PERIODONTOLOGY

● Definition : Periodontitis is a chronic inflammatory disease

of bacterial aetiology that affects the supporting tissues
around the teeth.

General symptoms of periodontitis :

● Bleeding gums
● Bad taste in mouth
● Dull aching pain
● Mobile teeth & may be
totally lost
Incidence : ( 2009 UK Adult Dental Health Survey)
● 37% of the adult population suffer from moderate levels
of chronic periodontitis (with 4-6mm pocketing)
● 8% of the population suffer from severe periodontitis
(with pocketing exceeding 6mm).
● Severe periodontitis has been found to affect 11% of
adults worldwide.
 Bidirectional process
● Periodontitis is a complex disease depending on bacterial
biofilm.

Bacterial Tissue
Dysbiosis Inflammation
biofilm Breakdown
RISK FACTORS
??
Modifiable factors
● Local ( acquired – anatomical )
● Systemic
Nonmodifiable factors
● Socioeconomic status
● Genetics
● Adolescence
● Pregnancy
● Age
● Leukaemia
Local factors :
● Acquired local modifiable factors:
1- plaque & calculus
2- restorations
3- RPD
● Anatomical local modifiable factors:
1- malpositioned tooth
2- root furcation
3- root grooves
4- E .pearl
Systemic modifiable risk factors :
● Smoking
● Diabetes
● Poor diet
● Certain medications
● stress
 Tobacco use
● The most important risk factor
● Effect of smoking
● Mechanism of smoking effect
● Signs of smoking effect.
Mechanism of smoking in pd dis:
Perio ttt for smoker pt :
● OHI
● Scaling ( supra & subgingival)
● No surgery , no implant
● Refer to specialist
 DIABETES
● Uncontrolled pt ↑ pd disease & vice versa.
● Impaired Wound healing – surgery
● Multiple lateral pd abscess
● Biomarkers
 Stress
● Suppress immunity
● Quality of life , less OH maintenance
● ↑ smoking & poor nutrition
 Medication
● Immunosuppressants
● Antihypertensive (Ca channel blockers)
● Antiepiliptic
Pregnancy
Mechanism of pregnancy effect in pd dis :

● ↑ in cariogenic bacteria due to changes in diet.

● Changes in gingival tissue due to changes in
vascular permeability.
● Increase estrogen & progesterone hormones.
Management :

● 1- pt reassurance , The severity of pregnancy gingivitis

reduces
● after delivery and reverts to the previous low level of
inflammation.
● 2- oral hygiene instructions &scaling.
● 3- if symptomatic or pt desires , so surgical excision is
indicated.
Periodontal diseases in pregnancy
● Pregnancy tumor
● Gingivitis
Systemic diseases associated with
perio-dis:
● Established association :
1. CVD
2. Diabetes
3. Pregnancy

● Emerging evidence
1. Rheumatoid artheritis
2. Chronic kidney diseases
3. Osteoporosis
 Emerging evidence
( still understudy)
● Alcohol abuse.
● Obesity
● Lack of physical activity
● Nutrition
 Periodontal screening
Basic Periodontal Examination(BPE)
● The Basic Periodontal Examination (BPE) was first developed
by the British Society of Periodontology in 1986 and has
recently been revised.
● The BPE is a simple and rapid screening tool that is used to
indicate the level of further examination needed and provide
basic guidance on treatment needed.
● Screening involves probing of the periodontal tissues to
assess:
1. bleeding on probing
2. plaque and calculus deposits
3. Pocket depth
How to record BPE for adults ?
 WHO probe
● The WHO probe (often called a BPE probe) has a ball end
0.5mm in diameter, and a black band from 3.5 to 5.5mm.
A light probing force of between 20-25 grams should be
used (equivalent to the force required to blanch a
fingernail is used when performing the BPE)

● There are 2 types of WHO probe :

