Periodontology

From WikiMD's WELLNESSPEDIA

A diagram of the periodontium
Inflamed gingiva before and after plaque control

Periodontology is the branch of dentistry concerned with the study, diagnosis, prevention, and treatment of diseases and conditions affecting the periodontium, the specialized supporting structures of the teeth. These structures include the gingiva, periodontal ligament, cementum, and alveolar bone. A dental specialist trained in this field is called a periodontist.

The periodontium includes the supporting tissues that attach the tooth to the surrounding alveolar bone.

Periodontology is a major dental specialty because periodontal health is essential for tooth stability, mastication, speech, oral hygiene, aesthetics, dental implant success, and overall oral health. Periodontal diseases, especially gingivitis and periodontitis, are among the most common chronic inflammatory diseases affecting humans. Advanced periodontitis can lead to tooth mobility, gingival recession, periodontal pocket formation, alveolar bone loss, tooth loss, and reduced quality of life.

From the perspective of dental education, periodontology requires a strong understanding of oral anatomy, histology, microbiology, immunology, pathology, radiology, pharmacology, occlusion, dental materials, surgery, implant dentistry, and preventive dentistry. It is both a biologic and clinical discipline.

Overview[edit]

Periodontology focuses on the preservation and restoration of the supporting tissues of the teeth and dental implants. The discipline includes the study of normal periodontal anatomy, periodontal disease mechanisms, risk factors, clinical diagnosis, periodontal instrumentation, surgical therapy, regenerative therapy, mucogingival therapy, implant placement, implant maintenance, and long-term periodontal maintenance.

Important areas of periodontology include:

Definition[edit]

Periodontology may be defined as the dental specialty that deals with the health, diseases, diagnosis, prevention, and treatment of the tissues that support and surround the teeth and dental implants.

The word is derived from:

  • Peri- meaning around
  • Odont meaning tooth
  • -ology meaning study of

Therefore, periodontology literally means the study of the tissues around the tooth.

Periodontium[edit]

The periodontium is the functional unit that supports the teeth in the jaws. It consists of four principal tissues:

Together, these tissues protect the underlying structures, attach teeth to bone, absorb functional forces, maintain tooth position, and provide a barrier against the oral microbial environment.

Components of the periodontium[edit]

Gingiva[edit]

The gingiva, commonly called the gums, is the part of the oral mucosa that surrounds the teeth and covers the alveolar processes of the jaws. It forms an important protective seal around the teeth.

The gingiva is divided into:

Healthy gingiva is usually coral pink, firm, stippled, and does not bleed during gentle probing. However, pigmentation, thickness, and contour vary among individuals.

Periodontal ligament[edit]

The periodontal ligament is a specialized connective tissue that connects the cementum of the tooth root to the alveolar bone. It is composed of collagen fibers, cells, blood vessels, lymphatics, and nerves.

Functions of the periodontal ligament include:

  • Tooth attachment
  • Shock absorption during chewing
  • Sensory perception
  • Nutrition of surrounding tissues
  • Remodeling of bone and cementum
  • Tooth eruption and minor tooth movement

The periodontal ligament is essential in orthodontics because orthodontic tooth movement depends on controlled remodeling of this ligament and adjacent bone.

Cementum[edit]

Cementum is a calcified tissue covering the root surface of the tooth. It provides attachment for periodontal ligament fibers and helps anchor the tooth in the alveolar socket.

Types of cementum include:

  • Acellular cementum - mainly involved in tooth attachment
  • Cellular cementum - more common near the root apex and involved in adaptation and repair

Cementum is less mineralized than enamel and more similar to bone. It can be exposed during gingival recession, leading to root sensitivity and increased risk of root caries.

Alveolar bone[edit]

The alveolar bone is the part of the maxilla and mandible that forms and supports the tooth sockets. It is continuously remodeled in response to function, inflammation, trauma, and tooth movement.

Important parts of the alveolar bone include:

  • Alveolar bone proper - the bone lining the socket, also called the lamina dura
  • Supporting alveolar bone - cortical and cancellous bone supporting the socket
  • Interdental septum - bone between adjacent teeth
  • Interradicular bone - bone between roots of multirooted teeth

Loss of alveolar bone is a defining feature of periodontitis.

