This document provides an overview of periodontal disease, including the periodontal team, causes, symptoms, classifications, diagnostic procedures, and treatments. The main points are: - Periodontal disease involves inflammation and infection of the gums and bone around the teeth. It is common and can be caused by plaque, calculus, poor oral hygiene, and certain medical conditions. - The periodontal team includes the periodontist, dental assistants, hygienists, and office staff who work together to treat and manage periodontal disease. - Diagnostic procedures include a medical history, examination, x-rays, and periodontal screening to assess the patient's condition and develop a treatment plan.

1. PERIODONTAL DISEASE
ETIOLOGY, PROGRESSION, AND PROCEDURES

2. INTRODUCTION
 The periodontist specializes in diseases of the tissue
around the root of the tooth
 This specialty deals with symptoms, probable causes,
diagnoses, and treatment of periodontal disease

3. PERIODONTAL TEAM
 The team in a periodontal office includes the periodontist,
dental assistants, dental hygienists, and business staff
 The periodontist coordinates treatment with the general
dentists In the overall care of the patient
 The periodontist screens the patient, performs the surgical
care, and provides continual care according to the patient’s
needs

4. PERIODONTAL TEAM
 The Dental Assistant
 Performs chairside assisting duties and expanded functions allowed by
state Dental Practice Acts
 Placing and removing periodontal dressing
 Removing sutures
 Performing coronal polishes
 Takes radiographs, takes impressions for study models, places
sealants, and administers fluoride treatments

5. PERIODONTAL TEAM
 Dental Assistant continued…
 Gives pre and postoperative instructions and prepares the treatment
room for surgery
 All in addition to treatment room preparation and maintenance and
sterilization procedures
 Involved in educating and motivating the patient throughout the
treatment
 Also may perform lab tasks, such as pouring study models

6. PERIODONTAL TEAM CONTINUED
 The Dental Hygienist
 Performs traditional hygiene procedures and, depending on the
state, administer local anesthetic
 In a periodontal practice, the hygienist often sees patients who
have more advanced periodontal disease; therefore,
responsibilities include root planning and clinical examination
procedures

7. PERIODONTAL DISEASE
 According to the American Academy of Periodontology,
three out of four adults will experience, to some degree,
periodontal problems at some time in their lives
 Periodontal disease occurs in children and adolescents
with marginal gingivitis and gingival recession
 The most prevalent conditions
 Periodontal disease involves the periodontium, which
represents the tissues that support the teeth

8. PERIODONTIUM
 Periodontium: the tissues that support the teeth
 *Gingiva—tissues that surround the teeth
 *Periodontal ligaments—fibers that surround the root
of the tooth and attach the cementum to the bone
 *Cementum—hard surface that covers the dentin on
the root of the tooth

9. PERIODONTIUM
 *Alveolar Bone—bone that forms the socket that
encases the root of the tooth
 Sulcus—space between the tooth and the free
gingiva. In healthy mouths, the sulcus is 1 to 3 mm
deep
 Epithelial Attachment—area at the bottom of the
sulcus where the gingiva attaches to the tooth

10. SYMPTOMS OF PERIODONTAL DISEASE
 Bleeding gums
 Loose teeth (mobility)
 Inflamed gingiva
 Abnormal contour of the
gingiva
 Periodontal pocket formation
 Malocclusions
 Halitosis
 Pain and tenderness
 Recession and discoloration
 All of these symptoms may be
present or the symptoms may
vary

11. CAUSES OF PERIODONTAL DISEASE
 Local irritants are a significate cause of periodontal disease
 One irritant, bacterial plaque, is a common cause of the inflammation
of the gingival tissues
 Bacterial plaque forms around the margin of the gingiva and, if left
undisturbed, mineralizes and appears as a yellow or brown deposit on
the teeth
 The mineralized, hard deposit is called calculus
 If plaque and calculus are not removed, they continue to grow and
develop on both supragingival and subgingival surfaces

12. CAUSES OF PERIODONTAL DISEASE CONT…
 Poor oral hygiene results in the buildup of plaque and
calculus
 When we do not brush and floss daily this can lead to plaque
formation and debris build up on the teeth
 Improper nutrition leads to overall poor health, which
often is evident in the gingival tissues
 When we eat a balanced diet, including foods that keep teeth
strong and the tissues free of disease, this can aid in maintaining
healthy mouth

13. CAUSES OF PERIODONTAL DISEASE CONT…
 Malocclusions can be a factor in periodontal disease
 Improper tooth alignment and occlusion can lead to
plaque and calculus formation in areas where food and
debris are not removed easily
 Patients with sensitive teeth or who need dental
restorations will favor these areas and alter chewing
patterns, putting additional pressure on periodontal
structures

