Lecture - Cogingival and periodontal diseases

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    GINGIVAL AND

    PERIODONTAL DISEASES

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    INTRODUCTION

    Oral mucosa consists of 3 zones:

    1.Gingiva & Hard Palate: Masticatory Mucosa.

    2. Dorsum of Tongue: Specialized Mucosa.

    3. Remaining oral Cavity: Oral Mucous membrane.

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    INTRODUCTION

    PERIODONTIUM:Investing & Supporting

    tissues of the tooth.

    GINGIVA: Protecting theunderlying tissues

    PERIODONTAL

    LIGAMENTS

    CEMENTUM

    ALVEOLAR BONE

    ATTACHMENTAPPARATUS

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    Gingiva is that part of

    the oral mucosa that

    covers the alveolar

    processes of the jaws

    and surrounds thenecks of the teeth

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    Any inherited or acquired disorder of the tissues

    surrounding and supporting the teeth(periodontium)

    can be defined as a periodontal disease.

    Periodontal disease usually refers to the

    common inflammatory disorders of gingivitis

    and periodontitis that are caused by pathogenicmicroflora in the biofilm or dental plaque that

    forms adjacent to the teeth on a daily basis.

    Developmental, traumatic, neoplastic,

    genetic, or metabolic origin

    PERIODONTAL DISEASES

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    Gingivitis, the mildest form of

    periodontal disease, is highlyprevalent and readily

    reversible by simple, effective oral

    hygiene.

    Gingivitis affects 5090% of adultsworldwide, depending on its

    precise definition

    Inflammation that extends deep into

    the tissues and causes loss of

    supporting connective tissue andalveolar bone is known as

    periodontitis .

    Periodontitis results in the formationof soft tissue pockets or deepened

    crevices between the gingiva and

    tooth root.

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    CLASSIFICATION (AAP

    1999)

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    GINGIVAL DISEASES

    PLAQUE INDUCED GINGIVALDISEASES

    most common form

    is a result of interaction between plaquebacteria & defence cells of the host.

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    CLINICAL FEATURES

    GINGIVITIS

    ACUTE/CHRONIC

    LOCALIZED/GENERALIZED

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    CLINICAL FEATURES

    Marginal gingivitis: inflammation

    involving the marginal gingiva

    Papillary gingivitis: involving the

    interdental papilla

    Diffuse gingivitis: involving the marginal

    gingiva, attached gingiva & interdental

    papilla

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    CLINICAL EXAMINATION

    The aim of the clinical examination is to identify signs of possible

    disease. The gingiva is assessed on the basis of the following

    parameters:

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    GINGIVAL DISEASES

    NON-PLAQUE INDUCED GINGIVALDISEASES

    Have different etiology & characteristic

    clinical presentation. Include specific bacterial, viral or

    fungal infections etc

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    NECROTIZING ULCERATIVE

    GINGIVITIS

    Vincents infection/ trench mouth

    Causes: fusiform bacillus &

    Bactereoids intermedius, Prevotellaintermedia

    Local predisposing factors:pre-existing gingivitis

    injury to gingiva

    smoking

    ORAL SIGNS:

    Punched out crater like depressions at the crest of

    interdental papillae extending to marginal gingiva.

    Covered with grey pseudomembranous slough / Red, shinyhemorrhagic

    Demarcated from the reminder gingival mucosa by

    pronounced linear erythema

    Pronounced Bleeding after slight stimulation

    Fetid odor

    Increased salivationDoes not lead to pocket formation , cause recession

    ORAL SYMPTOMS

    Lesions: extremely sensitive to touch

    Constant radiating gnawing pain ,

    spicy and hot foodMetallic foul taste

    EXTRA ORAL SIGNS AND

    SYMPTOMSLocal lymphadenopathy, Slight

    elevation in temperature,

    Leukocytosis, loss of appetite

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    ACUTE HERPETIC GINGIVOSTOMATITIS

    Caused by: HSV

    Most frequently in infants & childrenyounger than 6 yrs of age but can also

    be seen in adults

    ORAL SIGNS:

    Diffuse erythematous shiny involvement of gingiva and

    adjacent oral mucosa with varying degrees of edema and

    gingival bleeding.

    Initial stages: discrete spherical gray vesicles, on labial

    mucosa, buccal mucosa, soft palate, pharynx, tounge.