Normal periodontal anatomy[edit]

A sound understanding of normal anatomy is essential for diagnosing disease. Important anatomical landmarks include:

In a healthy periodontium, the gingival sulcus is shallow, the junctional epithelium attaches near the cementoenamel junction, and alveolar bone height is maintained near the cervical portion of the tooth.

Junctional epithelium and epithelial attachment[edit]

The junctional epithelium is a specialized epithelial structure that attaches the gingiva to the tooth surface. It forms an important biological seal between the oral environment and the underlying connective tissue.

This region is clinically important because:

  • It is the first line of defense against dental plaque biofilm.
  • It allows passage of immune cells into the gingival sulcus.
  • It is the site where periodontal pocket formation begins.
  • Apical migration of the junctional epithelium is associated with clinical attachment loss.

Gingival crevicular fluid[edit]

Gingival crevicular fluid is a serum-derived fluid found in the gingival sulcus or periodontal pocket. It contains inflammatory mediators, antibodies, enzymes, host cells, and bacterial products.

Gingival crevicular fluid is important in:

  • Host defense
  • Diagnosis of periodontal inflammation
  • Research into periodontal biomarkers
  • Understanding the host-microbial interaction

Dental plaque biofilm[edit]

Dental plaque is a structured microbial biofilm that forms on tooth surfaces, restorations, prostheses, and dental implants. It is the primary etiologic factor in gingivitis and periodontitis.

Plaque biofilm is not simply a mass of bacteria. It is an organized microbial community embedded in an extracellular matrix. Biofilm bacteria behave differently from free-floating bacteria and are more resistant to antimicrobial agents and host defenses.

Important features of dental plaque biofilm include:

  • Adhesion to tooth surfaces
  • Microbial succession
  • Extracellular polysaccharide matrix
  • Bacterial communication
  • Resistance to host defenses
  • Resistance to antimicrobial agents
  • Ability to trigger chronic inflammation

Calculus[edit]

Calculus, also called tartar, is mineralized dental plaque. It may be supragingival or subgingival.

  • Supragingival calculus is found above the gingival margin and is often visible clinically.
  • Subgingival calculus is found below the gingival margin and is associated with periodontal pockets.

Calculus itself is not the primary cause of periodontitis, but it provides a rough surface that promotes plaque retention and makes oral hygiene more difficult.

Host response in periodontal disease[edit]

Periodontal disease results from the interaction between microbial biofilm and the host immune-inflammatory response. Tissue destruction is not caused only by bacteria, but also by the host response to bacterial challenge.

Important host response mechanisms include:

Excessive or dysregulated inflammation can lead to destruction of collagen fibers, periodontal ligament breakdown, and alveolar bone resorption.

Microbiology of periodontal disease[edit]

Periodontal diseases are associated with complex microbial communities rather than a single organism. However, certain bacteria are strongly associated with periodontitis.

Important periodontal pathogens include:

The so-called red complex organisms, including Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola, are frequently associated with deeper periodontal pockets and advanced disease.

Etiology of periodontal diseases[edit]

Periodontal diseases are multifactorial. Dental plaque biofilm is essential for the initiation of most inflammatory periodontal diseases, but disease severity and progression depend on host susceptibility and modifying factors.

Important etiologic and contributing factors include:

  • Dental plaque
  • Calculus
  • Poor oral hygiene
  • Smoking
  • Diabetes mellitus
  • Genetic susceptibility
  • Immunosuppression
  • Stress
  • Poor nutrition
  • Hormonal changes
  • Certain medications
  • Iatrogenic factors
  • Overhanging restorations
  • Malpositioned teeth
  • Furcation anatomy
  • Occlusal trauma
  • Aging-related cumulative exposure

Risk factors[edit]

Smoking[edit]

Smoking is one of the strongest modifiable risk factors for periodontitis. Smokers may show more severe attachment loss, deeper periodontal pockets, greater bone loss, poorer healing, and reduced response to therapy.

Smoking can also mask clinical signs of inflammation because gingival bleeding may be reduced due to vascular effects.

