Periodontal Diseases

Chapter 55 (Periodontics) presents the role of the dental assistant in the clinical practice of periodontics, including the periodontal examination, charting, instruments, surgical and non-surgical techniques, and laser techniques.

Periodontal disease is an infectious disease process that involves inflammation of the structures of the periodontium (Table 14-1). The periodontium is made up of structures that surround, support, and are attached to the teeth (Fig. 14-1). Periodontal disease causes a breakdown of the periodontium, resulting in loss of tissue attachment and destruction of alveolar bone.

TABLE 14-1

Structures of the Periodontium

Name	Description
Gingivae	Commonly referred to as gums. This mucosa covers the alveolar process of the jaws and surrounds the necks of the teeth.
Epithelial attachment	Tissue at the base of the sulcus where the gingiva attaches to the tooth.
Sulcus	Space between the tooth and the free gingiva.
Periodontal ligaments	Dense connective fibers that connect the cementum covering the root of the tooth with the alveolar bone of the socket wall.
Cementum	Covers the root of the tooth. The primary function of the cementum is to anchor the tooth to the bony socket with attachments of the periodontal ligaments.
Alveolar bone	Bone that supports the tooth in its position within the jaw. The alveolar socket is the cavity in the bone that surrounds the tooth.

From Robinson D, Bird D: Essentials of dental assisting, ed 4, St Louis, 2007, Saunders.

FIGURE 14-1 Anatomical relationship of the normal gingivae. Gingival tissues include the alveolar mucosa, mucogingival junction, attached gingiva, free gingiva, and interdental papilla. (From Darby ML, Walsh MM: Dental hygiene: theory and practice, ed 3, St Louis, 2010, Saunders.)

Periodontal diseases are the leading cause of tooth loss in adults. Almost 75 percent of American adults have some form of periodontal disease, and most are unaware of the condition. Almost all adults and many children have calculus on their teeth. Fortunately, with early detection and treatment of periodontal disease, most people can keep their teeth for life.

Periodontal Disease and Systemic Health

Periodontal science has proven a relationship with several systemic diseases, including coronary artery disease, diabetes, and stroke, as well as delivery of low-birth-weight infants. This relationship is not likely to affect everyone, but certainly affects many. In these patients, periodontal infection is thought to be a risk factor for systemic disease just as high cholesterol is a risk factor for coronary heart disease (Box 14-1). Chronic inflammation appears to do harm to the entire body.

Causes of Periodontal Disease

Dental Plaque

Plaque is a soft mass of bacterial deposits that covers tooth surfaces. When the plaque layer is thin, it is not visible, but it stains pink when a disclosing agent (erythrosine stain) is applied (staining plaque is discussed further in Chapter 15). If it is not removed, plaque will continue to build up and will appear as a sticky white material (Fig. 14-2).

FIGURE 14-2 Clinical photo of 10-day-old supragingival plaque. The first symptoms of gingival inflammation (arrows) are becoming visible. (From Newman M, Takei T, Klokkevold P et al, editors: Carranza's clinical periodontology, ed 11, St Louis, 2012, Saunders.)

Although plaque is the primary factor causing periodontal disease, type of bacteria, length of time bacteria are left undisturbed on the teeth, and patient response to bacteria are all critical factors in the risk for periodontal disease. Plaque cannot be removed simply by rinsing the mouth. Bacteria in dental plaque cause inflammation by producing enzymes and toxins that destroy periodontal tissues and lower host defenses.

Calculus

Calcium and phosphate salts in the saliva form calculus, which is commonly called “tartar.” Calculus is a hard, stonelike material that attaches to the tooth surface. The surface of calculus is porous and rough and provides an excellent surface on which additional plaque can grow. Calculus can penetrate into the cementum on root surfaces. It cannot be removed by the patient and must be removed by the dentist or the dental hygienist with the use of scaling instruments. Regular, effective plaque control measures can minimize or eliminate the buildup of calculus. Plaque control measures are discussed in Chapter 15.

Calculus is usually divided into supragingival and subgingival types, even though these types often occur together.

Supragingival Calculus

Supragingival calculus is found on the clinical crowns of the teeth, above the margin of the gingiva. It is readily visible as a yellowish-white deposit that may darken over time (Fig. 14-3).

FIGURE 14-3 Heavy calculus deposits on the lingual surfaces of the lower anterior teeth. (Courtesy Dr. Edward J. Taggart, San Francisco, CA.)

Supragingival calculus occurs frequently near the openings of Wharton's ducts (on the lingual surfaces of the lower anterior teeth) and Stensen's ducts (on the buccal surfaces of the maxillary molars).

