PERIODONTITI

S
Drg. Ade Ismail A. K.,
MDSc.,Sp.Perio

Definition

Refers to inflammation of gingival tissues in association

with some loss of attachment of PDL and alveolar bone.
Due to progressive loss of attachment, destruction of
PDL and adjacent alveolar bone occurs.
The sulcular epithelium shifts apically along the root
surface, resulting in formation of periodontal pockets.

Radiograph

Periodontal disease
Gingivitis

Reversible
Soft tissue inflammation only
No attachment/bone loss

Periodontitis:

Irreversible
Evidence of attachment/bone loss
Always preceded by gingivitis

PATHOGENESIS
For more than a century, periodontitis has
been associated with dental plaque. But
periodontitis has been shown to be absent in
patients with extensive plaque also.
Recent evidence
indicates
periodontitis
results not from mere presence of plaque but
from changes in proportions of bacterial
species in plaque.
Chronic periodontitis is associated with
Actinobacillus
actinomycetecomitans,
Bacteroides
forsythus
and
Prevotella
intermedia.

CAUSATIVE FACTORS
1.
2.
3.
4.
5.
6.
7.

Dental Plaque / calculus

Advancing age
Smoking
Diabetes mellitus
Lower socioeconomic status
Poor oral hygiene
Other systemic diseases like bleeding
disorders, sarcoidosis, Hypophosphatasia
etc.
8. AIDS

Periodontal Disease
Classifications (AAP)
Gingival Diseases
Chronic Periodontitis
Aggressive Periodontitis
Periodontitis: manifestation of systemic
diseases
Necrotizing Periodontal Diseases
Abscesses of the periodontium
Periodontitis associated with endodontic
lesions
Developmental or acquired deformities and
conditions

1. CHRONIC PERIODONTITIS
- Localized
- Generalized
2. AGGRESSIVE PERIODONTITIS
- Localized
- Generalized
3. PERIODONTITIS WITH SYSTEMIC
DISEASES
- Associated with hematologic
disorders
- Associated with genetic diseases
- Diabetes mellitus

4. NECROTIZING PERIODONTAL
DISEASES
- Necrotizing ulcerative gingivitis
- Necrotizing ulcerative
periodontitis
5. ABSCESSES OF PERIODONTIUM
- Gingival abscess
- Periodontal abscess
- Pericoronal abscess
6. PERIODONTITIS ASSOCIATED WITH
ENDODONTIC LESIONS
7. DEVELOPMENTAL OR ACQUIRED
DEFORMITIES AND CONDITIONS

Chronic Periodontitis
Most common
Previously known as adult periodontitis
Slow to moderate disease progression,
about 1mm per year
Predominantly horizontal bone loss
Modified by systemic diseases, smoking,
stress

 Severity directly related to

accumulation of biofilm and
subgingival calculus
Episodic in nature: periods of
exacerbation and quiescence
Further classified by extent and
severity
Localized or generalized
slight, moderate, severe
Predominant Bacteria

Etiology

plaque and calculus, disease activity/

patient resistance

Signs & symptoms

Generalized gingivitis present.

Typically, gingival margins are blunted
along with gingival recession.

 PDL disease is said to be present

when loss of PDL attachment can be
demonstrated by perio probe in the
absence
of
significant
gingival
hyperplasia.
Pocket depth > 3-4 mm indicates PDL
destruction and resorption of alveolar

 High quality dental x rays reveal bone loss of

the alveolar bone surrounding the affected
teeth.
With advanced bone loss, tooth mobility is
present

Normal vs periodontitis

Normal alveolar bone

Alveolar bone after

periodontitis

Treatment and prognosis:

remove local etiologic factors, education,

control of associated factors

Aggressive Periodontitis
Severe bone loss (more often vertical
bone loss)
Rapid progression even in presence
of relatively small amount of bacterial
plaque
Less predictable response to therapy
Less common but can affect primary
and adult dentitions
Predominant Bacteria
Immune deficiencies or genetic
factors

Localized Aggressive
Periodontitis
Generalized Aggressive
Periodontitis

Definisi
severe attachment and bone loss around the first
molars and incisors (but not involving more than
two additional nonfirst molar/incisor teeth), which
occurs between the ages of 12 to 26 years.

