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 Periodontal Diseases

1-34. GENERAL

Periodontal diseases involve the periodontal tissues. When considering the causes of these diseases, both systemic and local factors must be taken into account. Periodontal diseases involve the supporting structure that maintains a tooth within the dental arch. This includes the periodontal ligament, the alveolar bone, and the gingiva. An inflammatory process or trauma generally initiates periodontal disease; however, systemic considerations can also influence the susceptibility and degree of involvement.

1-35. GINGIVITIS (Figures 1-4 and 1-5)

Gingivitis is an inflammation of the gingival tissues. It is characterized by the typical signs and symptoms of inflammation--swelling (edema), redness, pain, increased heat, and, sometimes, disturbance of function. Most patients that appear to have clinically healthy gingiva also have minute areas of inflammatory activity. The inflammation is caused by the toxic substances produced by bacteria in the mucinous plaques adjacent to the gingival tissue. Direct irritation from food impaction, toothbrush bristles, or toothpicks may also cause gingival inflammation. With inflammation, the gingival tissue appears to proliferate. The inflammatory gingival response causes a swelling of the tissue due to increased vascular activity. This increases the depth of the gingival sulcus (a furrow between the surface of the tooth and the gingiva) around the involved teeth, increasing the potential for continued and further gingival involvement. The increased depth of the sulcus allows additional debris to accumulate and more plaque to form. If this plaque is not removed, it may become calcified from the precipitation of calcium salts from the saliva. The calcified plaque is called calculus.

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Figure 1-4. Gingivitis, tissue inflammation.

NOTE: Inflammation of the gingival tissues is evident at the neck of these maxillary and mandibular anterior teeth. Note the redness and bulbous engorgement (edema) of the tissue as well as the lack of normal tissue texture. Dental plaque accumulation accounts for this inflammatory response.

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Figure 1-5. Gingivitis, fibrous tissue development.

NOTE: Long term dental neglect has resulted in a progressive inflammatory response That in some areas has initiated a fibrous tissue development. Note areas of inflammation and fibrous gingiva. Malpositioned teeth contribute to inadequate cleansing and dental plaque accumulation.)

1-36. PERIODONTITIS (Figure 1-6)

Periodontitis is an inflammation of the tissues supporting the teeth. It is also commonly known as "pyorrhea." If untreated, the tooth may be lost through destruction of the supporting tissues.

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Figure 1-6. The progress of periodontal destruction.

NOTE: Deposit of minerals from the saliva into dental plaque results in a hard calculus formation. The pockets between the teeth and gingival tissue deepen as periodontal disease progresses. Calculus formation in periodontal pockets makes plaque removal more difficult, contributing to progress of the disease and destruction of the bony support of the teeth.

Cause. Periodontitis is caused by the local irritants of bacterial plaque. By making plaque more difficult to remove, calculus deposits, poor fitting crowns, bands, and restorations contribute to developing periodontitis. Poor diet, endocrine disturbance, and systemic disease may serve as predisposing and contributing factors.

Effect. In periodontitis, the periodontal ligament, cementum, alveolar bone, and gingival tissues are destroyed. With this loss of support, the teeth may become loose. In this disease, the periodontal ligament separates from the cementum and a pocket forms between the tooth and the gingival tissue. The pocket becomes an entrance for bacteria. Inflammation follows. Alveolar bone is resorbed and the space created is partly filled with granulation tissue. With loss of bony support, the teeth may become loose. In periodontitis, the gingival tissue may take on a bluish appearance. Bad taste, bleeding gums, and hypersensitive teeth are common symptoms. Treatment includes management of the disease by the dental officer and vigorous home care by the patient.

1-37. LOCALIZED JUVENILE PERIODONTITIS

This disease is in fact a series of diseases in teens and young adults caused by bacteria and systemic disorder. It progresses so rapidly that conventional therapy is inadequate.

1-38. PERIODONTAL ABSCESS

A periodontal abscess is most frequently a sequel of untreated periodontal disease. It is a collection of pus along the sides of the tooth that may or may not involve the apical area. It can be caused by a foreign body such as calculus, a toothpick, or popcorn hull becoming lodged in the periodontal ligament or beneath the free margin of the gingival tissue. The irritant causes an inflammatory response and, because of minimal drainage through the periodontal sulcus, pus forms. A periodontal abscess may drain either through periodontal pockets or through the gingiva into the mouth. The most common signs and symptoms are swelling, dull pain in adjacent periodontal tissues, soreness of the gingiva, and shiny mucous membrane over the area. Establishment of drainage tends to reduce the acute symptoms.

1-39. NECROTIZING ULCERATIVE GINGIVITIS

Necrotizing ulcerative gingivitis (NUG), commonly called "trench mouth" or Vincent's disease, is a bacterial infection. It is usually associated with poor oral hygiene, smoking, and/or psychological stress, but may be seen in patients with good oral hygiene.

Cause. Although the exact cause of the disease is unknown, it is accompanied by an increase in the numbers of two organisms, the fusiform bacillus and medium-size spirochetes (Vincent's spirillum). It is doubtful that NUG is readily communicable. Instruction in oral hygiene is not only an important preventive measure but also an essential phase of the treatment. The infecting organisms can successfully invade and grow only in tissues whose resistance has been lowered. Therefore, proper diet, rest, exercise, and adequate oral hygiene can be good preventive measures.

Effect. Necrotizing ulcerative gingivitis is characterized by fetid breath and ulcerations covered by a whitish, yellowish, or gray pseudomembrane. They may be found in only a few areas or throughout the mouth. The most common site of these ulcers is the interproximal gingiva. The thin gray membrane covering the ulcer may be wiped off easily, exposing a highly inflamed area that bleeds very easily. There is a rapid destruction of the marginal and interproximal soft tissue. These tissues become so painful that it becomes difficult to brush the teeth and to masticate food. The onset of this infection is sudden, often with systemic symptoms of illness. In severe cases, there may be fever, an increased pulse rate, pallor of the skin, insomnia, and mental depression. Treatment includes procedures performed by the dental officer and home-care procedures performed by the patient.

1-40. PERICORONITIS

Pericoronitis is an inflammatory process occurring in gingival tissue found around the coronal (crown) portion of the teeth, particularly around partially erupted teeth. Similarly, operculitis is an inflammation of the gingival tissue flaps (operculi) found over partially erupted teeth. The most frequent site is the mandibular third molar region. The heavy flap of gingival tissues covering portions of the tooth crown of the tooth makes an ideal pocket for debris accumulation and bacterial incubation. In the acute phase, pain and swelling in the area are prominent features. Symptoms of a sore throat and difficulty in swallowing may be present. A partial contraction of muscles of mastication, causing difficulty in opening the mouth (trismus), may also be experienced. Abscess formation in the area may occur, leading to marked systemic symptoms of general malaise and fever. Treatment should be directed toward careful cleansing of the pocket area and followup care with warm saline irrigations. Antibiotic therapy may be indicated if the condition warrants. The prognosis for retention of the tooth is dependent upon the possibility of complete elimination of the inflammation and elimination of the gingival flap.

David L. Heiserman, Editor

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Revised: June 06, 2015