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Periodontal disease

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all about periodontal diseases

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Periodontal disease

  1. 1. Classification of Periodontal Disease The Periodontal Pocket Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues Furcation Involvement Bone Loss and Patterns of Bone Destruction In Periodontal Disease Trauma from Occlusion Gingival Disease in Childhood Juvenile Periodontitis Epidemiology of Gingival and Periodontal Disease
  2. 2. Classification of Periodontal Disease The Periodontal Pocket Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues Furcation Involvement Bone Loss and Patterns of Bone Destruction In Periodontal Disease Trauma from Occlusion Gingival Disease in Childhood Juvenile Periodontitis Epidemiology of Gingival and Periodontal Disease
  3. 3. Classification of Periodontal Disease Classification of Periodontal Disease The term periodontal disease is used in a general sense to encompass all diseases of the periodontium.  The most common disease is initiated by plaque accumulation in the gingivodental area and is basically inflammatory in character, termed marginal periodontitis or more accurately chronic destructive periodontitis.  The periodontal tissues can also be involved by other nosologic entities and many of these fall into degenerative or neoplastic categories. They are considered as periodontal manifestations of systemic diseases
  4. 4. Classification of Periodontal Disease CHRONIC DESTRUCTIVE PERIODONTITIS I. Periodontitis A. Marginal periodontitis 1. Slowly progressing 2. Rapidly progressing 3. Refractory B. Juvenile form of periodontitis 1. Generalized form 2. Localized form C. Necrotizing Ulcerative Periodontitis II. Trauma from occlusion* III. Periodontal atrophy* A. Presenile atrophy B. Disuse atrophy
  5. 5. Classification of Periodontal Disease MARGINAL PERIODONTITIS Clinical features: chronic inflammation of the gingiva, pocket formation, and bone loss. Tooth mobility and pathologic migration appear in advanced cases. Etiology: dental plaque Types: slowly progressing periodontitis, rapidly progressing periodontitis, refractory periodontitis
  6. 6. Classification of Periodontal Disease Slowly progressing periodontitis  Also called “adult type periodontitis” and is associated with abundant plaque and calculus  It is usually painless, but may be accompanied by sensitivity of exposed roots, dull, deep pain caused by forceful wedging of food into periodontal pockets, acute symptoms caused by periodontal abscess formation, and pulpal symptoms resulting from root caries  It is generalized or affects many teeth.
  7. 7. Classification of Periodontal Disease Rapidly progressing periodontitis  associated with scantier amounts of plaque and calculus  seen most commonly in young adults in their twenties, but can occur up to age 35, extreme inflammation, hemorrhage, proliferation of the marginal gingiva, exudation, and rapid bone loss.
  8. 8. Classification of Periodontal Disease Refractory periodontitis  refers to cases that do not respond to therapy and/or recur soon after adequate treatment for unknown reasons  accdg. to Page, it is due to the ff. mechanisms: abnormal host response, resistant organisms, or untreatable morphologic problems
  9. 9. Classification of Periodontal Disease 2-4 mm 4-6 mm 7 mm ↑ Marginal periodontitis is also subclassified on the basis of severity and degree of tissue destruction:
  10. 10. Classification of Periodontal Disease JUVENILE PERIODONTITIS  Includes advanced destructive lesions in children and adolescents Generalized form: includes the whole dentition, associated with systemic conditions as Papillon-Lefevre syndrome, hypophosphatasia, agranulocytosis, Down’s syndrome and others Localized form: previously termed as periodontosis, precocious advanced alveolar atrophy, juvenile atrophy, juvenile paradentosis, and juvenile parodontopathia; characterized by deep angular lesions localized in the first molars and incisors.
  11. 11. Classification of Periodontal Disease TRAUMA FROM OCCLUSION Clinical features: 1. Increased tooth mobility 2. Widening of the periodontal space, particularly in the gingival region of the root (angular destruction of bone.  These changes are adaptation phenomena to the increased function. It does NOT produce gingival inflammation or the formation of periodontal pockets.
  12. 12. Classification of Periodontal Disease PERIODONTAL ATROPHY Atrophy: decrease in the size of the tissue or organ or of its cellular elements after it has attained its normal mature size  Senile (physiologic atrophy) refers to generalized reduction in the height of alveolar bone, accompanied by recession of gingiva with overt inflammation or trauma from occlusion, occurring with increasing age.
  13. 13. Classification of Periodontal Disease Presenile atrophy  reduction in the height of periodontium that is uniform throughout the mouth and without apparent cause Disuse atrophy Results when the functional stimulation for the maintenance of the periodontal tissues is markedly diminished or absent.  characterized by thinning of periodontal ligament, thinning and reduction in the number of periodontal fibers and disruption of fiber bundle arrangement, thickened cementum, reduction in height of alveolar bone, and osteoporosis
  14. 14. Classification of Periodontal Disease The Periodontal Pocket Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues Furcation Involvement Bone Loss and Patterns of Bone Destruction In Periodontal Disease Trauma from Occlusion Gingival Disease in Childhood Juvenile Periodontitis Epidemiology of Gingival and Periodontal Disease
  15. 15. The Periodontal Pocket The Periodontal Pocket  A periodontal pocket is a pathologically deepened sulcus: it is one of the important clinical features of periodontal disease.
  16. 16. The Periodontal Pocket 1. Enlarged, bluish red marginal gingiva with a “rolled” edge separated from the tooth surface 2. A reddish blue vertical zone extending from the gingival margin to the attached gingiva 3. A break in the faciolingual continuity of the interdental gingiva 4. Shiny, discolored, and puffy gingiva associated with exposed root surfaces 5. Gingival bleeding6. Purulent exudate of the gingival margin or its response to digital pressure on the lateral aspect 7. Looseness, extrusion, and migration of teeth. 8. The development of diastemata where none existed.