Subgingival Calculus

Subgingival calculus forms on root surfaces below the gingival margin and can extend into the periodontal pockets. It can be dark green or black. The color is caused by stain that results from subgingival bleeding.

Unlike supragingival calculus, the location of subgingival calculus is not site specific. It is found throughout the mouth. Subgingival calculus provides a reservoir for bacteria and endotoxins. Subgingival calculus covered by plaque can cause greater disease than can be produced by plaque alone.

Tooth Deposits

Acquired pellicle—Thin film of protein that quickly forms on teeth. It can be removed by coronal polishing with an abrasive agent such as “prophy” paste.

Materia alba—Soft mixture of bacteria and salivary proteins, also known as “white material.” It is visible without the use of a disclosing agent and is common in individuals with poor oral hygiene.

Food debris—Particles of food that are impacted between the teeth after eating. Food debris does not simply become plaque. If fermentable carbohydrates are present, however, food debris may contribute to dental caries.

Other Risk Factors

A vast majority of periodontal diseases begin as inflammation caused by an accumulation of bacterial plaque. However, periodontal diseases may be triggered by other factors such as malocclusion, some medications (such as those used for control of blood pressure), and serious nutritional deficiencies.

Disease-causing bacteria are necessary for periodontal disease to occur, but they are not totally responsible for destruction of the periodontium. Other risk factors alter the body's response to bacteria that are present in the mouth. Risk factors involved will determine the onset, degree, and severity of periodontal disease. This is why there is a great deal of variability in the susceptibility of individuals to periodontal disease and in successful outcomes of treatment.

Periodontal disease results from the complex interaction of bacterial infection and risk factors. As the number of risk factors increases, the patient's susceptibility to periodontal disease also increases (Table 14-2).

TABLE 14-2

Common Risk Factors for Periodontal Disease

Risk Factor	Rationale
Smoking	Smokers have greater loss of attachment, bone loss, periodontal pocket depths, calculus formation, and tooth loss. Periodontal treatments are less effective in smokers than in nonsmokers.
Diabetes mellitus	Diabetes is a strong risk factor for periodontal disease. Individuals with diabetes are 3 times more likely to have attachment and bone loss. Persons who have their diabetes under control have less attachment and bone loss than do those with poor control.
Poor oral hygiene	Lack of good oral hygiene increases the risk of periodontal disease in all age groups. Excellent oral hygiene greatly reduces the risk of severe periodontal disease.
Osteoporosis	An association has been reported between alveolar bone loss and osteoporosis. Women with osteoporosis have increased alveolar bone resorption, attachment loss, and tooth loss compared with women without osteoporosis. Estrogen deficiency also has been linked to decreases in alveolar bone.
HIV/AIDS	Increased gingival inflammation is noted around the margins of all teeth. Often, patients with HIV/AIDS develop necrotizing ulcerative periodontitis (NUP).
Stress	Psychological stress is associated with depression of the immune system, and studies show a link between stress and periodontal attachment loss. Research is ongoing to identify the link between psychological stress and periodontal disease.
Medications	Some medications, such as tetracycline and nonsteroidal anti-inflammatory drugs (NSAIDs), have a beneficial effect on the periodontium, and others have a negative effect. Decreased salivary flow (xerostomia) can be caused by more than 400 medications, including diuretics, antihistamines, antipsychotics, antihypertensive agents, and analgesics. Antiseizure drugs and hormones such as estrogen and progesterone can cause gingival enlargement.
Local factors	Overhanging restorations, subgingival placement of crown margins, orthodontic appliances, and removable partial dentures also may contribute to the progression of periodontal disease.

Types of Periodontal Disease

The term periodontal disease includes both gingivitis and periodontitis, and these two basic forms of periodontal disease each has a variety of forms. It is important for the dental assistant to have a clear understanding of the characteristics of the healthy periodontium, which will serve as a foundation from which signs of disease can be identified. You may wish to review the appearance of healthy oral tissues as presented in Chapter 10.

Signs and Symptoms

The following signs and symptoms are most often seen in patients with periodontal disease:

• Red, swollen, or tender gingiva

• Bleeding gingiva while brushing or flossing

• Loose or separating teeth

• Pain or pressure when chewing

• Pus around the teeth or gingival tissues

Gingivitis

Gingivitis is inflammation of the gingival tissue. It may be the most common human disease and is one of the easiest to treat and control. Areas of redness and swelling characterize gingivitis, and the gingiva tends to bleed easily. In addition, there may be changes in gingival contour and loss of tissue adaptation to the teeth (Table 14-3).