● E- type probe : only one black band
3.5 – 5.5 mm
● C- type probe : 2 black bands
3.5 -5.5 , 8.5 – 11.5 mm
WHO probe
E- type ( epidemiological)
For each sextant ,you must know:
● Indications of scoring code.
● Ttt guidance
● Special investigations
● Follow up & reassessment
code 0 code 2
● no BOP
● BOP
● no calculus
● no depth ● Calculus
● No need for pd ttt. ● No depth or less than 3.5
code 1 mm
● BOP
● OHI + supra &
● No calculus
subgingival scaling
● No depth or less than 3.5 mm
● OHI
code 3 Code ( *)
● BOP ● Furcation involvement or total loss of
● Calculus attachment of 7mm or more.
● Depth <5.5mm
● ( black band is partially obscured)
● OHI+ scaling + RP ● Score 0,1,2,3 can be managed by the
● Detailed pd chart for the sexant. GP.
● Panorama or selective periapical. ● Score 4,* need specialist referral
code 4
● BOP
● Calculus
● Depth >5.5mm
● ( black band is totally obscured)
● OHI+ scaling + RP+ surgery.
● Detailed pd chart for all sexants
● Panorama or full mouth periapical
 Dilemma of X ray & BPE
● The gold standard X ray of periodontal assessment is (full mouth
periapical x ray) using long cone paralling technique.
● Horizontal BW is used to assess bone level in relation to CEJ (in
the same arch).
● Vertical BW is used to assess bone level in relation to CEJ (in
opposing arches).
● Vertical BW provides better visualization of bone level than
horizontal BW.
● Panorama is not indicated for routine pd screening, it is indicated
only for complex cases, where there are variety of dental concerns
. ( NEW GUIDANCE ?!)
Follow up
● For scores 0,1,2 → follow up every 12 months (annual
check-up)
● For scores 3,4, * → follow up after 3 months
Recording the BPE for children
Drawbacks of BPE ?
● A screening method only not diagnostic
● Third molar is excluded
● Gingival recession & gingival hyperplasia
are not considered .
● A single tooth in the sexant is added to the
next sexant.
 CLASSIFICATION OF
PERIODONTAL DISEASES
The new classification
What has changed ?
● Clinical health definition.
● Chronic & aggressive periodontitis into single category.
● Classification of necrotizing periodontal diseases.
● Classification of endo-perio lesions.
● Periodontitis characterized by staging, extent & grading.
● BPE pathway for diagnosis.
Periodontal health & gingivitis:
● Pt with an intact periodontium.
● Patient with a reduced periodontium due to a cause other than
periodontitis.
1- cr lengthening
2- ortho app.
3- endo-perio lesions
4- impacted third molar
5- restoration margins
● Patient with a reduced periodontium due to periodontitis.
 Gingival hyperplasia (overgrowth)
( false pocketing)
● Gingival overgrowth can be induced by irritation, plaque,
calculus, repeated friction or trauma, and by an increasing
number of medications ( Nifidipine , Cyclosporine,
Phenytoin).
● Mouth breathing can also lead to gingivitis and gingival
overgrowth as a result of drying and loss of salivary
protection
 Nonplaque induced
Hereditary gingival fibromatosis
 Chronic periodontitis
● Periodontitis = gingivitis + attachment loss ( PDL,
cementum , alveolar bone)
● All periodontits develops out of gingivitis but not all
gingivitis pregress to periodontits.
● It affects 50% of adult population.
● A successfully treated periodontitis pt remains a
periodontitis pt for life .
● The disease can progress at any time due to suboptimum
OH & uncontrolled risk factors.
 - Clinical features :
1. Bleeding
2. Pocketing
3. Tooth mobility
4. Tooth migration
5. Halitosis
6. Discomfort
CLINICAL ATTACHMENT LOSS
● NORMALLY :
PD = < 1 mm
Attachment loss = 0
Gingival recession = 0

