The document discusses the blood supply, nerve supply, and lymphatic drainage of the periodontium. It states that the periodontium receives its blood supply from branches of the internal maxillary artery and its lymphatic drainage involves drainage to local lymph nodes. It also describes the rich nerve supply to the periodontium derived from the trigeminal nerve and its branches. Changes in microcirculation and lymphangiogenesis occur in the periodontium during periodontal disease.

1. BLOOD SUPPLY,
NERVE SUPPLY &
LYMPHATIC
DRAINAGE OF THE
PERIODONTIUM DR.NEHA PRITAM
1sr Year MDS PGT
Department of Periodontics
HIDSAR

2. THE PERIODONTIUM
 The periodontium is
defined as those
tissues supporting
and investing the
tooth and consists of
cementum,
periodontal ligament
(PDL), bone lining
the alveolus
(socket), and that
part of the gingiva
facing the tooth.
Ten Cate's Oral Histology,Development,Structure and Function

3. The normal periodontium provides
the support necessary to maintain
teeth in function.
Four principle components
1. Gingiva
2. Periodontal ligament
3. Cementum
4. Alveolar bone

4. Fig.The anatomy of tooth with associated attachment apparatus

5. INTRODUCTION TO VASCULAR SUPPLY
 The orofacial structures have a very rich vascular
supply.
 A very important artery that supplies the maxillary and
mandibular teeth and their associated periodontium is
the internal maxillary artery.

6. Internal maxillary artery
 The maxillary artery or the internal maxilary artery is
one of the two terminal divisions of the external carotid
artery.
 The second terminal branch being the superficial
temporal artery

10. ARTERIAL SUPPLY OF MAXILLARY AND
MANDIBULAR teeth and their supporting structures
 The mandibular teeth and their supporting structures
are supplied by branches of inferior alveolar (dental)
artery, including mental ,sublingual and buccal arteries.
 The artery supply of maxillary teeth and their supporting
structure is by the posterior superior alveolar artery,
infraorbital artery, the greater palatine artery and the
sphenopalatine arteries.

11.  Microcirculatory tracts, blood vessels, and lymphatic
vessels play an important role in drainage of tissue fluid
and in the spread of inflammation.
 In gingivitis and periodontitis,
the microcirculation and
vascular formation change
greatly in the vascular network
directly under the gingival
sulcular epithelium and
junctional epithelium.

12. Blood vessels are easily evidenced in
tissue sections by means of immuno-
histochemical reactions against proteins
of endothelial cells (factor VIII and
adhesion molecules).
Before these techniques were developed,
vascularization patterns of periodontal
tissues had been described using histo-
enzymatic reactions for alkaline
phosphatase and adenosine
triphosphatase because of the great
activity of these enzymes in endothelial

14.  The gingiva receives its arterial
supply mainly from three sources:
 Supraperiosteal arteries
 Vessels of periodontal ligament
 Arterioles emerging from crests of
interdental septa

15.  Anatomic and histologic changes have been shown to
occur In the gingival microcirculation with gingivitis.
 In the absence of inflammation, the vascular network is
arranged in a regular, repetitive, and layered pattern.
 In contrast, the inflamed gingival vasculature exhibits an
irregular vascular plexus pattern, with the microvessels
exhibiting a looped, dilated, and convoluted
appearance.

16. Beneath the epithelium
on the outer gingival
surface, capillaries
extend into the
papillary connective
tissue between the
epithelial rete pegs in
the form of terminal
hairpin loops with
efferent and afferent
branches ,spirals and
varices.

17.  Along the sulcular epithelium ,capillaries are arranged in
a flat,anastomosing plexus that extents parallel to the
enamel from the base of the sulcus to the gingival
margin.
 In the col area,a mixed pattern of anastomosing
capillaries and loops occurs.

19.  Chronic periodontitis patients presented with
increased recruitment of neutrophils to the oral cavity.
Gene expression analysis revealed differences in the
expression levels of genes from several biological
pathways.
 The apoptosis network was significantly altered in
patients with chronic inflammation in the oral cavity,
with up-regulation of pro-survival members of the Bcl-2
family and down-regulation of pro-apoptosis members
in the same compartment.
 The percentages of viable neutrophils are significantly
increased in the oral cavity of chronic periodontitis
patients.
Lakschevitz FS, Aboodi GM, Glogauer M. Oral neutrophil transcriptome changes result in a pro-survival
phenotype in periodontal diseases. PloS one. 2013 Jul 11;8(7):e68983.