  17. 17. SYMPTOMS: 1. Localized pain or a sensation of pressure after eating, which gradually diminishes 2. A foul taste in localized areas. 3. A tendency to suck material from the interproximal spaces. 4. Radiating pain “deep in the bone” 5. A “gnawing” feeling or feeling of itchiness in the gums. The Periodontal Pocket
  18. 18. SYMPTOMS: 6. The urge to dig a pointed instrument into the gums with relief obtained from the resultant bleeding 7. Complaints that food sticks between teeth or that the teeth feel loose or a preference to eat on the other side. 8. Sensitivity to heat and cold; toothache in the absence of caries. The Periodontal Pocket
  19. 19. CLASSIFICATION: The Periodontal Pocket ACCDG. TO MORPHOLOGY ACCDG. TO NO. OF SURFACES INVOLVED I. Gingival Pocket II. Periodontal Pocket 1.Suprabony pocket 2.Infrabony pocket I. Simple II. Compound III. Complex
  20. 20. GINGIVAL POCKET  Relative or false pocket  formed by gingival enlargement without destruction of the underlying periodontal tissues.  The sulcus is deepened because of increased bulk of gingiva The Periodontal Pocket ACCDG. TO MORPHOLOG Y
  21. 21. PERIODONTAL POCKET  Absolute or true pocket  Occurs with destruction of supporting periodontal tissues  Has two types: 1. Suprabony – bottom of the pocket is coronal to the underlying alveolar bone 2. Infrabony – bottom of the pocket is apical to the underlying alveolar bone The Periodontal Pocket ACCDG. TO MORPHOLOG Y
  22. 22. The Periodontal Pocket
  23. 23. 1. SIMPLE – one tooth surface 2. COMPOUND – two or more surfaces 3. COMPLEX – a spiral type of pocket that originates on one tooth surface and twists around the tooth to involve one or more additional surfaces; most common The Periodontal Pocket ACCDG. TO NO. OF SURFACES INVOLVED
  24. 24. The Periodontal Pocket
  25. 25. Deepening of the gingival sulcus may occur by: 1. Movement of the gingival margin in the direction of the crown 2. Migration of the junctional epithelium apically and its separation from the tooth surface 3. Combination of both processes The Periodontal Pocket PATHOGENESIS
  26. 26. The Periodontal Pocket Plaque Gingival inflammation Pocket formation More plaque formation
  27. 27. Period of quiescence: Period of inactivity reduced inflammatory response and little or no loss of bone and CT attachment Gram+ bacteria proliferate and a more stable condition is established The Periodontal Pocket PEROIODONTAL DISEASE ACTIVITY Period of exacerbation: Period of activity There is build-up of unattached plaque, with gram-, motile, and anaerobic bacteria Bone and CT attachment are lost and pocket deepens Show bleeding and greater amounts of exudate May last for days, weeks or months
  28. 28. The Periodontal Pocket CLINAL FEATURES HISTOPATHOLOGIC FEATURES 1. Varying degrees of bluish red discoloration; flaccidity; smooth, shiny surface; and pitting on pressure 1. Circulatory stagnation; destruction of gingival fibers and surrounding tissues; atrophy of epithelium; edema and degeneration 2. Gingival wall may be firm and pink 2. Fibrotic changes 3. Bleeding upon probing 3. Increased vascularity; thinning and degeneration of epithelium 4. Inner aspect of pocket is painful upon exploring 4. Ulceration of the inner aspect of the pocket wall 5. Pus may be expressed by applying digital pressure 5. Suppurative inflammation of the inner wall
  29. 29. The Periodontal Pocket Microtopography of the Gingival Wall of Pocket 1. Area of relative quiescence flat surface with minor depressions and mounds and occasional shedding of cells 2. Area of bacterial accumulation Abundant debris and bacterial clumps (cocci, rods, filaments, few spirochetes) penetrating into enlarged intercellular spaces 3. Areas of emergence of leukocytes Leukocytes appear through holes in eintercellular spaces 4. Areas of leukocyte-bacterial interaction Leukocytes are covered by bacteria in an apparent process of phagocytosis 5. Areas of intense epithelial desquamation Consist of semiattached and folded epithelial squames 6. Areas of ulceration Exposed connective tissue 7. Areas of hemorrhage Numerous erythrocytes
  30. 30. The Periodontal Pocket The Pocket Contents Periodontal pockets contain debris consisting principally of: 1. Microorganisms and their products 2. Dental plaque 3. Gingival fluid 4. Food remnants 5. Salivary mucin 6. Desquamated epithelial cells 7. leukocytes
  31. 31. The Periodontal Pocket The following structural changes in cementum are seen: 1. Presence of pathologic granules (due to degeneration of sharpey’s fibers in cementum) 2. Areas of increased mineralization (decreased sensitivity) 3. Areas of demineralization (increased sensitivity, caries and pulpitis may occur • The dominant microorganism in root surface caries is Actinomyces viscosus The Root Surface Wall
  32. 32. The Periodontal Pocket 1. Cementum covered by calculus 2. Attached plaque 3. Unattached plaque 4. Junctional epithelium 5. Partially lysed CT fibers 6. Intact CT fibers
  33. 33. The Periodontal Pocket THE RELATIONSHIP OF THE PERIODONTAL POCKET TO BONE Suprabony pocket Infrabony pocket Base of the pocket is coronal to the crest of alveolar bone Base of the pocket is apical to the crest of alveolar bone Horizontal pattern of bone destruction Vertical (angular) pattern of bone destruction Restored transseptal fibers are arranged horizontally Restored transseptal fibers are arranged obliquely On the facial and lingual surfaces, the PDL fibers beneath the pocket follow their normal horizontal-oblique course On facial and lingual, the PDL fibers follow the angular pattern of the adjacent bone
  34. 34. The Periodontal Pocket A periodontal abscess (lateral or parietal abscess) is a localized purulent inflammation in the periodontal tissues. CLASSIFICATION ACCDG. TO LOCATION: 1. Abscess in the supporting periodontal tissue along the lateral aspect of the root 2. Abscess in the soft tissue wall of a deep periodontal pocket The Periodontal Abscess
  35. 35. The Periodontal Pocket The periodontal cyst is an uncommon lesion that produces localized destruction of the periodontal tissues along a lateral root surface, most often in the mandibular canine-premolar area. The following possible etiologies have been suggested: 1. Odontogenic cyst 2. Lateral dentigerous cyst 3. Primordial cyst 4. Stimulation of epithelial rests of PDL by infection from a periodontal abscess or from the pulp through an accessory canal The Periodontal Cyst
  36. 36. Classification of Periodontal Disease The Periodontal Pocket Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues Furcation Involvement Bone Loss and Patterns of Bone Destruction In Periodontal Disease Trauma from Occlusion Gingival Disease in Childhood Juvenile Periodontitis Epidemiology of Gingival and Periodontal Disease