Diabetes mellitus[edit]

Diabetes mellitus is strongly associated with periodontitis, especially when glycemic control is poor. Hyperglycemia can impair immune function, alter collagen metabolism, increase inflammation, and impair wound healing.

Periodontitis and diabetes have a bidirectional relationship. Periodontal inflammation may worsen glycemic control, while diabetes increases periodontal disease risk.

Genetic susceptibility[edit]

Some patients are more susceptible to periodontal destruction despite similar plaque exposure. Genetic factors may influence immune response, inflammatory mediator production, neutrophil function, and tissue repair.

Medications[edit]

Certain medications may affect periodontal tissues. Examples include:

Hormonal factors[edit]

Hormonal changes may influence gingival inflammation. Examples include:

Pregnancy-associated gingival inflammation is often related to increased inflammatory response to plaque rather than pregnancy alone.

Classification of periodontal and peri-implant diseases[edit]

Modern periodontal classification includes periodontal health, gingival diseases, periodontitis, other conditions affecting the periodontium, and peri-implant diseases. The 2017 World Workshop introduced a multidimensional system for periodontitis staging and grading and formally included peri-implant health and disease categories.[1]

Major categories include:

Periodontal health[edit]

Periodontal health refers to the absence of clinically detectable inflammation and destructive periodontal disease. Health may exist on an intact periodontium or on a reduced periodontium after successful treatment.

Features of periodontal health include:

  • Minimal or no bleeding on probing
  • No progressive attachment loss
  • No progressive bone loss
  • Physiologic probing depths
  • Absence of suppuration
  • Absence of uncontrolled inflammation
  • Patient ability to maintain plaque control

Gingivitis[edit]

Gingivitis is inflammation of the gingiva without loss of periodontal attachment. It is usually caused by plaque biofilm and is reversible with effective plaque control.

Clinical signs include:

  • Redness
  • Swelling
  • Bleeding on probing
  • Tenderness
  • Loss of stippling
  • Increased gingival crevicular fluid
  • Pseudopocketing due to swelling

Gingivitis does not involve destruction of the periodontal ligament or alveolar bone. However, untreated gingivitis may progress to periodontitis in susceptible individuals.

Types of gingival diseases[edit]

Gingival diseases may be classified as:

  • Dental plaque-induced gingivitis
  • Gingivitis modified by systemic factors
  • Gingivitis modified by medications
  • Gingival diseases of viral origin
  • Gingival diseases of fungal origin
  • Gingival diseases of genetic origin
  • Gingival manifestations of systemic conditions
  • Traumatic gingival lesions
  • Allergic gingival reactions

Periodontitis[edit]

Periodontitis is a chronic inflammatory disease of the periodontium characterized by progressive destruction of the periodontal ligament and alveolar bone. It is associated with clinical attachment loss, periodontal pocket formation, gingival bleeding, radiographic bone loss, and possible tooth mobility.

Clinical features may include:

  • Bleeding on probing
  • Periodontal pocketing
  • Clinical attachment loss
  • Gingival recession
  • Alveolar bone loss
  • Suppuration
  • Tooth mobility
  • Furcation involvement
  • Pathologic tooth migration
  • Halitosis
  • Tooth loss

Periodontitis is not simply an advanced form of gingivitis. It represents a destructive inflammatory process in a susceptible host.

Staging of periodontitis[edit]

The modern classification uses staging to describe severity and complexity of management. Staging considers clinical attachment loss, radiographic bone loss, tooth loss due to periodontitis, probing depths, furcation involvement, mobility, occlusal dysfunction, and need for complex rehabilitation.[2]

Stage General meaning Typical clinical interpretation
Stage I Initial periodontitis Early attachment loss and limited bone loss
Stage II Moderate periodontitis Established disease with moderate attachment and bone loss
Stage III Severe periodontitis with potential for tooth loss Deep pockets, vertical defects, furcation involvement, and increased treatment complexity
Stage IV Advanced periodontitis with extensive tooth loss and functional problems Severe disease with masticatory dysfunction, tooth mobility, bite collapse, or need for complex rehabilitation

Grading of periodontitis[edit]

Grading estimates the rate of disease progression, risk of future progression, and possible impact on systemic health. Grades include A, B, and C.[3]