14. CAUSES OF PERIODONTAL DISEASE CONT…
 Stress can lead to bruxism (grinding of teeth), which
puts pressure on the teeth and surrounding tissues
 The patient may not eat healthy foods or maintain
proper oral hygiene at a time of stress

15. CAUSES OF PERIODONTAL DISEASE CONT…
Systemic factors, including hormonal imbalances, hereditary
predispositions, and certain disease and medications, are often
reflected in the gingival tissues
 Hormonal changes due to
pregnancy
 Diabetes
 Cardiovascular disease
 Such as hypertension
 Blood disease
 Such as leukemia
 HIV infection
 Genetic conditions
 Such as down syndrome
 Emotional disorders,
 Systemic drugs
 Such as Dilantin or
immunosuppressant's
 Thyroid deficiencies

16. PERIODONTAL DISEASE STAGES
Healthy Tissues Gingivitis Early Periodontitis Moderate Periodontitis Advanced

17. PERIODONTAL DISEASE

18. CLASSIFICATIONS OF PERIODONTAL DISEASE
 There are two main classifications of periodontal disease
1. Gingivitis
2. Periodontitis

19. GINGIVITIS
 Inflammation of the gingival
tissues
 Common in all ages
 Causes may include
 Buildup of plaque and
calculus
 Poor-fitting appliances
 Poor occlusion
 Condition may occur in
association with
 Certain systemic diseases
(scurvy)
 Hormonal changes (pregnancy)
 Prolonged drug therapy

20. GINGIVITIS CONT…
 The tissues become reddish in color
 Interdental papilla may be swollen and bulbous
 Tissues may bleed after brushing and flossing
 Gingivitis precedes periodontitis but does not always
progress to it
 Proper brushing and flossing can reverse this condition in
some cases by removing the plaque

21. GINGIVITS

22. PERIODONTITIS
 Involves the formation of periodontal pockets
 This occurs when margins of the gingiva and periodontal
fibers recede and the supporting bone becomes inflamed
and destroyed
 There is an increase in tooth mobility as the pockets
become deeper
 May be furcation (area where the roots divide)
involvement in multirooted teeth

23. PERIODONTITIS
 Chronic periodontitis
 A progressive disease process with the patient experiencing loss
of tissue attachment and bone
 Aggressive periodontitis
 Form of periodontitis that acts rapidly and aggressively destroys
the tissue attachment and bone

25. PERIODONTITIS
 Necrotizing Ulcerative Gingivitis (NUG)
 Occurs most frequently in your adults 16-30
 Causes include stress, smoking, inadequate diet, and poor oral
hygiene
 Characteristics are inflamed gingiva, metallic taste, halitosis, pain,
and hemorrhage of the tissues
 Also knows as Vincent's disease and trench mouth
 Appears in individuals in the same unhealthy state and
frequently occurs in the college students around the time of final
examinations

26. PERIODONTITIS
 Necrotizing Ulcerative Periodontitis (NUP)
 HIV periodontitis
 Not limited to HIV patients, but is also seen in patients who are
severely malnourished and immunosuppressed
 Often in severe pain, sites bleed easily, and tissue and bone
destruction is extensive

27. PERIODONTAL DIAGNOSTIC PROCEDURES
 The first appointment with the periodontist is often an information-gathering appointment
 After completing the medical history, the patient is seated in the treatment room for an extraoral
and intraoral examination
 Radiographs and impressions are taken and periodontal screening is completed
 Developing rapport with the patient is essential for successful treatment; the patient must have
confidence in the dentist and the staff
 The patient has responsibility in the treatment of periodontal disease and should be educated
and motivated
 Importance of following OHI
 Diet suggestions and modifications
 Personal habit changes
 Routine office visits

28. MEDICAL DENTAL HISTORY
 Gives the operator and the patient the opportunity to learn about each other
 The operator gains information about
 Why the patient is seeking treatment
 If there is a systemic condition
 TB, HIV, AIDS, or diabetes
 How the patient feels about his or her teeth
 Previous dental treatment
 If the patient has any oral habits that have contributed to the present oral
condition

29. MEDICAL DENTAL HISTORY
 The patient has the opportunity to ask questions of the dentist and
gain an understanding of what is involved with periodontal
treatment
 The patients history must be accurate and complete
 A history checklist should open the way for significant conversation
between the patient, the DA, and/or the dentist

30. MEDICAL HISTORY
 Chief complaints
 Why did you come to the periodontist?
 What areas of your mouth are causing you concern?
 Any pain?