  37. 37. Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues  The extension of inflammation from the marginal gingiva into the supporting periodontal tissues marks the transition from gingivitis from periodontitis  The transition from gingivitis to periodontitis is associated with changes in the composition of bacterial plaque. In advanced stages, the number of motile organisms and spirochetes increases, whereas the number of coccoid and rods decreases Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues
  38. 38. Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues Interproximally: 1. From gingiva into the bone 2. From the bone into the PDL 3. From the gingiva into the PDL
  39. 39. Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues Facially and lingually: 1. From gingiva along the outer periosteum 2. From the periosteum into the bone 3. From the gingiva into the PDL
  40. 40. Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues THE EFFECT OF TRAUMA FROM OCCLUSION  Trauma from occlusion may cause the inflammatory exudate to be channeled between the transseptal fibers directly into the PDL which may lead to vertical bone losses and infrabony pocket formation.  Excessive pressure affects alignment of transseptal fibers so that they become angular instead of horizontal  Excessive tension causes stretching and unraveling of the principal fiber bundles of the PDL, reducing the barrier provided by the intact bundles
  41. 41. Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues CLINICAL ASPECTS OF INFLAMMATION IN THE PDL Tooth Mobility  The inflammatory exudate reduces tooth support by causing degeneration and destruction of the principal fibers and a break in the continuity between the root and the bone Pain  Superimposed acute inflammation may be the cause of considerable pain
  42. 42. Classification of Periodontal Disease The Periodontal Pocket Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues Furcation Involvement Bone Loss and Patterns of Bone Destruction In Periodontal Disease Trauma from Occlusion Gingival Disease in Childhood Juvenile Periodontitis Epidemiology of Gingival and Periodontal Disease
  43. 43. Bone Loss and Patterns of Bone Destruction In Periodontal Disease  Periodontitis is an infectious disease of the gingival tissue, changes that occur in bone are crucial because the destruction of bone is responsible for tooth loss.  The height and density of the alveolar bone are normally maintained by an equilibrium, regulated by local and systemic influences between bone formation and bone resorption. Bone Loss and Patterns of Bone Destruction In Periodontal Disease
  44. 44. Bone Loss and Patterns of Bone Destruction In Periodontal Disease  The most common cause of bone destruction in periodontal disease is the extension of inflammation from the marginal gingiva into the supporting periodontal tissues.  The inflammatory invasion of the bone surface and the initial bone loss that follows mark the transition from gingivitis to periodontitis.  The extension of inflammation to the supporting structures of a tooth may be modified by the pathogenic potential of plaque or the resistance of the host.
  45. 45. Bone Loss and Patterns of Bone Destruction In Periodontal Disease Periodontal destruction occurs in an episodic, intermittent fashion, with periods of inactivity or quiescence. The destructive periods result in loss of collagen and alveolar bone with deepening of the periodontal pocket. The reasons for the onset of destructive periods have not been totally elucidated. Periods of Destruction
  46. 46. Bone Loss and Patterns of Bone Destruction In Periodontal Disease 1. Bacterial plaque products induce the differentiation of bone progenitor cells into osteoclasts and stimulate gingival cells to release mediators that have the same effect. 2. Plaque products and inflammatory mediators can also act directly on osteoblasts or their progenitors, inhibiting their action and reducing their numbers. Mechanisms of Bone Destruction
  47. 47. Bone Loss and Patterns of Bone Destruction In Periodontal Disease Bone Destruction Caused by Trauma from Occlusion Another cause of periodontal destruction is trauma from occlusion.  Trauma from occlusion can produce bone destruction in the absence or presence of inflammation. When combined with inflammation, trauma from occlusion aggravates the bone destruction caused by the inflammation and causes bizarre bone patterns.
  48. 48. Bone Loss and Patterns of Bone Destruction In Periodontal Disease Bone Destruction Patterns in Periodontal Disease Horizontal Bone Loss Bone Deformities (Osseous Defects) • Vertical or Angular Defects • Osseous Craters • Bulbous Bone Contours • Reversed Architecture • Ledges
  49. 49. Bone Loss and Patterns of Bone Destruction In Periodontal Disease Horizontal Bone Loss  Horizontal bone loss is the most common pattern of bone loss in periodontal disease.  The bone is reduced in height, but the bone margin remains roughly perpendicular to the tooth surface. The interdental septa and facial and lingual plates are affected, but not necessarily to an equal degree around the same tooth.
  50. 50. Bone Loss and Patterns of Bone Destruction In Periodontal Disease
  51. 51. Bone Loss and Patterns of Bone Destruction In Periodontal Disease Bone Deformities (Osseous defects) Different types of bone deformities can result from periodontal disease. These usually occur in adults and have been reported in human skulls with deciduous dentitions. Their presence may be suggested on radiographs, but careful probing and surgical exposure of the areas is required to determine their exact conformation and dimensions.
  52. 52. Bone Loss and Patterns of Bone Destruction In Periodontal Disease Vertical and Angular Defects  occur in an oblique direction, leaving a hollowed- out trough in the bone alongside the root; the base of the defect is located apical to the surrounding bone.  In most instances, angular defects have been accompanying infrabony pockets; such pockets always have an underlying angular defect.  Angular defects are classified on the basis of the number of osseous walls.
  53. 53. Bone Loss and Patterns of Bone Destruction In Periodontal Disease
  54. 54. Bone Loss and Patterns of Bone Destruction In Periodontal Disease
  55. 55. Bone Loss and Patterns of Bone Destruction In Periodontal Disease Osseous craters  are concavities in the crest of the interdental bone confined within the facial and lingual walls.  Craters have been found to make up about one third (35.2%) of all defects and about two thirds (62%) of all mandibular defects. They are twice as common in posterior segments as in anterior segments.
  56. 56. Bone Loss and Patterns of Bone Destruction In Periodontal Disease Bulbous bone contours  are bony enlargements caused by exostosis, adaptation to function, or buttressing bone formation. They are found more frequently in the maxilla than in the mandible.