TABLE 14-3

Clinical Gingival Characteristics in Health and Disease

Characteristic	Health	Disease
Color	Uniformly pale pink with or without generalized dark brown pigmentation	Bright red Dark red, blue-red Pink if fibrotic
Consistency	Firm, resilient	Soft, spongy, dents easily when pressed with probe Bleeds readily to probing
Surface texture	Free gingival—smooth Attached—stippled	Loss of stippling, shiny Fibrotic with stippling Nodular Hyperkeratotic
Contour	Gingival margin is 1–2 mm above CEJ in fully erupted teeth. Marginal gingiva is knife-edge, flat; follows a curved line around the tooth and fits snugly around the tooth Papilla is pointed and pyramidal; fills interproximal spaces	Irregular margins from edema, fibrosis, clefting, and/or festooning. May be rounded, rolled, or bulbous; therefore more coronal to CEJ. May show recessions so that the anatomical root is exposed Bulbous, flattened, blunted, cratered
Size	Free marginal gingiva is near CEJ and adheres closely to the tooth	Enlarged from excess fluid in tissues or fibrotic from the formation of excess collagen fibers. Free marginal gingiva may be highly retractable with air
Probing depth	0–4 mm; no apical migration of JE	More than 4 mm with or without apical migration of JE

CEJ, Cementoenamel junction; JE, junctional epithelium.

From Darby ML, Walsh MM: Dental hygiene: theory and practice, ed 3, St Louis, 2010, Saunders.

Gingivitis is found only in the epithelium and in gingival connective tissues. No tissue recession or loss of connective tissue or bone is associated with gingivitis (Fig. 14-4). Other types of gingivitis are associated with puberty, pregnancy, and the use of birth control medications (Box 14-2 and Fig. 14-5). Orthodontic appliances tend to retain bacterial plaque and food debris, resulting in gingivitis (Fig. 14-6). Instruction regarding proper home care is a critical part of orthodontic treatment (see Chapter 60).

Box 14-2

Characteristics of Plaque-Induced Gingival Disease

I Dental Plaque–Induced Gingivitis *

Inflammation of the gingiva with plaque present at the gingival margin. Characterized by absence of attachment loss; clinical redness; bleeding upon provocation; and changes in contour, color, and consistency. No radiographic evidence of crestal bone loss is found. Local contributing factors may enhance susceptibility.

II Plaque-Induced Gingival Disease Modified by Systemic Factors

Endogenous Sex Steroid Hormone Gingival Disease

Includes puberty-associated gingivitis, pregnancy-associated gingivitis, and menstrual cycle gingivitis; characterized by an exaggerated response to plaque, reflected by intense inflammation, redness, edema, and enlargement with absence of bone and attachment loss; in pregnancy, may progress to a pyogenic granuloma (pregnancy tumor).

Diabetes Mellitus–Associated Gingivitis

Found in children with poorly controlled Type I diabetes mellitus. Characteristics similar to plaque-induced gingivitis, but severity is related to control of blood glucose levels rather than to plaque control.

Hematologic (Leukemic) Gingival Disease

Swollen, glazed, and spongy gingival tissues that are red to deep purple; enlargement is first observed in the interdental papilla; plaque may exacerbate condition but is not necessary for it to occur.

Drug-Influenced Gingival Enlargement

Occurs as a result of the use of phenytoin, cyclosporine, and calcium channel blockers such as nifedipine and verapamil. Onset usually occurs within 3 months of drug use and is more common in younger age groups. Characterized by an exaggerated response to plaque that results in gingival overgrowth (most commonly occurring in the anterior area and beginning in the interdental papilla); found in gingiva with or without bone loss but not associated with loss of attachment.

Gingival Disease Associated With Nutrition

Associated with a severe vitamin C deficiency and scurvy. Gingiva appears red, bulbous, spongy, and hemorrhagic.

^* Williams R: Periodontal disease: the emergence of a new paradigm, Compendium 19(suppl):4, 1999.

Data from Papapanou PN: Periodontal diseases: epidemiology, Ann Periodontol 1:1, 1996.

FIGURE 14-5 Medication-induced gingivitis. (From Perry D, Beemsterboer P: Periodontology for the dental hygienist, ed 4, St Louis, 2014, Saunders.)

FIGURE 14-6 Gingival inflammation and enlargement associated with orthodontic appliance and poor oral hygiene. (From Newman M, Takei T, Klokkevold P et al, editors: Carranza's clinical periodontology, ed 11, St Louis, 2012, Saunders.)