31. MEDICAL HISTORY
 Medical history
 Are you ill at this time?
 Currently undergoing any medical treatments?
 Medications?
 Allergies?
 List of conditions, diseases, ect to choose from

32. MEDICAL HISTORY
 Oral History
 Extractions? Restorations?
 Any problems after dental treatment?
 Any problems with your teeth, such as bleeding gums, pain,
mobility, sensitivity?

33. MEDICAL HISTORY
 Oral Habits
 Grinding, clenching, or mouth breathing?
 Do you smoke?
 Do you use alcohol or drugs?

34. MEDICAL HISTORY
 Family History
 History of periodontal disease?
 Oral Hygiene
 Which brushing technique do you use?
 Do you floss?
 What type of toothbrush and toothpaste do you use?
 Any kind of oral hygiene aids?

35. CLINICAL EXAMINATION
 Includes
 An extraoral exanimation of the face and neck
 An intraoral examination of the tongue, palate, buccal
mucosa, the teeth, and the oropharynx area
 The periodontal examination

36. EXTRAORAL EXAMINATION
 Includes observation of the skin and lips and
palpation of the lymph nodes and the
temporomandibular joint

37. INTRAORAL EXAMINATION
 Combines viewing and palpitating the tissues in the oral cavity
 The operator looks for abnormalities in the color, size, texture, and
consistency of all tissues
 Includes an oral cancer screening
 The condition of the teeth and any prosthetic appliances are
examined, noting any areas that might cause or contribute to
periodontal disease
 Any necessary treatment is recorded in the patients chart
 https://www.youtube.com/watch?v=yY9-7pOTROM

38. PERIODONTAL EXAMINATION
 A thorough examination of the periodontium using
periodontal charts
 Theses depict the condition of the patient’s periodontal
tissues
 Charting is either completed manually or on a computer
 The oral cavity is examined, and information is gathered
by the dentist or hygienist while the DA records the
information on the periodontal chart

39. PERIODONTAL EXAMINATION
 Patient oral hygiene is evaluated
 Periodontal probing measures the depth of the periodontal pocket
(depth of the sulcus) with a periodontal probe
 When the depth is greater than 3mm, it is termed a periodontal
pocket
 Six sites are probed and recorded on each tooth
 3 sites on the facial, and 3 sites on the lingual
 Probe is inserted unto the sulcus until the operator feels
resistance
 Calibrations on the probe measure the depth of the pocket

40. PERIODONTAL EXAMINATION
 Tooth mobility measures movement of the tooth within the socket
 Furcation involvement measures destruction of interradicular bone
in the furcation area of the multirooted teeth
 Appearance of the gingiva is evaluated in terms of color, size,
shape, texture, positon, consistency, bleeding, and amount of
exudate
 Bleeding during probing
 Recession of the gingival margin
 Occlusion is evaluated and described

41. PERIODONTAL SCREENING AND RECORDING SYSTEM (PSR)
 Another method that is used to evaluate the periodontal health of
a patient
 Designed to provide a simple, standardized system to effectively
screen and provide for detection of periodontal disease
 Not meant to replace the traditional periodontal exam, but it does
indicate when a partial or full periodontal eval is needed
 Involved dividing the mouth into sextant sections
 A specially designed probe is used
 All six areas on each tooth are probed, but only the highest
screening score in each sextant is recorded

42. RADIOGRAPHIC INTERPRETATION
 Radiographs show the teeth and the level and position of
the alveolar bone
 When periodontal disease is present, the alveolar bone
recedes both vertically and/or horizontally
 X-rays must be as dimensionally accurate as possible
 Usually, a full-mouth series is taken; panoramic
radiographs are also taken as an adjunct

43. PRESENTATION OF TREATMENT PLAN
 Periodontist determines the appropriate treatment plan
for the patient
 Charts, radiographs, study models, and photographs are
used to educate the patient at a consultation appointment
 The patients role in the treatment in discussed
 Must be actively involved in the treatment and
motivated to follow the home-care plan and keep
treatment appointments

44. CHEMOTHERAPEUTIC AGENTS
 Most patients have an excellent response to mechanical removal of plaque
and calculus from the tooth root surface
 For those that do not respond to the removal of deposits, and/or for those
that have aggressive forms of perio, the periodontist may also prescribe
therapeutic agents
 Including antibiotics and nonsteroidal anti-inflammatory agents
 Administered days to weeks before surgical procedures and during and after
nonsurgical treatments
 The anti-inflammatory drugs reduce the level of inflammation
 Ibuprofen and aspirin