● In periodontitis :
PPD= > 1 mm (from FGM to base of the pocket)
Gingival recession GR = distance from CEJ to free gingival
margin (FGM)
CAL = PPD + GR
 Aggressive periodontitis
Characterized by :
● Rare , severe , rapidly progressive
● Causative bacteria ( aggregatibacter
actinomycetemcomitans )
● Rapid onset
● No contributing medical history
● Runs in families
● Affects young age < 35yrs
● Amount of Plaque is out of proportion with periodontitis.
Are we dealing with two different
diseases?!
● No evidence of different pathophysiology.
● Little consistent evidence that they are different diseases.
● Rates of progression of periodontitis consistent across the
population worldwide.
● Some people in each cohort exhibits different trajectories.
● Classification based only on severity fails to capture complexity
that influence treatment.
● Finally, you have to keep the door open that evidence might
change.
 Periodontal abscess
● History
● percussion
● probing
● Probing sinus
● Discharge
● swelling
● Timing
● Vitality test
● Radiographic bone loss ( vertical – apical)
Endo-perio lesions
= combined lesion
Ttt :
● Incision & drainage if abscess is present ( +/-)
antibiotics.
● Orthograde RCT.
● Periapical / periodontal surgery.
Classification
● Endo – perio with root damage
1- Root canal or pulp chamber perforation.
2-External root resorption.
3-Root fracture or cracking

● Endo- perio with no root damage

A. Periodontitis pt
B. Non periodontitis pt
● Grade 1 : narrow deep pocket of 1 tooth surface
● Grade 2: wide deep pocket of 1 tooth surface.
● Grade 3: wide deep pocket > 1 tooth surface
 ANUG , ANUP
Contributing factors :
● Stress
● Smoking
● Poor oral hygiene
● Immunosupression (HIV)
● Malnutrition
Micro-organism : fusiform spirochete.
ttt : starts only after healing of acute ulceration.
Classification of NU diseases
Chronic severely Temporarily &/or moderate
compromised patients compromised patient

Necrotizing gingivitis Necrotizing gingivitis

Necrotizing periodontitis Necrotizing periodontitis
Noma

Risk factors: Risk factors:

1. HIV / AIDS ( CD4 >200 1. Stress
detectable viral load) 2. Malnutrition
2. Severe malnutrition 3. Smoking
3. Extreme poor living 4. Previous NPD
conditions. 5. Local factors
 Gingival Recession
Irreversible regression of the gingiva below normal level of
attachment.

Mainly anatomically thin buccal plate of bone

● + traumatic tooth brushing
● Or plaque induced marginal inflammation
● Or traumatic occlusion
● Or orthodontic appliance
Miller`s
classification
Treatment of gingival recession
● Oral hygiene instructions
● Mucogingival surgery ( free graft or pedicle
flap)
● Thin acrylic gingival stent or veneer
 DIAGNOSIS OF
PERIODONTAL DISEASES
● History taking
● Examination ( BPE then detailed pd
chart)
Periodontal examination
● visual inspection ( color , OH , gingival contour
, suppuration , swelling)
● BPE
● Detailed pd chart
6 point periodontal charting
William`s probe
Periodontal measurements :
● Gingival recession = distance from CEJ to free gingival
margin (FGM)
● Pocket depth = distance from FGM to base of the pocket
● Attachment loss = gingival recession + pocket depth
Periodontal indices :
Bleeding on probing ( marginal bleeding index)
● Score 0 → no bleeding on probing
● Score 1 → bleeding on probing
Plaque index ( assessed by disclosing tablets)
● Score 0 → no plaque
● Score 1 → looks clean but plaque can be removed from
gingival 1/3 with probe
● Score 2 → visible plaque
● Score 3 → tooth surface is covered with abundant plaque
Tooth mobility ( assessed using instruments handles)
● Grade 1 : <1 mm in horizontal direction
● Grade 2 : 1-2mm in horizontal direction
● Grade 3 : movement of the crown in horizontal & vertical
direction.
Furcation involvement (Nabers probe)
● Class 1 : probe can be inserted < 3 mm between the roots.
● Class 2 : probing > 3 mm but not through the width of furcation
area.
● Class 3 : through & through destruction in furcation area.
 Nabers porbe
( furcation invovement)
Periodontal pocketing
● False pocket
● True pocket (supra & intrabony) apical
migration of junc. epi.
● Radiographic examination
● Diagnosis
1. Type of periodontitis
2. Staging, extent , grading , current disease status
3. Risk factor profile

● Ttt plan
● Monitoring ( clinical & radiographic reassessment)
Bleeding on probing (BOP) has been the most useful indicator of
disease activity .
Abscence of (BOP) is an indicator of periodontal stability
For plaque induced periodontitis :
● Extent = distribution
● Staging = severity
● Grading = rate of progression
● Current disease status = activity & stability
Extent
Staging
Grading
Current disease status
Example :
● Generalized periodontitis , stage 4 , grade B , currently
unstable.