  57. 57. Bone Loss and Patterns of Bone Destruction In Periodontal Disease
  58. 58. Bone Loss and Patterns of Bone Destruction In Periodontal Disease Reversed architecture  Reversed architecture defects are produced by loss of interdental bone, including the facial plates, lingual plates, or both, without concomitant loss of radicular bone, thereby reversing the normal architecture. Such defects are more common in the maxilla.
  59. 59. Bone Loss and Patterns of Bone Destruction In Periodontal Disease
  60. 60. Bone Loss and Patterns of Bone Destruction In Periodontal Disease Ledges  Ledges are plateau-like bone margins caused by resorption of thickened bony plates
  61. 61. Bone Loss and Patterns of Bone Destruction In Periodontal Disease
  62. 62. Classification of Periodontal Disease The Periodontal Pocket Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues Furcation Involvement Bone Loss and Patterns of Bone Destruction In Periodontal Disease Trauma from Occlusion Gingival Disease in Childhood Juvenile Periodontitis Epidemiology of Gingival and Periodontal Disease
  63. 63. Furcation Involvement  The term furcation involvement refers to the invasion of the bifurcation and trifurcation of multirooted teeth by periodontal disease.  The prevalence of furcation involved molars is not clear. Whereas some reports indicate that the mandibular first molars are the most common sites and the maxillary premolars are the least common, others have found higher prevalence in upper molars.  The number of furcation involvements increases with age. Furcation Involvement
  64. 64. Furcation Involvement Clinical Features: 1. The tooth may or may not be mobile and is usually symptom free. 2. Tooth is sensitive to thermal changes (caused by caries or lacunar resorption of the root in furcation area) 3. Recurrent or constant throbbing pain (caused by pulp changes) 4. Sensitivity to percussion (caused by acute inflammatory involvement of the periodontal ligament.
  65. 65. Furcation Involvement Possible Etiologies: 1. Trauma from occlusion 2. Presence of enamel projections in the furcation 3. Proximity of furcation to cemento-enamel junction 4. Presence of accessory pulpal canals in the furcation area (may extend pulpal inflammation to the furcation)
  66. 66. Furcation Involvement Diagnosis: Furcation involvements have been classified as Grades I, II, III, and IV according to the amount of tissue destruction  Grade I – incipient bone loss  Grade II – partial bone loss  Grade III – total bone loss with through-and- through opening of the furcation  Grade IV – similar to Grade III but with gingival recession exposing the furcation to view.
  67. 67. Furcation Involvement
  68. 68. Furcation Involvement
  69. 69. Classification of Periodontal Disease The Periodontal Pocket Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues Furcation Involvement Bone Loss and Patterns of Bone Destruction In Periodontal Disease Trauma from Occlusion Gingival Disease in Childhood Juvenile Periodontitis Epidemiology of Gingival and Periodontal Disease
  70. 70. Trauma from Occlusion  Trauma from occlusion refers to tissue injury resulting from occlusal forces exceeding the adaptive capacity of the tissues.  Trauma from occlusion is the tissue injury – not the occlusal force.  An occlusion that produces such injury is called a traumatic occlusion. Trauma from Occlusion
  71. 71. Trauma from Occlusion Acute Trauma  Acute trauma from occlusion results from an abrupt change in occlusal force such as that produced by biting on a hard object or restorations and prosthetic appliances that interfere with or alter the direction of occlusal forces on the teeth. The results are tooth pain, sensitivity to percussion, and increased tooth mobility.
  72. 72. Trauma from Occlusion Chronic Trauma  Chronic trauma from occlusion is more common than acute form.  It most often develops from gradual changes in the occlusion produced by tooth wear, drifting movement, and extrusion of teeth, combined with parafunctional habits such as bruxism and clenching, rather than as a sequela of acute periodontal trauma.
  73. 73. Trauma from Occlusion Primary trauma from occlusion  occurs if trauma from occlusion is considered the primary etiologic factor in periodontal destruction and if the only local alteration to which a tooth is subjected is one of occlusion Secondary trauma from occlusion  occurs if trauma from occlusion is considered a secondary cause of periodontal destruction; this is the case when the adaptive capacity of the tissues to withstand occlusal forces is impaired.  Alveolar bone loss is the most common cause of secondary trauma and may be difficult to remedy.
  74. 74. Trauma from Occlusion Stages of Tissue Response The tissue response occurs in three stages. The first is injury, the second is repair, and the third is adaptive remodelling of the periodontium
  75. 75. Trauma from Occlusion Stage I : Injury  produced by excessive occlusal forces  Different lesions are produced by pressure and tension. Severe tension causes widening of the periodontal ligament, thrombosis, hemorrhage, tearing of the periodontal ligament, and resorption of alveolar bone  Severe pressure causes necrosis of the periodontal ligament and bone. The bone is resorbed from viable periodontal ligament adjacent to necrotic areas and from marrow spaces, a process called undermining resorption. Stages of Tissue Response
  76. 76. Trauma from Occlusion Stage II : Repair  Repair is constantly occurring in the periodontium. The damaged tissues are removed, and new connective tissue cells and fibers, bone, and cementum are formed in an attempt to restore the injured periodontium.  When bone is resorbed by excessive occlusal forces, nature attempts to reinforce the thinned bony trabeculae with new bone.  The attempt to compensate for lost bone is called buttressing bone formation and is an important feature of the reparative process. Stages of Tissue Response
  77. 77. Trauma from Occlusion Stage III : Adaptive remodeling of the Periodontium  If the repair process cannot keep pace with the destruction caused by the occlusion, the periodontium is remodeled in an effort to create a structural relationship in which the forces are no longer injurious to the tissues.  This results in a thickened periodontal ligament, which is funnel-shaped at the crest, and angular defects in the bone, with no pocket formation. The involved teeth become loose. Stages of Tissue Response
  78. 78. Trauma from Occlusion Effect of insufficient Occlusal Force  Insufficient stimulation causes degeneration of the periodontium, manifested by thinning of the periodontal ligament, atrophy of the fibers, osteoporosis of the alveolar bone, and reduction in bone height. Hypofunction results from an open bite relationship, an absence of functional antagonists, or unilateral chewing habits that neglect one side of the mouth.
  79. 79. Trauma from Occlusion Reversibility of Traumatic Lesions  Trauma from occlusion is reversible.  The injurious force must be relieved for repair to occur.