Grade Rate of progression General interpretation
Grade A Slow progression Low rate of attachment or bone loss relative to age and plaque burden
Grade B Moderate progression Disease progression commensurate with plaque deposits and typical risk
Grade C Rapid progression Destruction exceeds expectations for plaque level; risk factors such as smoking or uncontrolled diabetes may be present

Risk modifiers include:

  • Smoking
  • Diabetes mellitus
  • Radiographic bone loss relative to age
  • Direct evidence of progression over time
  • Pattern of destruction
  • Response to standard therapy

Extent and distribution of periodontitis[edit]

Periodontitis may also be described by extent and distribution:

  • Localized - less than 30 percent of teeth affected
  • Generalized - 30 percent or more of teeth affected
  • Molar-incisor pattern - characteristic involvement of molars and incisors

This description helps students and clinicians communicate the pattern of disease clearly.

Necrotizing periodontal diseases[edit]

Necrotizing periodontal diseases are severe inflammatory conditions characterized by necrosis of gingival tissues, pain, bleeding, and rapid tissue destruction.

They include:

Risk factors include:

  • Severe immunosuppression
  • HIV infection
  • Malnutrition
  • Smoking
  • Psychological stress
  • Poor oral hygiene

Clinical features include punched-out interdental papillae, spontaneous bleeding, pain, pseudomembrane formation, halitosis, fever, and lymphadenopathy.

Periodontal abscess[edit]

A periodontal abscess is a localized purulent infection within the periodontal tissues. It often arises from an obstructed periodontal pocket, foreign body impaction, incomplete calculus removal, or acute exacerbation of chronic periodontitis.

Signs and symptoms may include:

  • Localized swelling
  • Pain
  • Tooth tenderness
  • Suppuration
  • Deep periodontal pocket
  • Tooth mobility
  • Fever in severe cases
  • Regional lymphadenopathy

Management may involve drainage, debridement, irrigation, occlusal adjustment, systemic antibiotics when indicated, and definitive periodontal therapy.

Gingival recession[edit]

Gingival recession is apical migration of the gingival margin, exposing the root surface. It may occur with or without periodontitis.

Causes and contributing factors include:

  • Traumatic tooth brushing
  • Thin gingival biotype
  • Tooth malposition
  • Frenum pull
  • Orthodontic movement outside the alveolar envelope
  • Periodontal inflammation
  • Aging-related cumulative changes
  • Iatrogenic factors

Consequences include:

  • Root sensitivity
  • Root caries
  • Aesthetic concerns
  • Plaque retention
  • Non-carious cervical lesions

Treatment may include behavior modification, desensitizing therapy, restoration of cervical lesions, or periodontal plastic surgery such as connective tissue grafting.

Mucogingival conditions[edit]

Mucogingival conditions involve the relationship between gingiva, alveolar mucosa, teeth, and frena. Periodontists evaluate these conditions when planning restorative, orthodontic, implant, and aesthetic therapy.

Examples include:

  • Gingival recession
  • Lack of attached gingiva
  • Aberrant frenum attachment
  • Shallow vestibule
  • Gingival excess
  • Thin periodontal phenotype
  • Root coverage defects

Periodontal examination[edit]

A complete periodontal examination is essential for diagnosis and treatment planning.

Key components include:

  • Medical and dental history
  • Periodontal risk assessment
  • Plaque assessment
  • Gingival inflammation assessment
  • Bleeding on probing
  • Probing pocket depth
  • Clinical attachment level
  • Gingival recession
  • Furcation involvement
  • Tooth mobility
  • Fremitus
  • Occlusal evaluation
  • Radiographic evaluation
  • Diagnosis and prognosis
  • Patient education and motivation

Periodontal probing[edit]

Periodontal probing measures the depth of the gingival sulcus or periodontal pocket using a periodontal probe.

Important probing measurements include:

  • Probing depth
  • Clinical attachment level
  • Bleeding on probing
  • Suppuration
  • Furcation involvement
  • Gingival margin position

Probing should be performed gently and consistently. Excessive force may cause discomfort and inaccurate measurements.