Gingivitis is painless and often remains unrecognized until a dental professional emphasizes its importance. Improved daily oral hygiene practices may reverse gingivitis.

1 What is dental plaque?

2. What is calculus?

3. The term periodontal disease includes both _______ and _______.

Periodontitis

Periodontitis is inflammation of the supporting tissues of the teeth. The inflammatory process progresses from the gingiva into the connective tissue and alveolar bone that support the teeth (Fig. 14-7). The connective tissue attachment at the base of a periodontal pocket is destroyed as the disease progresses.

FIGURE 14-7 Cross-section of a tooth and associated anatomical structures. A, Illustrates the depth of a normal gingival sulcus. B, Illustrates a periodontal pocket.

At one time, it was believed that periodontitis progressed slowly and at a constant rate. All individuals were thought to be equally susceptible to periodontitis. This is no longer true. The current view of periodontitis is that the disease can take several forms, all of which are infections caused by groups of microorganisms living in the oral cavity. All forms of periodontal disease appear to be related to changes in the many types of bacteria found in the oral cavity.

Description of Periodontal Disease

Periodontal disease is described in terms of disease severity and how much of the mouth is affected:

• If less than 30% of sites in the mouth are affected, the disease is considered localized

• If more than 30% of sites in the mouth are affected, the disease is considered generalized (Fig. 14-8)

FIGURE 14-8 Generalized chronic periodontitis in a 38-year-old woman with a 20-year history of smoking at least one pack of cigarettes per day. A, Clinical view shows minimal plaque and inflammation. Probing produced negligible bleeding, which is common with smokers. Patient reported spacing between the right maxillary incisors, which was associated with advanced attachment bone loss. B, Radiographs show severe, generalized, horizontal pattern of bone loss. Maxillary and mandibular molars have already been lost through advanced disease and furcation involvement. (From Newman M, Takei T, Klokkevold P et al, editors: Carranza's clinical periodontology, ed 11, St Louis, 2012, Saunders.)

The severity of the disease is determined by assessment of the amount of lost attachment, as follows:

• Slight or early

• Moderate

• Severe or advanced

On the basis of disease severity and the amount of tissue destruction that has occurred by the time of examination (Box 14-3), the American Academy of Periodontology has identified seven basic case types of periodontal disease.

4 What is the definition of periodontitis?

5. How many basic types of periodontal disease have been identified by the American Academy of Periodontology?

6. How is the severity of periodontal disease determined?

▪ Legal and Ethical Implications

One of the most common types of malpractice lawsuits alleges that the dentist failed to diagnose the condition and inform a patient that he or she had periodontal disease.

A common scenario is that the dentist had discussed the need for improved oral hygiene care with the patient at every visit but did not document those conversations. Years later, when the resulting periodontal disease became a serious problem, the patient did not recall these instructions and denied being told about the causes of periodontal disease. It is important to observe and chart the patient's oral hygiene status. Be certain to document all home care instructions that have been given to the patient. In addition, it is important to document that the patient has been clearly informed about the potential for future periodontal disease if home care does not improve. ▪

▪ Eye to the Future

Traditionally, nonsurgical examination of the sulcus has been limited to the use of explorers and radiographs. Perioscopy is a new procedure in which a miniature dental endoscope is used, along with video, lighting, and magnification technology. It enables the operator to look into a deep subgingival pocket to explore the gingival sulcus and to determine the precise location of root deposits, granulation tissue, caries, and root fractures. The goal of periodontal therapy is to get the root surfaces as clean as possible so that tissues can heal; now, with the use of the perioscope, the operator can actually see any remaining calculus that might have been missed. In addition, the perioscope enables the operator and the patient to look at defects (magnified up to 46 times) on the enamel and cementum and identify initial decay and/or cracks that were previously camouflaged.

Credit for perioscopy: state-of-the-art technology. (Courtesy DentalView, Inc., Irvine, CA.)

A miniature camera is attached to a tiny probe and then is gently placed into the sulcus. Images are immediately displayed on a chairside video screen for the operator and patient to see.

To maintain sterility, a disposable sterile sheath is placed around the perioscope before each patient use. There is very little discomfort during the procedure, and often, the patient does not require the use of local anesthesia. This device may one day become a new standard of care in the diagnosis and treatment of patients with periodontal disease worldwide. ▪

▪ Critical Thinking

1. Laura Sinclair is a 24-year-old patient in your dental practice. During her routine checkup, the dentist notices that Laura has some slight bleeding around the molars and slightly reddish gingival margins around other teeth. Laura insists that her home care practices have not changed. What other factors might be involved in causing this mild gingivitis in Laura?