  80. 80. Trauma from Occlusion The Influence of Trauma from Occlusion on the Progression of Marginal Periodontitis  The local irritants that initiate gingivitis and periodontal pockets affect the marginal gingiva but trauma from occlusion occurs in the supporting tissues and does not affect the gingiva  Trauma from occlusion does not cause periodontal pockets or gingivitis, nor does it have any influence on bacterial repopulation of pockets after scaling and root planing.  Occlusal stresses however increase the periodontal destruction induced by periodontitis.
  81. 81. Trauma from Occlusion Clinical and Radiographic Signs of Trauma from Occlusion  The most common clinical sign of trauma to the periodontium is increased tooth mobility.  The radiographic signs include: 1. Increased width of periodontal space 2. Vertical destruction of interdental septum 3. Radioluscence and condensation of alveolar bone 4. Root resorption
  82. 82. Trauma from Occlusion PATHOLOGIC MIGRATION  Pathologic migration refers to tooth displacement that results when the balance among the factors that maintain physiologic tooth position is disturbed by periodontal disease  occurs most frequently in the anterior region  Pathologic migration in the occlusal or incisal direction is termed extrusion.
  83. 83. Classification of Periodontal Disease The Periodontal Pocket Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues Furcation Involvement Bone Loss and Patterns of Bone Destruction In Periodontal Disease Trauma from Occlusion Gingival Disease in Childhood Juvenile Periodontitis Epidemiology of Gingival and Periodontal Disease
  84. 84. Gingival Disease in Childhood Gingival Disease in Childhood The perodontium of the deciduous dentition: 1. The gingival of deciduous dentitions is pale pink, firm and either smooth or stippled(the latter is found in 35 percent of children from 5 to 13 year of age). 2. The interdentally gingival is broad faciolingually and tends to be relatively narrow mesidestally,in formity with the contour of the a proximal tooth surfaces. 3. The mean gingival sulcus depth for the primary dentations is 2.1mm ± 0.2mm.
  85. 85. Gingival Disease in Childhood
  86. 86. Gingival Disease in Childhood Physiologic Gingival Changes Associated with Tooth Eruption The following are physiological changes in the gingival associated with tooth eruption: 1. pre-eruption bulge - before the crown appears in the oral cavity , the gingival presents a bulged that is firm , may be slightly blanched, and conforms to the underlying crown contour of the teeth.
  87. 87. Gingival Disease in Childhood 2. Formation of the Gingival Margin - The marginal gingival and sulcus develop as the crown penetrates the oral mucosa. In the course of eruption the gingival margin is usually edematous ,rounded, and slightly Reddened 3. normal prominence of the gingival margin - During the period of mixed dentition it is normal for the marginal gingiva around the permanent teeth to be quit promenant ,particulary in the maxillary anterior region.
  88. 88. Gingival Disease in Childhood
  89. 89. Gingival Disease in Childhood TYPES OF GINGIVAL DISEASE 1. Chronic Marginal Gingivitis 2. Localized Gingival Recession 3. Acute Gingival infections
  90. 90. Gingival Disease in Childhood Chronic Marginal Gingivitis  This is the most prevalent type of gingival change in childhood. The gingival exhibits all the change in color, size, consistency, and surface texture characteristic of chronic inflammation .  a fiery red surface discoloration is often superimposed on underlying chronic change.  gingival color change and swelling appear to be more common expressions of gingivitis in children than are bleeding and increased pocket.
  91. 91. Gingival Disease in Childhood
  92. 92. Gingival Disease in Childhood Etiology  In children ,as in adult, the most common cause of gingivitis is plaque. Local conditions such as materia alba and poor oral hygiene favor its accumulation.  in preschool children ,the gingival response to bacterial plaque. Was found to be markedly reduced from that in adult.  dental plaque appears to form more rapidly in children(age 8 to 12 years) than in adult.
  93. 93. Gingival Disease in Childhood Calculus  Is uncommon in infants it occur in approximately 9 per cent of children between the age of 4 and 6 years, in 18 percent between 7 and 9 years, in 33 to 43 percent between 10 and 15 year age.  in children with cystic fibrosis, calculus formation is more common (occurring in 77 per cent ages 7 to 9 years, and in 90 per cent at age 10 to 15 years) and more severe; this is probably related to increased concentration of phosphate, calcium, and protein in saliva.
  94. 94. Gingival Disease in Childhood  Gingivitis associated with tooth eruption is frequent and has given rise to the term eruption gingivitis.  Tooth eruption eruption per se dose not cause gingivitis. The inflammation result from plaque accumulation around erupting teeth.  Plaque retention around deciduous teeth facilities plaque formation around permanent teeth.  Partially exfoliated, loss deciduous teeth frequently cause gingivitis.  Other factors favoring plaque build-up are food impaction and materia alba accumulation around tooth partically destroyed by caries.
  95. 95. Gingival Disease in Childhood  Children frequently develop unilateral chewing habits to avoid loss or carious teeth, aggravating the accumulation of plaque on non-chewing side.  Gingivitis occur more frequently and with greater severity around malposed teeth because of increase tendency to accumulate plaque and materia alba.  Severe changes include gingival enlargment, bluish red discoloration, ulceration.  Gingival health and contour are restored by correction of malposition.
  96. 96. Gingival Disease in Childhood  Gingivitis is increased in children with excessive overbite and overjet, nasal obstruction, and mouth breathing habit.
  97. 97. Gingival Disease in Childhood LOCALIZED GINGIVAL RECESSION  Gingival recession around individual teeth or groups of teeth is a common source of concern.  The gingival may be inflamed or free of disease, depending on the presence or absence of local irritants.  In children the position of the tooth in the arch is most important.  Gingival recession occurs on teeth in labial version or on those that are tilted or rotated so that the root projection labials.
  98. 98. Gingival Disease in Childhood
  99. 99. Gingival Disease in Childhood ACUTE GINGIVAL INFECTIONS Acute herpetic gingivostomatitis  this is most common type of acute gingival infections in childhood  it often occurs as a sequela of upper respiratory tract infections. Candidiasis  This is mycotic infection of the oral cavity caused by the fungus candida albicans. Most often acute but may be chronic
  100. 100. Gingival Disease in Childhood ACUTE GINGIVAL INFECTIONS Acute necrotizing ulcerative gingivitis  The incidence of (ANUG) in childhood is low.  In children living in area chronic malnutration is common and in children with down’s sydrome, the incidence and severity of ANUG seem to be increased  Acute herpetic gingivostomatitis, which is more common childhood, is occasionally erroneously diagnosed as ANUG
  101. 101. Gingival Disease in Childhood TRAUMATIC CHANGES IN THE PERIODONTIUM  traumatic change may occur in the periodontal tissue of deciduous teeth under several condition.  In the process of shedding deciduous teeth, resorption of teeth and bone weakens the periodontal support ,so that the existing functional forces are injyrious to the remaining supporting tissue.