20. Venous
and lymphatic
drainage

21. VENOUS AND LYMPHATIC DRAINAGE
 The venous and lymphatic drainage of gingiva is closely
related to the arterial supply.
 In the maxilla, the gingival lymphatic vessels drain into
the deep cervical lymph nodes.
 In the mandible they drain into the
mental,submandibular and cervical lymph nodes.

22. THE SUPERFICIAL AND DEEP CERVICAL
LYMPH NODES

23. LYMPHATIC SYSTEM
 The lymphatic system is a network of lymph nodes are
connected lymphatic vessels, which plays an important role in
protecting the body from infection.
 The role of the lymphatic system is removing excess fluids,
cellular and protein debris, microorganisms and other
elements and is important in controlling diffusion and
resolution of inflammatory process.

24. The lymphatic drainage of the gingiva brings in
the lymphatics of the connective tissue
papillae.It progresses into the collecting network
external to the periosteum of the alveolar
process, then to the regional lymph nodes,
particularly the submaxillary group.
In addition, lymphatics just beneath the
junctional epithelium extend into the periodontal
ligament and accompany the blood vessels.

26.  The lymphatic system is a part of the overall lymphoid
system of the body and a component of the immune
system of the body. It is an accumulation of tiny
channels or tubules with small nodular structures called
lymph nodes interconnecting them.
 The system functions by returning fluids to the
bloodstream from the various tissues of the body.

27.  Gingival lymphatics are crucial for transcapillary fluid
balance in the steady-state condition and during acute
perturbation.
 Lymphangiogenesis takes place in gingiva during
periodontal disease development.
 Moreover, gingival lymphatic vessels protect against P.
gingivalis induced periodontitis, probably by enhancing
clearance of bacterial products and promoting humoral
immune responses.
i

29. SOME OF THE MAJOR LYMPH NODE
GROUPS IN THE HEAD AND NECK AREA
 Retropharyngeal nodes
A group of nodes behind the throat wall and involved in
throat infections. These nodes drain to the upper deep
cervical lymph nodes.

30. FIG.LOCATION OF THE RETROPHARYNGEAL NODES
WITH RELTAION TO THE PHARYNX AND THE SKULL
BASE.

31.  Submental nodes
 Found beneath the chin.
 The lymphatic channels from the mandibular incisors, the
tip of the tongue, and the midline of the lower lip and chin
drain into these nodes.

32.  Submandibular nodes
 grouped around the submandibular gland near the
angle of the mandible.
 The areas that drain into these nodes are all of the
maxillary teeth, maxillary sinus, the mandibular canines
and all mandibular posterior teeth; the floor of the mouth
and most of the tongue; the cheek area; the hard
palate; and the anterior nasal cavity.

34.  Upper deep cervical nodes
A number of nodes drain into this node-The submandibular
nodes; the nodes behind the back throat wall, known as the
retropharyngeal nodes; the parotid nodes in front of the
ear and the parotid gland; and others drain into this.

35.  Lower deep cervical nodes
 They drain the upper deep cervical nodes and many of
the nodes at the back of the neck, frequently referred to
as occipital nodes, as well as some glands in the
anterior neck. From the lower deep cervical nodes, the
lymphatic fluid drains into the junction of the subclavian
and internal jugular veins.

37. SPREAD OF DISEASES BY LYMPH NODES
 The terms primary nodes, secondary nodes, and
tertiary nodes are often used in discussions about
infections and cancer, both of which spread through
lymphatic channels.
 These terms refer to the groups of nodes that are
affected in a disease process.

38. Primary
group of
nodes
Secondary
group of
nodes
Tertiary
group of
nodes

39. Infections originating in
the middle of the lower
lip would spread first to
the submental nodes
Secondarily to the
submandibular nodes
Then to the upper deep
cervical nodes(which in
this instant would be
tertiary nodes of
involvement)

40.  An understanding of this concept is necessary to
comprehend also the spread of oral cancer.
 Each group of nodes acts as a resistance barrier against
the spread of cancer.

41.  The nodes slow the spread, and if the cancer is
detected early enough, it can be treated more
successfully.
 Once the infection or the cancer reaches the lower deep
cervical nodes and passes through them, it enters the
bloodstream, moving directly into the heart and then
throughout the body.

42.  With this in mind, it is easy to understand why cancer on
the tip of the tongue does not result in as high a
mortality rate as does cancer that begins further back
on the tongue or in the throat.

