Etiology and Progression

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
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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