Clinical attachment level[edit]

Clinical attachment level is the distance from the cementoenamel junction to the base of the periodontal pocket. It is one of the most important measures of periodontal destruction.

Clinical attachment level is more informative than probing depth alone because probing depth may be influenced by gingival enlargement or recession.

Bleeding on probing[edit]

Bleeding on probing indicates gingival inflammation and ulceration of the pocket epithelium. It is useful in assessing disease activity and patient plaque control.

Absence of bleeding on probing is a strong indicator of periodontal stability, while persistent bleeding suggests ongoing inflammation.

Periodontal charting[edit]

Periodontal charting records periodontal findings for each tooth. A full periodontal chart typically includes six probing measurements per tooth.

Commonly recorded items include:

  • Probing depths
  • Gingival recession
  • Clinical attachment levels
  • Bleeding on probing
  • Suppuration
  • Furcation involvement
  • Mobility
  • Mucogingival defects
  • Missing teeth
  • Implant status

Periodontal charting is essential for diagnosis, treatment planning, monitoring, medico-legal documentation, and communication among clinicians.

Radiographic evaluation[edit]

Dental radiography is used to evaluate alveolar bone levels, calculus deposits, furcation involvement, root anatomy, crown-root ratio, periapical pathology, and implant bone support.

Common radiographs include:

Radiographs should be interpreted together with clinical findings. Radiographs show bone levels but do not directly show current attachment loss or active inflammation.

Radiographic bone loss patterns[edit]

Periodontal bone loss may be:

  • Horizontal bone loss - generalized reduction in bone height
  • Vertical bone loss - angular or intrabony defects
  • Furcation bone loss - bone loss between roots of multirooted teeth
  • Crater-like bone loss - interdental osseous defects

The morphology of bone defects helps determine whether regenerative therapy may be possible.

Furcation involvement[edit]

Furcation involvement occurs when periodontal bone loss exposes the area between roots of multirooted teeth.

Furcation involvement is clinically significant because:

  • It complicates plaque control.
  • It reduces long-term tooth prognosis.
  • It may require special instrumentation.
  • It may influence surgical planning.
  • It may affect decisions about extraction or root resection.

Tooth mobility[edit]

Tooth mobility may result from attachment loss, occlusal trauma, inflammation, periodontal ligament widening, or reduced bone support. Mobility should be assessed carefully and interpreted in context.

Mobility may be physiologic or pathologic. Progressive mobility in the presence of periodontitis is a warning sign for advanced periodontal breakdown.

Occlusion and periodontium[edit]

Occlusion refers to the relationship of the teeth during function. Excessive occlusal forces may contribute to widened periodontal ligament space, mobility, fremitus, and discomfort.

Trauma from occlusion does not initiate plaque-induced periodontitis by itself, but it may modify disease expression in a reduced periodontium.

Diagnosis[edit]

A periodontal diagnosis should describe the disease type, severity, extent, stage, grade, and relevant modifying factors.

Example diagnosis:

Generalized periodontitis, Stage III, Grade C, with molar furcation involvement and smoking as a risk modifier.

Another example:

Localized plaque-induced gingivitis on an intact periodontium.

A good diagnosis should guide treatment planning rather than merely label the disease.

Prognosis[edit]

Periodontal prognosis estimates the likely future of a tooth or dentition based on current disease severity, risk factors, anatomy, function, and patient compliance.

Factors affecting prognosis include:

  • Amount of remaining bone support
  • Probing depths
  • Clinical attachment loss
  • Furcation involvement
  • Tooth mobility
  • Crown-root ratio
  • Root anatomy
  • Caries risk
  • Endodontic status
  • Occlusion
  • Smoking
  • Diabetes control
  • Patient oral hygiene
  • Compliance with maintenance care
  • Restorability

Prognosis may be assigned at the patient level and tooth level.

Treatment planning in periodontology[edit]

Periodontal treatment planning should be comprehensive, sequenced, and patient-centered.

Major phases include:

  • Emergency phase
  • Systemic phase
  • Initial or cause-related therapy
  • Re-evaluation
  • Surgical therapy when needed
  • Restorative or prosthetic phase
  • Implant phase when indicated
  • Supportive periodontal therapy

Treatment planning should consider the patient's medical status, expectations, finances, risk factors, ability to maintain oral hygiene, and long-term prognosis.