  102. 102. Gingival Disease in Childhood TRAUMATIC CHANGES IN THE PERIODONTIUM  Excessive occlusal forces may be produced by malalignament, mutilation, loss or extraction of teeth or by dental restoraton. In the mixeddentition stage ,the periodontium of permanent teeth may be traumatizing because the permanent teeth bear increased occlusal load .  The periodontal ligament of an erupting permanent tooth may be injured by occlusal forces transmitted through the deciduous tooth it is replacing
  103. 103. Gingival Disease in Childhood The Oral Mucous Membrane in Childhood Diseases  Childhood disease present specific alteration in the oral mucosa include gingival disease. Among these are the communicable diseases such as : -varicella(chickenpox) -rubeola(measles) -scarlatina(scarlet fever) -diphtheria
  104. 104. Classification of Periodontal Disease The Periodontal Pocket Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues Furcation Involvement Bone Loss and Patterns of Bone Destruction In Periodontal Disease Trauma from Occlusion Gingival Disease in Childhood Juvenile Periodontitis Epidemiology of Gingival and Periodontal Disease
  105. 105. Juvenile Periodontitis  Juvenile periodontitis refers to cases of severe, rapid periodontal destruction and premature tooth loss in children and teenagers, the etiology of which is not understood.  These cases occur infrequently and can be classified as 1. Those occurring in otherwise healthy individuals (localized form) 2. Those associated with a variety of diseases of other systems Juvenile Periodontitis
  106. 106. Juvenile Periodontitis GENERALIZED FORM This type of juvenile periodontitis attacks the whole dentition or a large part of it and is associated with systemic disturbances  Papillon-lefevre syndrome  Down’s Syndrome  Neutropenias  Hypophosphatasia  Acute and Subacute Leukemia  Prepubertal periodontitis
  107. 107. Juvenile Periodontitis Papillon-Lefevre Syndrome  a syndrome characterized by hyperkeratotic skin lesions, severe destruction of the periodontium, and in some cases, calcification of the dura  Periodontal lesions consist of early inflammatory involvement leading to bone loss and exfoliation of teeth By the age of 15 years, patients are usually edentulous except for the third molars  The syndrome is inherited and appears to follow an autosomal recessive pattern of inheritance Generalize d form
  108. 108. Juvenile Periodontitis Down’s Syndrome  a congenital disease caused by a chromosomal abnormality and characterized by mental deficiency and growth retardation  Periodontal disease in Down’s syndrome is characterized by formation of deep periodontal pockets associated with a substantial plaque accumulation and moderate gingivitis  these findings are usually generalized, although they tend to be more severe in the lower anterior region Generalize d form
  109. 109. Juvenile Periodontitis Neutropenia  destructive generalized periodontal lesions have been described in children with neutropenia Hypophosphatasia  a rare familial skeletal disease, which in some cases results in loss of primary teeth, particularly the incosors Acute and Subacute Leukemia  these diseases in children are accompanied by gingival changes Generalize d form
  110. 110. Juvenile Periodontitis Prepubertal periodontitis  these cases are rare, and they start during or immediately following eruption of the primary teeth  An extremely acute inflammation and proliferation of the gingival tissues, with rapid destruction of bone, are found  All primary teeth are affected, but the permanent dentition may not be affected Generalize d form
  111. 111. Juvenile Periodontitis LOCALIZED FORM  previously known as diffuse atrophy of the alveolar bone, deep cementopathia, parodontitis marginalis progressiva, paradontosis, periodontosis Disease of the periodontium occurring in an otherwise healthy adolescent which is characterized by a rapid loss of alveolar bone about more than one tooth of the permanent dentition
  112. 112. Juvenile Periodontitis Age and Sex Distribution  juvenile periodontitis affects both males and females and is seen most frequently in the period of puberty and the age of 25 years Distribution of Lesions  The classic distribution is in the region of the first molars and incisors, with the least destruction in the cuspid-premolar area Localized form
  113. 113. Juvenile Periodontitis Clinical Findings  The most striking feature of early juvenile periodontitis is the lack of clinical inflammation in the presence of deep periodontal pockets  There is a small amount of plaque, forming a thin film on the tooth and rarely mineralizing to become calculus  Clasically, one sees a distolabial migration of the maxillary incisors, with diastema formation Localized form
  114. 114. Juvenile Periodontitis Clinical Course  The rate of bone loss is about three to four times faster than that in typical periodontitis Histopathology  A thin, frequently ulcerated pocket epithelium, infiltrated by numerous leukocytes covers large areas of inflammatory cell accumulation composed mainly of plasma cells and blast cells, with lymphocytes and macrophages present in small numbers Localized form
  115. 115. Juvenile Periodontitis Histopathology  Collagen and other tissuecomponents constitute only a small proportion of the diseased site as compared with the situation in adult-type periodontitis Bacteriology  The two bacteria that have been considered pathogens in juvenile periodontitis are Actinobacillus actinomycetemcomitans and Capnocytophaga Localized form
  116. 116. Classification of Periodontal Disease The Periodontal Pocket Extension of Inflammation from the Gingiva to The Supporting Periodontal Tissues Furcation Involvement Bone Loss and Patterns of Bone Destruction In Periodontal Disease Trauma from Occlusion Gingival Disease in Childhood Juvenile Periodontitis Epidemiology of Gingival and Periodontal Disease
  117. 117. Epidemiology of Gingival and Periodontal Disease Dental epidemiology is the study of pattern (distribution) and dynamics of dental diseases in a human population Pattern implies that certain people are selected for attack by a disease and that the association between a disease and an affected population can be described as age, sex, racial or ethnic group, occupation, social characteristics, place of residence, susceptibility , and exposure to specific agents, to name only a few Epidemiology of Gingival and Periodontal Disease
  118. 118. Epidemiology of Gingival and Periodontal Disease Dynamics refers a temporal pattern and is concerned with trends, cyclic patterns, and the time that elapses between the exposure to inciting factors and the onset of the specific disease Epidemiologic indices are attempts to quantitate clinical conditions on a graduated scale, thereby facilitating comparison among populations examined by the same criteria and methods.