Etiology
Disease is based on 3 factors:
Bacteria (certain kind)
Host response
Possibly genes

Bacteria: A.a (Actinobacillus

actinomycetemcomitans)
Host Response: Impaired PMNs
(phagocytosis, chemotaxis and decreased
receptors)
Genes

Distribution of Lesions
Localised lesion (Localised
Juvenile Periodontitis)
First molars and incisors affected
Bilaterally symmetric patterns of
bone loss seen frequently

Generalized Juvenile
Periodontitis

Prevalence
Less the 1%
Highest prevalence amongst black males
followed by black females, white females and
white males
Seen between puberty and 20yrs of age
Actinobacillus
actinomycetemcomitans

very strongly associated with LAP

A.a is not found in health individuals or in
healthy sites of LAP patients
A.a is very aggressive and causes a marked
antibody response
A.a invades the tissues thus to eradicate
it, one must take systemic antibiotics or
resect the tissue

Clinical findings
No clinical inflammation
Deep periodontal pockets
Small amount of plaque
Calculus is rarely present
Mobility and drifting to teeth are common
initial symptoms
Distolabial migration of maxillary incisors
with diastema formation common
Dentinal hypersensitivity
Deep, dull, radiating pain on mastication
Periodontial abscess formation
Regional lymph node enlargement

Clinical feature

Radiographic findings
Vertical loss of alveolar bone around first
molars and incisors

Prognosis

Poor individuals with prepubertal gingivitis frequently

become edentulous at an early age

TREATMENT & RROGNOSIS

Unlike chronic periodontitis, scaling
and root planing alone do not stop
the disease.
Combination of antibiotics along with
mechanical removal of subgingival
plaque and inflamed periodontal
tissues is needed to counteract the
effects of leukocyte defect and
pathogenicity of involved organisms.
Generally, patients with localized
disease show stable course, while
those
with
generalized
disease

Keep in mind:
In order to control the disease, A.a must
be minimized
SRP NEVER removes 100% of bacteria
Without maintenance, disease will
proceed
Disease has a high recurrence rate after
first year therapy

SRP and Good OH will not eliminate

A.a
Subgingival gels, irrigation and
antibiotics will not eliminate A.a
Best Bet:
Systemic Antibiotics
Surgery to remove granulation
tissue in which A.a fester

Antibiotics:
Flagyl/Metronidazole and
Amoxicillin

Sequencing 1
OHI, patient education
Gross calculus debridement if indicated
Surgical treatment of pockets > 5 mm, root planing and
curettage of pockets < 5mm. Chlorhexidine 1-2 weeks
post
Surgery and interproximal brushing
Antibiotic therapy concurrent with surgery and/or root
planning
Post surgery evaluation 4-6 weeks: success measured by
good OH, decreased pockets, no BOP, gain in
attachment

Sequencing 2
Retreatment of deep, bleeding pockets
Maintenance every 3 months
Radiographs as needed
Reinforce OH
Prophylaxis/RP

Oral hygiene !

Necrotizing Periodontal
Diseases
Necrotizing Ulcerative
Gingivitis (NUG)
Necrotizing Ulcerative
Periodontitis (NUP)

Definition

An
infection charac terized by
necrosis
of
gingival
tissues,
periodontal ligament, and alveolar
bone

Clinical Features
Clinical appearance of NUG
Severe deep aching pain
Very rapid rate of bone
destruction
Deep pocket formation not
evident

Treatment
Local debridement
Oral hygiene instructions
Oral rinses
Pain control
Antibiotics
Modify predisposing factors
Proper follow-up

 Local debridement
Most cases adequately treated by
debridement and sc/rp
Anesthetics as needed
Consider avoiding ultrasonic
instrumentation due to risk of HIV
transmission

Oral hygiene instructions

 Oral rinses (frequent, at least

until pain subsides allowing
effective OH)
Chlorhexidine gluconate 0.12%;
1/2 oz 2 x daily
Hydrogen peroxide/water
Povidone iodine

Pain control

Periodontal Abscesses
Acute or chronic
Localized, purulent
infection
Most often with
untreated chronic
periodontitis
Rapid bone loss
Immediate treatment

 Cardinal principles of incision and

drainage are followed.
Analgesics
and
antibiotics
are
prescribed to reduce the pain and
fever, if present.
Treatment
for
underlying
periodontitis is undertaken after the
abscess is treated satisfactorily.

PERICORONITIS
Acute pericoronitis is treated with
antiseptic lavage under under the
gingival flap to remove food debris
and bacteria.
Once the acute phase passes, either
the impacted tooth is extracted or the
gingival flap is surgically removed.

Periodontitis Associated with

Endodontic Lesions

associated with caries, fractured tooth, trauma

Require endodontic therapy
Combined perio/endo lesions
diff. periodontal abs

Developmental or acquired
deformities and conditions

Anatomic factors
Restorations
Occlusal trauma
Mucogingival deformities
Recession
Pseudopockets

Gingival recession

TERIMAKASI
H