Patient education and motivation[edit]

Successful periodontal therapy depends heavily on patient participation. The clinician must teach the patient that periodontitis is a chronic inflammatory disease requiring long-term control.

Patient education includes:

  • Nature of plaque biofilm
  • Role of daily oral hygiene
  • Importance of interdental cleaning
  • Smoking cessation
  • Diabetes control
  • Diet and general health
  • Need for periodontal maintenance
  • Realistic expectations
  • Signs of recurrence

Dental students should understand that instrumentation without behavior change often leads to relapse.

Oral hygiene instruction[edit]

Oral hygiene instruction should be individualized.

Common methods include:

  • Tooth brushing
  • Modified Bass brushing technique
  • Electric toothbrush use
  • Dental floss
  • Interdental brushes
  • Oral irrigators
  • Antimicrobial mouth rinses
  • Tongue cleaning
  • Denture and appliance hygiene

Interdental brushes are often more effective than floss in open interdental spaces and periodontal patients.

Scaling and root planing[edit]

Scaling and root planing is a non-surgical periodontal procedure that removes plaque, calculus, and contaminated root surface deposits.

Goals include:

  • Reduction of bacterial biofilm
  • Removal of calculus
  • Reduction of inflammation
  • Pocket depth reduction
  • Gain or stabilization of clinical attachment
  • Creation of a root surface compatible with healing

Scaling and root planing may be performed with hand instruments, ultrasonic scalers, or both.

Periodontal instruments[edit]

Common periodontal instruments include:

  • Periodontal probe
  • Explorer
  • Sickle scaler
  • Universal curette
  • Gracey curette
  • Ultrasonic scaler
  • Piezoelectric scaler
  • Magnetostrictive scaler
  • Hoe scaler
  • File scaler
  • Periodontal knife
  • Surgical curette

Dental students must learn instrument adaptation, angulation, lateral pressure, activation stroke, and ergonomic positioning.

Re-evaluation after initial therapy[edit]

Re-evaluation is performed after initial periodontal therapy to assess healing and determine the need for further treatment.

Re-evaluation includes:

  • Plaque control assessment
  • Bleeding on probing
  • Probing depths
  • Suppuration
  • Mobility
  • Furcation status
  • Patient compliance
  • Risk factor control

Persistent deep pockets, bleeding, suppuration, or progressive attachment loss may require surgical therapy or additional non-surgical treatment.

Periodontal surgery[edit]

Periodontal surgery is performed when non-surgical therapy alone cannot achieve adequate access, pocket reduction, regeneration, or correction of mucogingival problems.

Types of periodontal surgery include:

Periodontal flap surgery[edit]

Periodontal flap surgery involves reflecting gingival tissues to gain access to root surfaces and alveolar bone. It allows direct visualization for debridement, root planing, osseous reshaping, or regenerative procedures.

Indications include:

  • Persistent deep periodontal pockets
  • Inaccessible subgingival calculus
  • Vertical bone defects
  • Furcation involvement
  • Need for osseous correction
  • Need for regenerative therapy

Osseous surgery[edit]

Osseous surgery reshapes or recontours alveolar bone to reduce periodontal pockets and create maintainable architecture.

Procedures include:

  • Osteoplasty
  • Ostectomy
  • Osseous recontouring
  • Apically positioned flap

Osseous surgery must be planned carefully to avoid excessive attachment loss and aesthetic compromise.

Regenerative periodontal therapy[edit]

Regenerative periodontal therapy aims to restore lost periodontal structures, including cementum, periodontal ligament, and alveolar bone.

Regenerative techniques include:

  • Guided tissue regeneration
  • Bone grafting
  • Enamel matrix derivative
  • Growth factors
  • Biologic mediators
  • Barrier membranes
  • Combination therapy

Ideal defects for regeneration often include deep, narrow intrabony defects with remaining bony walls.

Guided tissue regeneration[edit]

Guided tissue regeneration uses barrier membranes to exclude epithelium and gingival connective tissue from the wound, allowing periodontal ligament and bone cells to repopulate the root surface.