43.  The tip of the tongue generally drains through four
groups of nodes before it enters the bloodstream and
spreads throughout the body, whereas cancer in the
posterior portion of the tongue or in the throat travels to
the upper deep cervical nodes, on to the lower deep
cervical nodes, and into the bloodstream.

44. SPREAD OF INFECTIONS IN FASCIAL SPACES
 Another way through which infections may spread is
through fascial spaces.
 Although infection spread through fascial spaces is
much less common, it displays much more dramatic
clinical symptoms.

45.  The spaces between muscle and tissue layers are referred to as fascial
layers or planes, and infections may spread here.

46.  In general, dental infections start in the maxilla or
mandible at the apex of a tooth or in the periodontal
space around a tooth.
 Most periodontal space infections cause a swelling of
the gingival or mucosal tissue within the oral cavity.
 Infections at the apices of the teeth cause swelling in
one of two directions: buccal or lingual. Most buccal
swellings also lead to a swelling in the vestibule of the
oral cavity.

47.  This swelling is sometimes referred to as a gumboil.
 The infection comes to a pointed head, breaks through
the mucosa, and drains into the oral cavity.

48. fig,.buccal space infection

49. Entry of infections into the buccal space is dependent on their
relationship to the attachment of the buccinator muscle.

51.  Infection spreading into the sublingual ,submandibular
space causes a swelling into the floor of the mouth. If it
spreads into the submental space, it will cause a
swelling beneath the chin, sometimes referred to as
Ludwig’s angina. These infections continue to spread
by gravity if not treated.

52.  The importance of this section is not to be able to
completely describe or define the boundaries of these
spaces or potential spaces, but to understand how the
origin or location of the original infection determines the
pathway it will follow and the potential outcome if left
untreated.

53. MAXILLARY INFECTIONS
 If the infection does not open into the maxillary buccal
vestibule or onto the palate, it may spread toward three
areas—the nasal cavity, the maxillary sinus, or the soft-
tissue spaces of the cheek or the area below the eye.

54.  The area involved is related to the tooth involved. A
swelling below the eye is usually related to infection
from an anterior tooth, usually the maxillary canine,
whereas swelling in the cheek is usually related to
infection in a posterior tooth

55. NERVE SUPPLY

56.  Neural elements are extensively distributed throughout the
gingival tissues. Within the gingival connective tissues, most
nerve fibers are myelinated and are closely associated with
the blood vessels.
 Gingival innervation is derived from fibers arising from nerves
in the periodontal ligament and from the labial, buccal, and
palatal nerves.
 The following nerve structures are present in the connective
tissue: a meshwork of terminal argyrophilic fibers, some of
which extend into the epithelium; Meissner-type tactile
corpuscles; Krause-type end bulbs, which are temperature
receptors; and encapsulated spindles

57.  The neural tissue in human periodontium is associated
with the terminal part of a nerve trunk from which
myelinated nerve fibres leave and in some instances
divide into three or more nerve fibres.

58.  Innervations in various regions of the oral cavity is
supplied by the second and third divisions of the
trigeminal nerve.

60.  Innervations in various regions of the oral cavity is
supplied by the second and third divisions of the
trigeminal nerve.
 Trigeminal nerves have sensory, motor, and
intermediate roots, which are mounted directly to the
brain.

61.  The nerve supply of gingiva follow the vascular supply.
 In the maxilla,the gingiva is supplied by the posterior
,middle and the anterior superior alvoelar
nerves,branches of infraorbital nerves,the greater
palatine nerve and nasopalatine nerve.

62.  The middle superior alveolar nerve is present in 80% of
individuals
 The buccal nerve supplies variably in the buccal molar
region.

63.  In the mandible,gingiva is largerly suplied by the inferior
alveolar nerve.
 The buccal nerve supplies buccal gingiva in relation to
molars and premolars.
 Branches of lingual nerve supplies the lingual aspect of
all lower teeth.

65. REFERENCE
 Lakschevitz FS, Aboodi GM, Glogauer M. Oral neutrophil
transcriptome changes result in a pro-survival phenotype in
periodontal diseases. PloS one. 2013 Jul 11;8(7):e68983.
 Griffin CJ, Harris R. Innervation of human periodontium I.
Classification of periodontal receptors. Australian dental
journal. 1974 Feb;19(1):51-6.
 Carranza’s clinical periodontology
Newman Takei Klokkevoid Carranza
 Ten Cate’s Oral Histology Developent Structure and Function

66. CONCLUSION
 A thoughrough understanding of the anatomical
structures,vasculature and innervations of the
periodontium is necessary for the clinical point of view
and before making any surgical intervention in this area.