45. PERIODONTAL INSTRUMENTS
 Periodontal instruments are designed to probe, scrape,
file, and cut the hard surfaces of the teeth, alveolar bone,
and soft tissues of the gingiva
 Must be kept sharp
 Usually the hygienist is responsible for maintaining
periodontal hand instruments

46. INSTRUMENT SHARPENING
 Sharp edges make the operators work easier and faster,
improve the quality of the procedures, and enhance
patient comfort
 Can be done manually or mechanically

47. PERIODONTAL PROBES
 The primary instrument used in the periodontal
examination
 Is used to measure the depth of the periodontal pockets
 Also, recession, bleeding, or exudate
 Calibrations on the probe are in millimeters and vary
depending on the manufacturer and operators preference
 Marking may be indentations or color coded

48. PERIODONTAL PROBE
HTTPS://WWW.YOUTUBE.COM/WATCH?V=EJWBYRFTIYQ

50. EXPLORERS
 Used to detect and locate
calculus, tooth irregularities,
faulty margins on
restorations, and furcation
involvement
 Gives the operator the best
tactile information
assessment
 Working ends are thing and
sharp

51. CURETTES
 A hand instrument
used for removing
subgingival calculus
and smoothing the
root surface
 Working end has a
cutting edge on one
or both sides and
the end is rounded
 Designed to adapt
to the curves of the
root surfaces

52. SCALERS
 Hand instruments
that are used to
removed hard
deposits such as
supragingival and
subgingival calculus
from the teeth
 Working end of a
scaler has two sharp
edges that come to a
point

53. SCALER AND CURETTE

54. FILES
 Used in a pulling motion interproximally to remove
calculus and for root planning
 Also used to remove overhanging margins of dental
restoration

55. ULTRASONIC INSTRUMENTS
 Used to remove hard deposits, stains, and debris during scaling,
and root-planning procedures
 Typically used as an adjunct to manual scaling procedures
 They generate high-power vibrations to a headpiece with a variety
of tips
 These vibrations cause calculus to fracture and be dislodged
 Cause heat, the units have cooling systems that circulate water
through the hand pieces and out openings at the tip
 The water spray cools and also flushes the area

56. ULTRASONIC UNIT AND TIPS
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57. AIR POLISHING SYSTEMS
 Method used by the dentist or the hygienist to polish the
teeth following a prophy
 Primary objective of polishing is to remove extrinsic stain,
supragingival plaque and soft debris while polishing the tooth
surface
 Also used to clean the tooth prior to sealant placement and
bonding procedures
 Uses a fine powder abrasive, air that is delivered under
pressure, and water through the nozzle of the hand piece

58. PERIODONTAL KNIVES
 Used to remove
gingival tissue during
periodontal surgery

59. INTERDENTAL KNIVES
 These are periodontal knives that are used to remove soft
tissue interproximally

60. SURGICAL SCALPEL
 Used to periodontal surgical procures to remove gingival
tissue

61. ELECTROSURGERY
 Uses tiny electrical currents to incise the gingival tissue
and also coagulate the blood during the procure

62. PERIOSTEAL ELEVATORS
 Used to reflect soft tissue away from the bone

63. PERIODONTAL SCISSORS, RONGEURS, AND FORCEPS
 Periodontal scissors: used during periodontal surgery,
mainly to remove tags of tissue and to trim margins
 Rongeurs: hinged pliers used to shape the soft tissue
 Tissue forceps: used to retract tissue or to hold the tissue
in place

64. LASERS
 A medical device that generates a precise beam of
concentrated light energy
 Dentist must complete training to become qualified to use
lasers
 Uses include procedures on hard and soft tissues

65. NONSURGICAL PERIODONTAL PROCEDURES
 Occlusal Adjustment
 Scaling and Polishing
 Root Planing
 Gingival Curettage
 Postoperative Treatment

66. OCCLUSAL ADJUSTMENT
 Involve adjustment of the occlusal surface to
eliminate detrimental forces and to provide
functional forces for stimulation of a healthy
periodontium

67. SCALING AND POLISHING
 Purpose is to remove plaque, calculus, and stains
 This procedure is called prophylaxis
 Can be performed by the dentist or hygienist
 Depending on the state Dental Practice Act, DA’s can
remove supragingival deposits and/or perform the coronal
polish