  119. 119. Epidemiology of Gingival and Periodontal Disease Prevalence is the proportion of persons affected by a disease at a specific point in time Incidence is defined as the rate of occurrence of new disease in a population during a given interval of time
  120. 120. Epidemiology of Gingival and Periodontal Disease INDICES USED TO STUDY PERIODONTAL PROBLEMS The indices that are discussed can be divided according to the variable measured 1. The degree of inflammation of the gingival tissues 2. The degree of periodontal destruction 3. The amount of plaque accumulated 4. The amount of calculus present
  121. 121. Epidemiology of Gingival and Periodontal Disease Indices Used to Assess Gingival Inflammation 1. Papillary-Marginal Attachment Index 2. Periodontal Index 3. Gingivitis Component of the Periodontal Disease Index 4. Gingival Index 5. Indices of Gingival Bleeding • Sulcus Bleeding Index • Bleeding Points Index • Interdental Bleeding Index • Gingival Bleeding Index
  122. 122. Epidemiology of Gingival and Periodontal Disease Papillary-Marginal Attachment Index (Schour and Massler)  Originally the PMA index was used to count the number of gingival units affected with gingivitis  The developers of this index eventually added a severity component for assessing gingivitis; the papillary units (P) were scored on a scale of 0 to 5, and the marginal (M) and attached (A) gingiva were scored on a scale of 0 to 3. Indices Used to Assess Gingival Inflammation
  123. 123. Epidemiology of Gingival and Periodontal Disease Periodontal Index (Russel)  The PI was intended to estimate the extent of deeper periodontal disease than the PMA index by measuring the presence or absence of gingival inflammation and its severity, pocket formation, and masticatory function 0 – negative 1 – mild gingivitis 2 – Gingivitis 6 – Gingivitis with pocket formation 8 – Advanced destruction with loss of masticatory function Indices Used to Assess Gingival Inflammation
  124. 124. Epidemiology of Gingival and Periodontal Disease Gingivitis Component of the Periodontal Disease Index (Ramfjord)  The Periodontal Disease Index (PDI) is similar to the PI in that both are used to measure the presence and severity of periodontal disease  The PDI does so by combining assessments of gingivitis and gingival sulcus depth on six selected teeth (#3, 9, 12, 19, 25, 28)  A numerical score for the gingival status component of the PDI is obtained by adding the values for all of the gingival units and by dividing by the number of teeth Indices Used to Assess Gingival Inflammation
  125. 125. Epidemiology of Gingival and Periodontal Disease Gingival Index (Loe and Silness)  The gingival index (GI) was developed solely for the purpose of assessing the severity of gingivitis and its location in four possible areas: the distofacial papilla, the facial margin, the mesiofacial papilla, and the entire lingual gingival margin.  Totaling the scores around each tooth yields GI score for the area. 0.1 – 1.0 Mild gingivitis 1.1 – 2.0 Moderate gingivitis 2.1 – 3.0 Severe gingivitis Indices Used to Assess Gingival Inflammation
  126. 126. Epidemiology of Gingival and Periodontal Disease Indices of Gingival Bleeding  The Sulcus Bleeding Index (SBI) of Muhlemman and Mazor uses bleeding on gentle probing as the first criterion for indicating gingival inflammation  The Bleeding Points Index (Lenox and Kopczyk) was developed to assess a patient’s oral hygiene performance. It determines the presence or absence of gingival bleeding interproximally and on the facial and lingual surfaces of each tooth Indices Used to Assess Gingival Inflammation
  127. 127. Epidemiology of Gingival and Periodontal Disease Indices of Gingival Bleeding  The Interdental Bleeding Index (caton and Polson) utilizes a triangle-shaped toothpick made of soft, pliable wood to stimulate the interproximal gingival tissue  The Gingival Bleeding Index (GBI) of Ainamo and Bay was developed as an easy and suitable technique for the practitioner to assess a patient’s progress in plaque control Indices Used to Assess Gingival Inflammation
  128. 128. Epidemiology of Gingival and Periodontal Disease Indices Used to Measure Periodontal Destruction 1. Gingival Sulcus Measurement Component of the Periodontal Disease Index 2. Extent and Severity Index 3. Radiographic Approaches to Measuring Bone Loss • Gingival-Bone Count Index • Periodontitis Severity Index Indices Used to Measure Periodontal Destruction
  129. 129. Epidemiology of Gingival and Periodontal Disease Gingival Sulcus Measurement Component of the Periodontal Disease Index (Ramfjord)  The technique developed by Ramfjord for measuring gingival sulcus depth with a calibrated periodontal probe involves measuring the distance from the cemento-enamel junction to the free gingival margin to the bottom of the gingival sulcus or pocket  The difference between the two measurements yields the gingival sulcus depth, which translates into gingival attachment Indices Used to Measure Periodontal Destruction
  130. 130. Epidemiology of Gingival and Periodontal Disease Extent and Severity Index (Carlos and coworkers)  The ESI was developed because of a lack of satisfaction with previous indices of periodontal disease  It expresses the percentage of sites that exhibit disease (E) and measures mean attachment loss in millimeters (S). Hence the ESI = (E, S) Indices Used to Measure Periodontal Destruction
  131. 131. Epidemiology of Gingival and Periodontal Disease Radiographic Approaches to Measuring Bone Loss  The Gingival-Bone Count Index, developed by Dunning and Leach, records the gingival condition and the level of the crest of alveolar bone  The Periodontitis Severity Index (PSI) was developed by Adams and Nystrom to assess the presence or absence of periodontitis. The presence of interproximal bone loss is determined radiographically using a modified Schei ruler Indices Used to Measure Periodontal Destruction
  132. 132. Epidemiology of Gingival and Periodontal Disease Indices Used to Measure Plaque Accumulation 1. Plaque Component of the Periodontal Disease Index 2. Simplified Oral Hygiene Index 3. Turesky-Gilmore-Glickman Modification of the Quigley-Hein Plaque Index 4. Plaque Index 5. Modified Navy Plaque Index 6. Patient Hygiene Performance Index