2. Roger Fernandez is a 63-year-old man who has come into your office for a new patient examination. His medical history indicates that he is taking medications for his Type I diabetes mellitus. On the basis of this information, do you think you might see any unusual conditions in his oral tissues? If so, what and why?

3. A pregnant patient has been scheduled to come into your office for an emergency appointment. The receptionist tells you and the dentist that this patient is very concerned about her painful and bleeding gums, which she never had before. What is your first impression as to the possible cause of this pregnant patient's problems?

4. Karyn Mentr is a 28-year-old woman who is pregnant with her first child. She has moderate early signs of periodontal disease. This is her first visit to your office, and the dentist wants to begin periodontal treatment immediately, but Mrs. Mentr wants to wait until after her baby is born. Why do you think the dentist wants to begin periodontal treatment immediately? ▪

Box 14-3

Characteristics of Periodontitis

I Chronic Periodontitis *

Onset at any age but most prevalent in adults. Characterized by inflammation of the supporting structures of the teeth, loss of clinical attachment due to destruction of the periodontal ligament, and loss of adjacent bone. Prevalence and severity increase with age. The following levels of chronic periodontal classification have been identified:

• Slight or Early Periodontitis: Progression of gingival inflammation into the alveolar bone crest and early bone loss that results in slight attachment loss of 1 to 2 mm with periodontal probing depths of 3 to 4 mm

• Moderate Periodontitis: A more advanced state of the previous condition, with increased destruction of periodontal structures, clinical attachment loss of up to 4 mm, moderate to deep pockets (5–7 mm), moderate bone loss, tooth mobility, and furcation involvement not exceeding class I in molars

• Severe or Advanced Periodontitis: Further progression of periodontitis with severe destruction of periodontal structures, clinical attachment loss greater than 5 mm, increased bone loss, increased pocket depth (usually 7 mm or greater), increased tooth mobility, and furcation involvement greater than class I in molars

II Aggressive Periodontitis ^†

Occurs before age 35 and is associated with rapid rate of progression of tissue destruction, host defense defects, and composition of subgingival flora. The following subclassifications have been identified:

• Prepubertal Periodontitis: Onset occurs between eruption of the primary teeth and puberty; occurs in localized forms usually not associated with a systemic disease and generalized forms usually accompanied by alterations in neutrophil functioning; clinically manifests as attachment loss around primary and/or permanent teeth

• Juvenile Periodontitis: Localized and generalized forms. Generalized form (GJP) occurs late in the teenage years with a variable microbial origin that may include Actinobacillus actinomycetemcomitans (Aa) and Porphyromonas gingivalis (Pg) and affects most teeth

• Localized form is associated with less-acute clinical signs of inflammation than would be expected on the basis of severity of destruction. The localized form (LJP) is associated with bone and attachment loss that is most often confined to permanent first molars and/or incisors. Onset occurs at or around puberty; associated with Actinobacillus actinomycetemcomitans (Aa) and neutrophil dysfunction

III Necrotizing Periodontal Disease ^‡

• Necrotizing Ulcerative Gingivitis (NUG): A gingival infection of complex origin (e.g., plaque, temporary depression of polymorphonuclear neutrophil [PMN] functioning, stress, poor diet) that is characterized by sudden onset of pain, necrosis of the tips of the gingival papillae (punched out appearance), and bleeding. Secondary features include fetid breath and a pseudomembrane covering. Fusiform bacteria, Prevetella intermedia, and spirochetes have been associated with gingival lesions

• Necrotizing Ulcerative Periodontitis (NUP): Characterized by necrosis of gingival tissues, periodontal ligament, and alveolar bone. Associated with immune disorders such as HIV infection and immunosuppressive therapies; characteristics include severe and rapid periodontal destruction. Extensive necrosis of the soft tissue occurs simultaneously with alveolar bone loss, resulting in lack of deep pocket formation

^* Slavkin HC: Building a better mousetrap: toward an understanding of osteoporosis, J Am Dent Assoc 150:1632, 1999.

^† Fedi P, Vernino A, Gray J: The periodontic syllabus, Philadelphia, 2000, Lippincott Williams and Wilkins.

^‡ Armitage G: Development of a classification system for periodontal diseases and conditions, Ann Periodontol 4:1, 1999.

From Darby M, Walsh M: Dental hygiene theory and practice, ed 3, St Louis, 2010, Saunders.

Pageburst Integrated Resources

As part of your Pageburst Digital Book, you can access the following Integrated Resources:

Key Terms Flashcards

Labeling Exercises

Identify the Structures of the Periodontium

Identify the Periodontal Pocket and Structures

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