68. ROOT PLANING
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 After the plaque and calculus are removed from the periodontal
pocket and root surface, the cementum is often rough and
irregular
 This provides a surface ideal for accumulation of plaque and
calculus formation
 The roughness is removed by root planning
 This is a process of planning or shaving the root surface with
curettes and other periodontal instruments to leave a smooth root
surface
 Anesthetic is sometimes given to the patients for comfort

69. GINGIVAL CURETTAGE
 A procedure that involves scraping the inner gingival walls
of the periodontal pockets to removed inflamed tissue and
debris

70. POSTOPERATIVE TREATMENT
 The DA, following the dentists directions, will give the patient
postoperative instructions including:
 Pain control: depending on the extent of the procedure and
tissues involved
 Oral hygiene
 Antibacterial therapy: rinse; also fluorides because they have
bactericidal effects against the formation of plaque
 Diet and smoking: avoid spicy foods, citrus fruits, and alcohol; no
smoking-irritates the tissues and delays the healing process

71. SURGICAL PERIODONTAL PROCEDURES
 Preoperative instructions
 Gingivectomy
 Gingivoplasty
 Periodontal Flap Surgery
 Osseous Surgery
 Mucogingival Surgery
 Gingival Grafting
 Frenectomy
 Guided Tissue Regeneration

72. GINGIVECTOMY
 Surgical removal of diseased gingival tissue that forms the
periodontal pocket
 The pocket must be eliminated to prevent the
accumulation of debris and bacteria
 Performed by a periodontist

73. GINGIVOPLASTY
 Reshaping the gingival tissue to remove deformities such
as clefts, craters, and enlargements
 Does not involve the removal of periodontal pockets; it is
completed to recontour the gingiva and often
immediately follows a gingivectomy

74. PERIODONTAL FLAP SURGERY
 Involves surgically separating the gingiva from the underlying
tissue
 Once the tissue is retraced, the periodontist has good visibility
and access to bone, tooth, and the tooth roots
 When the flap is retracted, the diseased tissue and debris are
removed, the roots are planed, and the alveolar bone is
trimmed and contoured
 A periodontal dressing may be applied to protect the surgical
site

75. OSSEOUS SURGERY
 Removes defects/deformities in the bone cause by periodontal disease and
other related conditions
 Bone grafting: offers some hope to restore lost bone and regeneration of a
functional attachment of the periodontium
 Several types of bone replacement grafts
 Autogenous: cortical can cancellous bone extracted from intraoral and extraoral sites
 Allogeneic: tissue transplanted between people of the same species
 Xenogeneic: tissues from a different species (cows and pigs are most often used for
humans)
 Alloplastic: various synthetic materials
 Autogenous have the best results

76. MUCOGINGIVAL SURGERY
 Reconstructive surgery on the gingiva and/or mucosa
tissues
 Two common examples of mucogingival surgery are
gingival grafting and the frenectomy

77. GINGIVAL GRAFTING
 Tissue is taken from one site and placed on another
 A graft is the then obtained from the donor site, often the palate
area
 This graft is positioned carefully and sutured securely in place

78. FRENECTOMY
 Is a complete removal of
the frenum, including the
attachment to the
underlying bone
 The frenum many be
removed if it is attached
too close to the marginal
gingiva

79. GUIDED TISSUE REGENERATION
 Uses barrier membranes to maintain a space between the
gingival flap and the root surface of the tooth in order for
tissues to regenerate in a periodontal defect

80. PERIODONTAL DRESSING
 Are placed after periodontal surgical procedures
 Do not have any medicinal qualities; they are bandages used to
protect the tissue during the healing process
 Objective of the periodontal dressing
 Minimizing postoperative infection and hemorrhage
 Protecting the tissues during mastication
 Covering the surgical site in order to reduce pain due to trauma or
irritation
 Providing support for teeth that are mobile
 Helping to hold flaps in position

81. TYPES OF PERIODONTAL DRESSINGS
 Zinc Oxide-Eugenol Materials
 Powder or liquid form that can be mixed before the procedure and stored for later use
 Eugenol can cause an allergic reaction
 Noneugenol Materials
 Two-paste system: one tube of base and one tube of accelerator
 Do not cause sensitivity problems
 Light-cured Periodontal Dressing
 Comes in syringes
 Placed over the tissues and then light cured
 Gelatin-base Dressings
 Good stability and dissolve in 24-48 hours

82. PERIODONTAL MAINTENANCE PROCEDURES
 The patient determines the success of the treatment by
being committed and following the designed therapy
 Perio disease is an ongoing process, but continual care
maintains the status of periodontal health after surgery
 Dedicated home oral-hygiene routines and periodic visits
to the dentist are necessary for successful periodontal care