● Risk factors :
● 1- smoking
● 2- uncontrolled diabetic
A 78-year-old man complains of loose teeth. He has not attended the dentist in many years,
and a detailed examination reveals:
● poor plaque control
● Widespread periodontal probing depths of >8 mm
● Furcation involvement of a number of teeth
● Generalized horizontal bone loss of up to 70%.
He is a smoker of 5 pack years (currently smoking five cigarettes a day) but is otherwise fit
and well. What is the single most appropriate diagnosis? ★
A Generalized stage III, grade A periodontitis
B Generalized stage III grade C periodontitis
C Generalized stage IV, grade B periodontitis
D Localized stage III, grade A periodontitis
E Localized stage IV, grade B periodontitis
Treatment with Antimicrobials
● Systemic
● local
Systemic antimicrobials
● Pd abscess 5 day regimen
● Pericoronitis 3 day regimen
● ANUG 3 day regimen
● Aggressive periodontitis 7-10 days regimen
● Ch periodontitis not justified
● For periodontal abscess & pericoronitis: antibiotics are
required only if there are systemic manifestations or spread
of infection.

● For ANUG & aggressive periodontitis: antibiotics are

required in the initial phase of therapy.
Good NEWS !
Local antimicrobials :
● Indications :
1- recurrent isolated deep pocket.
2- failure of nonsurgical plaque control
3- if surgery is not feasible ( medically compromised)

Adv:
1. ↑ local dose
2. ↓ unwanted systemic effects
3. Prolonged exposure of the pathogens to the drug
Periodontal surgery
 Periodontal surgery
Contraindications :
● Poor plaque control
● Medically compromised pt.
● Smoking
● Poor long term prognosis
● Unmotivated & careless pt.
General principles :
● Local anaesthesia
● Flap ( full or split)
● Suturing ( interrupted interproximal)
● Periodontal pack ( ZOE or ZnO Eugenol free )
● Chlorohexidine 0.2% 10 ml bd
Split flap
● A periodontal flap is a section of gingiva &/or mucosa
surgically separated from the underlying tissues to
provide visibility of and access to the bone and root
surface.

● A flap also allows the gingiva to be displaced to a

different location in patients with mucogingival
involvement.
Periodontal access surgery
Modified Widman flap
● Open debridement of root surface with minimal amount of
trauma .
● Adv:
↓ trauma & exposure of underlying bone so close adaptation
after repositioning
↓ post operative sensitivity & aesthetic problems
Apical repositioning flap
● Expose alveolar bone & include the option for osseous
surgery to correct intrabony defects.
● Osseous surgery are .. osteoplasty ( recontouring of bone)
& ostectomy ( excision of bone to eliminate intrabony
defects)
● Adv :
Excellent access to root surface debridement .
Excellent access for osseous surgery to correct intrabony
defects.
 Resective surgery
● Gingivectomy
● Crown lengthening
 Gingivectomy
● Indications :
1. Supra-alveolar deep false pockets .
2. Reshape severely damaged gingiva
3. Treat gingival enlargement
4. Temporary crown is needed prior to prosthesis.
● Disadv:
1. Loss of attached gingiva
2. Row wound
3. Expose root surface→ ↑ root caries & ↑ sensitivity
4. No value in ttt of intrabony pockets.
Aesthetic gingivectomy
Functional gingivectomy
 Clinical Crown lengthening
● Apical repositioning flap + recontouring of bone
● Crown lengthening surgery involves the removal of the
periodontal tissues to increase the clinical crown height for
aesthetic reasons or to provide adequate sound tooth tissue
for restoration.
 Regenerative surgery (GTR)
● Using a barrier to epithelial migration prior to completion
of surgical or nonsurgical therapy.
● The aim is thus to promote re-growth of cementum,
periodontal ligament (PDL) and alveolar bone.

