gingival margin, to the alveolar
mucosa.
●The gingiva and the alveolar mucosa are separated by
(muco-gingival junction).

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The gingiva consists of three parts:
1) Free gingiva (marginal): extends from most coronal
part of gingiva to epithelial attachment with tooth.
2) Attached gingiva: extends from the epithelial
attachment to muco-gingival junction (MGJ).
3) Inter-dental papillae: triangular projection of the
gingivae filling the area between adjacent teeth.

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●The gingiva consists of dense collagen fibers which
can be divided into ( Alveologingival – Dentogingival –
Circular – Dentoperiosteal – Transseptal ) groups.
●The fibers FIRMLY bind the gingiva to the teeth.

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Periodontium:
●A connective tissue structure attached to the
periosteum of both the mandible and maxilla.
●It provides:
1) Attachment.
2) Support.
3) Nutrition.
4) Synthesis and resorption.
5) Mechanoreception.

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Periodontal Ligaments (PDL):
●The main element of the periodontium.
●Consists of collagen fibers embedded in bone and
cementum, giving support to the tooth in function.
●These fibers also known as (Sharpey’s fibers), follow a
wavy course and terminate either cementum or bone.

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Five principal fiber groups in the
(PDL):
1) Transseptal fibers: extend interproximally between
adjacent teeth.
2) Alveolarcrest fibers: extend from cementum to the
alveolar crest.
3) Horizontal fibers: at right angles from cementum to
the alveolar bone.
4) Oblique fibers: (the most numerous fibers) extend in
oblique direction apically, attaching cementum to
alveolar bone.
5) Apical fibers: from cementum to alveolar bone (at
the apex of the root).

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Cellular elements in PDL:
1) Fibroblasts: the main synthetic cells which produce
collagen.
2) Cementoblasts, cementoclasts, osteoblasts,
osteoclasts: maintain the viability of their respective
tissues.
3) Mast cells and epithelial rest: play a role in
pathological conditions of the periodontium.

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Dentogingival junction (DGJ):
●At the base of the gingival sulcus.
●The depth of sulcus varies in healthy individuals,
averaging 1.8 mm.
●Sulcular depth up to 3mm is maintainable.
●Maintenance depends on :
i. Tight and shallow sulci.
ii. Optimal plaque control and success of periodontal
therapy.

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Diseases of the periodontium:
●Periodontal disease is a term describes any condition
of the periodontium other than normal.
●Periodontal diseases must be recognized and treated
before any fixed prosthodontics.

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Gingival Hyperplasia Acute necrotizing
ulcerative gingivitis
Juvenile periodontitis: severe loss of attachment
and destruction of alveolar bone around
one or more permanent teeth.

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Etiology:
●Most gingival and periodontal diseases result from
microbial plaque, which cause inflammation and
subsequent pathological processes.
●Other causes of inflammation include: calculus,
acquired pellicle, materia alba, and food debris.

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Microbial plaque:
●Sticky substructure composed of bacteria and its
byproducts in an extracellular matrix.
●If left undisturbed, it gradually covers the entire tooth
surface, and can be removed only by mechanical
means.

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Calculus:
●It’s chalky or dark deposit attached to the tooth
structure.
●It’s essentially a microbial plaque that has undergone
mineralization over time.
●Calculus can be found supragingival and/or
subgingival.

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Acquired salivary pellicle acts as a natural barrier
to prevent a tooth's surface
from making direct contact with acids
and to protect it from erosive demineralization.
Acquired pellicle:
●Thin brown or gray film of salivary proteins that
develops on teeth after they have been cleaned.

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Materia alba:
●White coating composed of microorganisms, dead
epithelial cells, and leukocytes that adheres loosely to
the tooth.
●It can be removed by water spray or rinsing.

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Structure of the dental plaque:
●Bacteria make up 70% of the mass.
●Remainder in intracellular matrix (carbohydrates, proteins,
calcium and phosphate ions).
Bacteria Intracellular
Matrix

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As the plaque mass increases and
matures:
●Flora progress apically from supra gingival position.
●There’s evidence that the increase in gram –
organisms leads to an increase in disease activity, and
cause both direct and indirect tissue damage.
●Gram +
●Aerobics
●Coccoid.
●Gram -
●Anaerobic.
●Rod-like.

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Vedio: plaque structure and
formation:

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Pathogenesis:
Initial lesion:
●Stage 1 is the beginning of the inflammation (caused
by bacteria in plaque).
●Starts within (2-4 days) of plaque formation.
●Bacteria and its toxins after entering the connective
tissue stimulate or activate (neutrophils – mast cells),
this cause:
1) Vasodilation of the capillaries and so increasing of
the blood flow.
2) Increase vascular permeability, which leads to
escape of plasma fluids (exudate).

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Early lesion:
●Within (4-7 days) if the inflammation persists.
●The predominant inflammatory cells are (lymphocytes
– monocytes - macrophages).
●Increase in gingival sulcular fluid.
●Loss of collagen from the marginal gingiva.

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Established lesion:
●Within (7-21 days).
●Continuing loss of connective tissue, with persistence
of features of early stage.
●The predominant inflammatory cells are (plasma cells).
●Pocket formation may begin.

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Advanced lesion:
●Loss of connective tissue apical to (CEJ), and
increasing of the probing depth.
●The lesion extends to the alveolar bone, and the bone
converted to fibrous connective tissue and is
subsequently lost.
●The predominant inflammatory cells are (plasma cells).
Periodontitis:
●When the loss of connective tissue attachment occurs,
the lesion transforms from gingivitis to periodontitis.

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VEDIO: stages of gingival
inflammation:

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Examination, Diagnosis,
And Treatment Planning

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●The diagnosis and treatment planning should be
completed before therapy is initiated.
●Traditional clinical assessment: (probing depth,
bleeding upon probing, clinical attachment level,
radiographic evidence of bone loss, and patient’s
symptoms).
●The timing and sequence of treatment plan is very
important in correcting the patient’s problem
efficiently as possible

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Working model of periodontal treatment:
Initial therapy:
1) Control of microbial plaque (tooth brushing – flossing
– others).
2) Scaling and polishing.
3) Correction of defective and/or overhanging
restorations.
4) Root planning.
5) Strategic tooth removal.
6) Stabilization of mobile teeth.
Evaluation of initial therapy.

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Surgical therapy:
1) Soft tissue procedures ( Gingivectomy - Open
debridement - Mucosal repair ).
2) Hard tissue procedures ( Bone induction - Osseous
resection ).
3) Treatment of furcation involvement ( Odontoplasty
– Osteoplasty – Root Amputation – Hemisection –
Restoration ).
Evaluation of surgical therapy.

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Guided tissue regeneration:
●( Hard and soft tissue procedures ).
●Technique.
●Restoration.
●Maintenance.
●Prognosis.