    Vesicles rupture, form small painful ulcers, with red elevated

    halo margin and depressed yellowishgray central portion

    ORAL SYMPTOMS

    Generalized soreness of the oral

    cavity

    Interfering with eating and drinking.

    Ruptured vesicles: painful, sensitiveto touch

    EXTRA ORAL SIGNS AND

    SYMPTOMS

    Fever, Generalized malaise

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    DESQUAMATIVE GINGIVITIS

    Is not a disease entity but a clinical

    term used to describe a unique

    condition of gingiva characterized byintense redness & desquamation of

    the surface epithelium.

    The clinical presentation includes thegingival manifestations of a variety of

    diseases like lichen planus,

    pemphigus vulgaris, bullous

    Intense erythema, desquamation, and ulceration of

    free and attached gingiva

    May be asymptomatic, if symptomatic: mild burning

    sensation to intense pain.

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    DRUG INDUCED GINGIVAL ENLARGEMENT

    SIGNS & SYMPTOMS:

    The growth starts as painless , beadlike enlargement of theinterdental papillae and extends to facial and lingual gingival

    margin.

    As condition progresses marginal and interdental papillae

    unite into massive fold covering considerable portion of

    crowns and interfere with occlusionAnticonvulsants(Phenytoin),

    immunosuppressants(Cyclosporines)and calcium channel

    blockers(Nifedipine)

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    PLASMA CELL GINGIVITIS

    Some of the compounds that cause

    contact allergy to in the gingiva are,

    mercurial compounds, like amalgam,

    tartar control tooth pastes, like,pyrophosphates, can lead to intense

    erythema of gingival tissue.

    Elimination of the offending agentusually leads to resolution of the

    lesion within a week.

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    PERICORONITIS

    SIGNS & SYMPTOMS:Gingival flap associated with incompletely erupted tooth :

    chronically inflamed: red swollen suppurative, tender with

    radiating pain to ear, throat floor of mouth.

    Foul taste, extraoral swelling, trismusEXTRA ORAL SIGNS AND

    SYMPTOMS

    Local lymphadenopathy, Slight

    elevation in temperature,Leukocytosis, malaise

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    ENLARGEMENT IN PREGNANCY

    MARGINAL: results from aggravation of previous

    inflammation

    Does not occour without the presence of plaque

    Generalized

    More prominent interproximally than on facial and lingual

    surfaces

    Enlarged gingiva is bright red or magenta, soft , friable,

    smooth and shiny surface.

    TUMOR LIKE: PREGNANCY TUMOR: Inflammatory

    response to bacterial plaque, modified by patients condition.

    Discrete mushroom like flattened spherical masses that

    protrudes from gingival margin or more often from

    interproximal areas, dusky red or magenta, smooth,

    glistening surface, numerous red pinpoint markings.Superficial lesion and does not invade bone.

    ESTROGEN / PROGESTERONE

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    ENLARGEMENT IN PUBERTY

    MALE / FEMALE ADOLESCENTS

    Marginal and interdental : characterized by prominent

    bulbous interproximal papillae.

    Facial gingiva enlarged, lingual gingiva: unaltered

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    PERIODONTITIS

    Any inflammatory disease of the

    supporting tissues of the tooth

    caused by specificmicroorganisms, resulting in

    progressive destruction of the

    periodontal ligament and alveolarbone with pocket formation,

    recession, or both.

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    CLINICAL EXAMINATION

    PERIODONTALPROBING

    Periodontal pockets should be examined for

    their presence, type and distribution in relation

    to each tooth.

    This can be done by systematic and careful

    probing with Williams graduated probe.

    The Williams periodontal probe is marked in

    millimeters at the following distances from the

    probe tip. 1, 2, 3, 5 then 7, 8, 9 and 10

    millimeters

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    Incorrect angle correct angle

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    Periodontal probing is accomplished for allsurfaces of every tooth in the dentition.

    During probing, a periodontal probe should beused with gentle pressure and it should be"walked" around the entire circumference ofeach tooth.

    Probing depth is recorded for all teeth on eachof six locations (buccal, lingual, mesio-buccal,mesio-lingual, disto-lingual, disto-buccal).

    The probe should be inserted parallel to thelong axis of the tooth and walked around eachsurface of each tooth to detect the depth ofpocket at each surface.

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    CLINICAL EXAMINATION

    CLINICAL ATTACHMENT LOSS

    While probing, the level of cemento enamel

    junction should also be noted.