Materials may include:

  • Resorbable membranes
  • Non-resorbable membranes
  • Bone graft materials
  • Biologic agents

Bone grafting[edit]

Bone grafting may be used in intrabony defects, ridge augmentation, sinus augmentation, and implant site development.

Types of graft materials include:

The choice of graft depends on the defect, treatment goals, patient factors, and clinician preference.

Mucogingival and periodontal plastic surgery[edit]

Periodontal plastic surgery addresses soft tissue defects around teeth and implants.

Procedures include:

Indications include gingival recession, inadequate keratinized tissue, aesthetic concerns, root sensitivity, and implant soft tissue deficiencies.

Crown lengthening[edit]

Crown lengthening is a periodontal surgical procedure that exposes more tooth structure by repositioning gingiva and sometimes removing bone.

Indications include:

  • Restorative access
  • Subgingival caries
  • Tooth fracture
  • Short clinical crowns
  • Altered passive eruption
  • Aesthetic gingival correction

Crown lengthening must respect the biologic width, now commonly referred to as supracrestal tissue attachment.

Periodontology and dental implants[edit]

Periodontists play an important role in dental implant therapy. Their responsibilities may include:

  • Implant site evaluation
  • Extraction and socket preservation
  • Bone grafting
  • Sinus augmentation
  • Ridge augmentation
  • Implant placement
  • Soft tissue grafting
  • Management of peri-implant diseases
  • Implant maintenance

Periodontal principles are essential for implant success because dental implants also require healthy surrounding soft and hard tissues.

Peri-implant health and disease[edit]

Peri-implant tissues can develop inflammatory diseases similar to periodontal tissues.

Important conditions include:

Peri-implant mucositis[edit]

Peri-implant mucositis is inflammation of the soft tissues around a dental implant without progressive bone loss. It is often reversible with plaque control and professional therapy.

Peri-implantitis[edit]

Peri-implantitis is a plaque-associated inflammatory disease around dental implants characterized by inflammation and progressive supporting bone loss.

Clinical signs may include:

  • Bleeding on probing
  • Suppuration
  • Increased probing depth
  • Radiographic bone loss
  • Soft tissue swelling
  • Implant mobility in advanced cases

Periodontal-systemic connections[edit]

Periodontal diseases are associated with several systemic conditions. Association does not always prove causation, but periodontal inflammation may contribute to systemic inflammatory burden.

Conditions associated with periodontal disease include:

The strongest and most clinically important relationship is between periodontitis and diabetes.

Periodontitis and diabetes[edit]

The relationship between periodontitis and diabetes mellitus is bidirectional. Diabetes increases the risk and severity of periodontitis, while periodontal inflammation may make glycemic control more difficult.

Clinical implications include:

  • Assess glycemic control.
  • Communicate with the patient's physician when needed.
  • Emphasize plaque control.
  • Provide periodontal therapy.
  • Monitor healing carefully.
  • Place patients on appropriate maintenance intervals.

Periodontitis and cardiovascular disease[edit]

Periodontitis has been associated with cardiovascular disease, possibly through systemic inflammation, bacteremia, endothelial dysfunction, and shared risk factors such as smoking. Patients should be advised that periodontal treatment supports oral health and may reduce inflammatory burden, but it is not a substitute for medical cardiovascular care.

Periodontics and orthodontics[edit]

Periodontal health is important before, during, and after orthodontic treatment. Orthodontic movement in the presence of uncontrolled periodontal inflammation may worsen attachment loss.

Important considerations include:

  • Control inflammation before orthodontics.
  • Evaluate bone support.
  • Monitor gingival recession risk.
  • Consider thin periodontal phenotype.
  • Coordinate care between periodontist and orthodontist.
  • Maintain excellent oral hygiene during treatment.

Periodontics and restorative dentistry[edit]

Periodontics is closely linked to restorative dentistry. Poorly contoured restorations, overhanging margins, subgingival excess cement, and violation of supracrestal tissue attachment can contribute to periodontal inflammation.