● Aim of the memberane :

1- physical barrier
2- biological function by growth factors which activate
UDMC to osteocytes.
The barrier may be :
● Nonresorbable membrane ( old )
● Resorbable membrane ( recent) .. vicryl , Biogide
● Resorbable + growth factors.

● GTR = barrier membrane only

Or barrier membrane + bone grafts
Or barrier membrane + Enamel Matrix Derivatives
(Emdogain) derived from Hertwig`s sheath & applied locally
to help form acellular cementum.
Types of bone grafts :
● Autograft : graft from the same body
● Xenograft: graft from an animal ( Bio-oss®)
● Allograft : graft from another person
● Alloplast : synthetic bone substitute (PerioGlas®)
● Isograft :Genetically indentical
● Ceramics & bioactive molecules: Composite :
Intraoral sites of bone graft :
● Maxillary tuberosity
● Bony exostoses
● Edentulous ridge
● Extraction sites
● Mandibular symphesis ( the best)
● Mandibular body
● Osteoplasty & osteotomy sites
● External oblique ridge ( the most common)
● Allograft is the highest resorption rate
● Autograft is the cheapest
● Alloplast is the worst.
Mucogingival surgery
● Indication : correction of local gingival defects ( gingival
recession)
● Free grafts :
Palatal grafts ( the best aesthetic results)
● Pedicle flap :
Double papilla flap
Lateral repositional flap
Coronally repositional flap
Coronally repositioning flap
Lateral repositioning flap
Double papilla flap
Furcation involvement
Class 1 : <3 mm
❖ Scaling & root planing
❖ Furcationplasty
Class 2 : >3 mm & not full width
❖ GTR with graft material or EMD
Class 3 : through & through
❖ Tunnel preparation
❖ Root resection
❖ Hemisection
❖ Extraction
 Principles (phases) of
Periodontal Treatment
Initial phase of treatment
● Removal of underlying causes & modification of risk factors
● OHI ( oral hygiene instructions)
● Supragingival plaque control ( nonsurgical perio therapy)
Mechanical ( toothbrushing , interdental cleansing aids)
Chemical ( chlorohexidine mouthwash 0.2% 10 ml 1 min rinse
twice per day for a week )
● Removal of plaque retentive factors.
● Scaling & root surface debridement
 Corrective phase
● Further nonsurgical plaque control
● Surgical plaque control
● Selected use of antimicrobials
● Occlusal adjustment
● Any required restorative dentistry
 Supportive phase
● Reinforce pt. motivation to prevent recurrence of disease &
maintain good oral hygiene .
● The first 6 mon after corrective phase is a( Healing phase)
● Then regular follow up ( maintenance phase ) 3-4 mon.
intervals
Peri-implant mucositis
peri-implantitis
● peri-implant mucositis
● it can be likened to gingivitis.
● It involves inflammation of the peri-implant tissues,
● Signs & symptoms : swelling, redness, tenderness and bleeding on
probing without any concurrent bone loss.
●
● Peri-implantitis
● It can be likened to periodontitis.
● It involves progressive loss of alveolar bone support around the
implant. However, peri-implantitis is different from periodontitis
and can progress more rapidly. Hence, detection and management
are important.
 Referral policy
As a guideline for referral policy using periodontal treatment
assessment criteria:
● Complexity 1: cases should generally have treated in
general dental practice.
● Complexity 2: cases may be either treated by GDP or
referred.
● Complexity 3: cases should mostly be referred.
When to refer ?
1. The severity of the disease & complexity of the ttt
required.
2. The patient`s desire to see a specialist or undergo
specialist ttt.
3. The GDP`s knowledge, experience & training to treat
patients with a range of problems.
4. The presence of other complicating factors such as a
patient medical history or other comorbidity.
Role of GDP in perio ?
● 1- modification of risk factors
2- OHI
3- nonsurgical plaque control (mechanical & chemical)
4- removal of plaque retentive factors
5- scaling & root surface debridement
Role of specialist ?
● surgical perio therapy which is involved in corrective
phase of therapy as ( access surgery , resective ,
regenerative , mucogingival , furcation involvement )
THANK YOU