  133. 133. Epidemiology of Gingival and Periodontal Disease Plaque Component of the Periodontal Disease Index  The plaque component of the PDI is used on the six teeth selected by Ramfjord (#3, 9, 12, 19, 25, and 28) after staining with Bismarck brown solution  The criteria measure the presence and extent of plaque on a scale of 0 to 3, looking specifically at all interproximal facial and lingual surfaces the index teeth. Indices Used to Measure Plaque Accumulation
  134. 134. Epidemiology of Gingival and Periodontal Disease Simplified Oral Hygiene Index (Greene and Vermillion)  The OHI-S measures the surface area of the tooth covered by debris and calculus  It consists of two components: a Simplified Debris-Index (DI-S) and a Simplified Calculus Index (CI-S). Each component is assessed on a scale of 0 to 3.  The six tooth surfaces examined in the OHI-S are the facial surfaces of the teeth #3, 8, 14, and 24 and the lingual surfaces of #19 and 30. Indices Used to Measure Plaque Accumulation
  135. 135. Epidemiology of Gingival and Periodontal Disease Turesky-Gilmore-Glickman Modification of the Quigley-Hein Plaque Index  Plaque was assessed on the facial and lingual surfaces of all teeth after using a disclosing agent  A plaque score per person was obtained by totaling all of the plaque scores and dividing by the number of surfaces examined. Indices Used to Measure Plaque Accumulation
  136. 136. Epidemiology of Gingival and Periodontal Disease Plaque Index (Silness and Loe)  The PlI is unique among the indices because it ignores the coronal extent of plaque on the tooth surface area and assess only the thickness of plaque at the gingival area of tooth  It examines distofacial, facial, mesiofacial, and lingual surfaces  The PlI score for the area is obtained by totaling the four plaque scores per tooth. Indices Used to Measure Plaque Accumulation
  137. 137. Epidemiology of Gingival and Periodontal Disease Modified Navy Plaque Index  This index records the presence or absence of plaque, by a score of 1 or 0 respectively, on nine areas of tooth surface of the six index teeth used by Ramfjord.  A modified navy plaque index score per person is obtained by totaling all nine of the subdivision scores per tooth surface and dividing by the number of tooth surfaces examined Indices Used to Measure Plaque Accumulation
  138. 138. Epidemiology of Gingival and Periodontal Disease Patient Hygiene Performance Index (Podshadley and Haley)  The PHP index was the first index developed for the sole purpose of assessing an individual’s performance in removing debris after toothbrushing instruction  It records the presence or absence of debris as 1 or 0 respectively, using the six surfaces of the six OHI-S teeth Indices Used to Measure Plaque Accumulation
  139. 139. Epidemiology of Gingival and Periodontal Disease Indices Used to Measure Calculus(Podshadley and Haley) 1. Calculus component of OHI-S 2. Calculus component of PDI 3. Probe Method of Calculus Assessment 4. Calculus Surface Index 5. Marginal Line Calculus Index
  140. 140. Epidemiology of Gingival and Periodontal Disease Indices Used to Measure Calculus(Podshadley and Haley) 1. Calculus component of OHI-S 2. Calculus component of PDI 3. Probe Method of Calculus Assessment 4. Calculus Surface Index 5. Marginal Line Calculus Index
  141. 141. Epidemiology of Gingival and Periodontal Disease Indices Used to Measure Calculus Calculus component of OHI-S 0 = No calculus 1 = Supragingival calculus covering not more than 1/3 of root surface 2 = Supragingival calculus cover 1/3 - 2/3 3 = Supragingival calculus cover more than 2/3
  142. 142. Epidemiology of Gingival and Periodontal Disease Calculus component of PDI (Ramfjord)  The calculus component of the PDI assesses the presence and extent of calculus on the facial and lingual surfaces of six teeth on a numerical scale of 0 to 3. Probe method of Calculus Assessment (Volpe and associates)  developed for longitudinal studies of the quantity of of supragingival calculus formed Indices Used to Measure Calculus
  143. 143. Epidemiology of Gingival and Periodontal Disease Calculus Surface Index (Ennever and coworkers)  The CSI is one of two indices that are used in short- term clinical trials of calculus-inhibitory agents, to determine rapidly whether a specific agent has any effect on reducing or preventing supragingival or subgingival calculus Marginal Line Calculus Index (Muhlemann and Villa)  This index was developed to assess the accumulation of supragingival calculus on the gingival 3rd of tooth or along the margin of the gingiva Indices Used to Measure Calculus
  144. 144. Epidemiology of Gingival and Periodontal Disease Factors Affecting the Prevalence and Severity of Gingivitis and Periodontitis 1. Age -prevalence and severity of periodontal disease increases directly with increasing age 2. Sex - In general, males consistently have a higher prevalence and severity of periodontal disease 3. Race - Blacks had more periodontal disease than whites
  145. 145. Epidemiology of Gingival and Periodontal Disease Factors Affecting the Prevalence and Severity of Gingivitis and Periodontitis 4. Education and Income -periodontal disease is inversely related to increasing levels of education, as well as increasing levels of income 5. Place of Residence - prevalence and severity of periodontal disease are slightly higher in rural than in urban areas 6. Geographic Area - Children and youths living in South have slightly higher PI scores than in Midwest and West accdg to NHES
  146. 146. Epidemiology of Gingival and Periodontal Disease Etiological Factors of Gingival and Periodontal Disease 1. Oral Hygiene - the strong positive association that exists between poor oral hygiene and gingival and periodontal disease makes poor hygiene the primary etiologic agent 2. Nutrition - A secondary factor in the etiology of periodontal disease - The nutrients that have been specifically associated with the periodontal tissues are vit. A, B complex, C, and D and calcium and phosphorus
  147. 147. Epidemiology of Gingival and Periodontal Disease Etiological Factors of Gingival and Periodontal Disease 3. Fluorides - some investigators reported lower prevalence and severity of gingival and periodontal disease in optimally fluoridated areas 4. Adverse Habits - tobacco smoking and betel nut chewing have been associated with increased periodontal disease 5. Professional Dental Care - The incidence and severity of periodontal disorders are lower under in individuals having regular dental care

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