Marginal periodontitis

THE NORMAL PERIODONTIUM

The periodontium consists of those tissues that surround and
anchor the tooth in the maxillary and mandibular alveolar
process. These tissues include the gingiva and gingival
attachment to the tooth, cementum, periodontal ligament, and
alveolar bone.
When viewed clinically, the only portion of periodontium that
is visible to the unaided eye is the oral aspect of the gingival
epithelium. When healthy, this area of gingiva is normally
coral pink with variations in melanin pigmentation among
different racial groups.
 MARGINAL PERIODONTITIS
Chronic periodontitis is a common plaque-induced periodontal infection
that is a major cause of tooth loss throughout the world. This form of
periodontitis was once called adult periodontitis because it was thought
to be primarily found in adults.
However, epidemiologic data suggest that the disease can also be found
in children and adolescents. Chronic periodontitis has been historically
considered as a slowly progressive disease. However, there are also data
indicating that some patients may experience short periods of rapid
progression.
 MARGINAL PERIODONTITIS

Although chronic periodontitis can be distributed in localized and

generalized patterns throughout the mouth, the two forms appear to be
identical with regard to their etiology and pathogenesis.
There is a general consensus that chronic periodontitis is initiated and
sustained by dental plaque biofilms, but host responses to plaque
bacteria are responsible for most of the tissue destruction.
 Classification of periodontitis
1. Gingival diseases(G)
2. Chronic periodontitis(CP)
3. Aggressive periodontitis(AP)
4. Periodontitis as a manifestation of systemic diseases(NP)
5. Necrotizing periodontal diseases
6. Periodontal abscesses
7. Periodontitis with endodontal lesions
8. Developmental and acquired deformation and conditions
 Classification of periodontitis
1. Gingival diseases (G)
A. Gingival diseases caused by plaque
B. Gingival lesions not induced by plaque
2. Chronic periodontitis (CP)
A. Localised
B. Generalised
3. Aggressive periodontitis (AP)
A. Localised
B. Generalised
 Classification of periodontitis
4. Periodontitis as a manifestation of systemic
diseases (NP)
A. Connected with blood diseases
B. Connected with genetic disorders
C. Not otherwise defined
5. Necrotizing periodontal diseases
A. Necrotizing ulcerous gingivitis (NUG)
B. Necrotizing ulcerous periodontitis (NUP)
 Classification of periodontitis
6. Periodontal abscesses
A. Gingival abscess
B. Periodontal abscess
C. Pericoronal abscess
7. Periodontitis with endodontal lesions
A. Combined paro-endo lesion
 Factors Associated with Chronic
Periodontitis

• Age: Clinical attachment loss and alveolar bone loss become more
prevalent, extensive,and severe with advancing age. Although early
loss can occur before the age of 20 years, by 30 to 39 years of age at
least two thirds of U.S. adults have 1 or more sites with clinical
attachment loss of 2 mm or more.
 Factors Associated with
Periodontitis
• Sex: In the United States and in most industrialized populations, male
individuals of every age group have more attachment loss, deeper
pockets, and more bleeding on probing than females.4 However, such
differences have not been observed in all untreated populations and
developing nations.
This suggests that sex differences arise from behavioral differences,
culturally related or otherwise, and not because of true differences in
predisposition to the disease. For example, it has been reported that in
the United States male individuals have poorer oral hygiene and more
calculus than females.
 Factors Associated with Chronic
Periodontitis
• Oral Hygiene, Calculus, and Gingival Inflammation
Bacterial plaque is both necessary and sufficient to cause gingivitis.
However, undisturbed bacterial plaque alone is not sufficient to cause
periodontitis. Plaque plays a central role in the initiation of gingival
inflammation and calculus formation, and poor plaque control has been
shown to have a deleterious effect on the success of periodontal
treatment. Furthermore, periodontal disease is preventable in most
individuals through a combination of frequent professional care and
improved oral hygiene.
 Factors Associated with Chronic
Periodontitis
• Oral Hygiene, Calculus, and Gingival Inflammation
However, the independent effect of oral hygiene in preventing
periodontitis has not been established. A few reports indicate that
persons with greater plaque scores are more likely to experience
progressive periodontal disease.
Similarly, gingival inflammation appears to be a good clinical predictor
of future loss of attachment.159 It is not surprising that calculus and
gingival inflammation are better predictors of periodontal disease than
plaque scores.
 Factors Associated with Chronic
Periodontitis
• Tobacco Use
Cigarette smoking is the strongest modifiable risk factor
for the occurrence of periodontal disease. People who
smoke are two to six times more likely to have
periodontitis than those who do not smoke. This relation is
independent of potential confounders including oral
hygiene. In other words, even in subjects with good oral
hygiene, smokers have significantly more bone loss than
nonsmokers.
Tobacco use has also been proven to adversely affect the
outcomes of periodontal treatment and increase the
chances of disease recurrences among treated populations
 Factors Associated with Chronic
Periodontitis
• Diabetes
Individuals with diabetes, especially those with poor metabolic control,
have more extensive and severe periodontal destruction than otherwise
healthy persons. The most prevalent forms of diabetes are type 1
(formerly insulindependent)and type 2 (formerly noninsulin-dependent)
diabetes mellitus. The onset of type 1 diabetes generally occurs before
30 years of age, whereas the more common type 2 diabetes peaks in
incidence during the fifth decade of life.
 Factors Associated with Chronic
Periodontitis
• Diabetes
However, the deleterious effect of diabetes on the periodontium appears
to be cumulative, because patients with long-term diabetes tend to have
greater attachment or bone loss than those who have had diabetes for
shorter periods.
The metabolic control of diabetes is also strongly related to the
incidence and severity of periodontal disease.
 Factors Associated with Chronic
Periodontitis

• Nutrition
Persons with severe nutritional deficiencies are at an increased risk for
development of acute periodontal lesions (see Chapter 31). For example,
severe vitamin C deficiency leads to gingival lesions characterized by
severe inflammation and spontaneous bleeding.
 ETIOLOGY
The microflora of sites displaying the clinical features of chronic
periodontitis exhibit a spectrum of bacterial species similar to that found
in naturally occurring gingivitis. However, the proportions of the
individual bacteria usually vary between the two diseases.
Because it is believed that gingivitis precedes all cases of chronic
periodontitis, the microflora of the latter represents a further maturation
of subgingival plaque biofilms. In general, sites with chronic
periodontitis will be populated with greater proportions of gram-
negative organisms and motile bacteria (e.g., Treponema denticola and
other spirochetes).
 ETIOLOGY
Although grampositive bacteria represent a substantial proportion of
subgingival biofilms in cases of chronic periodontitis, certain gram-
negative bacteria with pronounced virulence properties have been
strongly implicated as etiologic agents (e.g., P. gingivalis and
Tannerella forsythensis [formerly Bacteroides forsythus]).
 ETIOLOGY
• An important feature of the microbiology of periodontal infections is
that the putative pathogens rarely constitute a major component of the
entire dental plaque biofilm. Indeed, usually the suspected pathogen is
less than 5% of the recoverable isolates from the entire plaque
biomass. Coaggregating bacteria such as Actinomyces naeslundii, S.
sanguis, and Fusobacterium nucleatum are among the most
numerous bacteria isolated from dental plaque irrespective of disease
status.