    This is the distance from the cemento-enamel

    junction to the base of the pocket andrepresents the best measure of disease severity

    in terms of loss of support for the teeth.

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    CLINICAL EXAMINATION

    CLINICAL ATTACHMENT LOSS

    The Periodontal Probe is a suitable instrument forthe assessment of loss of attachment.

    The evidence of loss of attachment can be in the form of: Recession (which results in part of the root being visible in

    the mouth) or

    Pockets or Recession + Pockets

    Pockets are measured as the distance between theterminal end of the probe at the pocket base and the

    gingival margin.

    An increased probing depth as measured beyond the

    CEJ is considered as attachment loss.

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    CLINICAL EXAMINATION

    CLINICAL ATTACHMENT LOSS

    Recession is measured from the visible CEJ to

    the gingival margin using the Periodontal Probe

    as the measuring instrument.

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    CLASSIFICATION OF GINGIVAL

    RECESSION (P.D. MILLER)

    Class I: marginal tissue recession that does notextend to the mucogingival junction. There is noloss of bone or soft tissue in the interdental area.

    Class II: marginal gingival recession that extendsto or beyond the mucogingival junction. There isno loss of bone or soft tissue in the interdentalarea

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    Class III: : marginal tissue recession thatextends to or beyond the mucogingival

    junction. In addition, there is loss of boneand/or soft tissue in the interdental area orthere is malpositioning of teeth.

    Class IV: marginal tissue recession thatextends to or beyond the mucogingivaljunction with severe bone loss and soft

    tissue interdentally or severe malpositioningof teeth.

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    If recession and a probing depth coexist at one site, the

    amount of attachment from the CEJ is the sum of the

    two figures.

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    CLINICAL EXAMINATION

    TOOTH MOBILITY

    Tooth mobility is represented by the Romannumerals I, II or III. Mobility is detected by

    using the end of the handle of two instruments(e.g. mirror and periodontal probe).

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    CLINICAL EXAMINATION

    FURCATION

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    CLINICAL EXAMINATION

    Furcation involvement can be readily detectedin good periapical or bitewing radiographs.Clinically it can be confirmed by using theperidontal or Nabers probe.

    If the probe can go into the furcation thatindicates there is loss of attachment in thefurcation, an open arrow should be used.

    If the probe can go through the furcation e.g.,buccal to lingual or mesial to distal, thatindicates no attachment remains around the

    furcation, a closed arrow should be used.

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    DISEASED CONDITIONS

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    CHRONIC PERIODONTITIS

    Periodontoclasia/ pyorrhea/ pyorrhoeaalveolaris

    Most common form

    Begins as marginal gingivitis, whichusually progresses, if untreated or

    improperly treated, to chronic

    periodontitis.

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    PERIODONTAL ABSCESS

    It is a destructive process occurring in theperiodontium, resulting in localized collections of pus,

    communicating with the oral cavity through the

    gingival sulcus or other periodontal sites and not

    arising from the tooth pulp.

    The important characteristics of the periodontal

    abscess include:

    localized accumulation of pus in the gingival wall of

    the periodontal pockets; usually occurring on thelateral aspect of the tooth; the appearance of

    oedematous red and shiny gingiva; may have a

    dome like appearance or may come to a distinct

    point.

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    RADIOGRAPHIC ASSESSMENT

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    Gingivitis and acuteperiodontitis do not have

    any specific radiographic

    features

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    Calculus is

    prominently visibleon the second

    premolar, first

    molar,

    and second molar.

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    Widening of the

    periodontal

    ligament

    space

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    Bone loss is

    considered horizontal

    when the crest of the

    proximal bone remainsparallel to an imaginary

    line drawn between the

    cemento-enamel

    junctions of adjacent

    teeth.

    Horizontal bone loss proximal to the

    posterior teeth.

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    Bone loss is

    considered vertical

    when the crest of the

    proximal bone is not

    parallel to an imaginaryline drawn between the

    cemento-enamel

    junctions of adjacent

    teeth.

    Vertical (angular) bone loss mesial to the

    maxillary molar.

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    Furcation involvement of molar teeth inAdvanced periodontal disease.

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    Lateral periodontal abscess

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    LOCALIZEDAGGRESSIVEPERIODONTITIS

    A. Loss of bone support in the area of the firstmolars and incisors of both maxillary and mandibular right

    quadrants

    B. left quadrants of the same patient depicted

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    RADIOGRAPHIC ASSESSMENT

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