Restorative-periodontal principles include:

  • Maintain cleansable margins.
  • Avoid overhanging restorations.
  • Respect supracrestal tissue attachment.
  • Manage crown contours.
  • Preserve papillae when possible.
  • Ensure adequate ferrule and restorability.
  • Coordinate crown lengthening when necessary.

Periodontics and prosthodontics[edit]

In prosthodontics, periodontal health determines the prognosis of abutment teeth and implant-supported restorations.

Important considerations include:

  • Crown-root ratio
  • Tooth mobility
  • Periodontal support
  • Furcation involvement
  • Occlusal scheme
  • Splinting
  • Hygiene access
  • Implant distribution
  • Maintenance requirements

Periodontics and endodontics[edit]

Periodontal and endodontic lesions may mimic each other or occur together.

Types include:

  • Primary endodontic lesion
  • Primary periodontal lesion
  • Combined endodontic-periodontal lesion
  • Vertical root fracture
  • Root perforation

Correct diagnosis is essential because treatment differs. Pulp vitality testing, probing patterns, radiographs, and clinical history help determine the primary source.

Antibiotics in periodontology[edit]

Antibiotics are not routinely required for all periodontal therapy. They may be used selectively when systemic involvement, aggressive disease patterns, specific pathogens, or acute infections are present.

Examples include:

  • Acute periodontal abscess with systemic signs
  • Necrotizing periodontal disease
  • Selected cases of rapidly progressing periodontitis
  • Medically compromised patients when indicated
  • Adjunctive therapy in specific clinical situations

Antibiotic use should follow principles of antimicrobial stewardship.

Antiseptics and local antimicrobials[edit]

Adjunctive agents may include:

  • Chlorhexidine
  • Essential oil mouth rinses
  • Povidone-iodine irrigation
  • Local antimicrobial delivery systems
  • Desensitizing agents
  • Fluoride varnish for root caries risk

These agents do not replace mechanical plaque removal.

Lasers in periodontology[edit]

Dental lasers have been used as adjuncts in periodontal therapy. Potential uses include soft tissue surgery, bacterial reduction, pocket therapy, frenectomy, and peri-implant procedures.

Students should understand that lasers are adjunctive tools and should be evaluated based on evidence, safety, indications, cost, and clinician skill.

Supportive periodontal therapy[edit]

Supportive periodontal therapy, also called periodontal maintenance, is long-term care after active treatment. It is essential because periodontitis is a chronic disease with risk of recurrence.

Maintenance visits may include:

  • Medical history update
  • Plaque control review
  • Periodontal charting
  • Bleeding assessment
  • Risk assessment
  • Scaling and debridement
  • Reinforcement of oral hygiene
  • Radiographs when indicated
  • Monitoring of implants
  • Adjustment of maintenance interval

Maintenance intervals are individualized based on risk and may commonly range from about 3 to 12 months depending on disease severity, risk factors, and stability.[4]

Periodontal emergencies[edit]

Periodontal emergencies include:

  • Periodontal abscess
  • Necrotizing gingivitis
  • Necrotizing periodontitis
  • Acute herpetic gingivostomatitis
  • Pericoronitis
  • Postoperative bleeding
  • Acute implant infection

Students should recognize pain, swelling, fever, lymphadenopathy, dysphagia, spreading infection, and airway risk as signs requiring urgent management.

Prevention[edit]

Prevention is a major goal of periodontology.

Preventive measures include:

  • Effective tooth brushing
  • Interdental cleaning
  • Regular dental examinations
  • Professional prophylaxis
  • Smoking cessation
  • Diabetes control
  • Healthy diet
  • Management of xerostomia
  • Fluoride use when root caries risk exists
  • Early treatment of gingivitis
  • Periodontal maintenance for patients with prior periodontitis

Public health importance[edit]

Periodontal diseases are common chronic diseases with effects on chewing, speech, aesthetics, comfort, self-esteem, and tooth retention. Periodontal disease can increase dental treatment costs and contribute to oral health disparities.

Public health strategies include:

  • Oral health education
  • Access to preventive dental care
  • Smoking cessation programs
  • Diabetes screening and control
  • Community dental services
  • Integration of oral and medical care
  • Public awareness of gum disease

Teaching points for dental students[edit]

Important teaching points include:

  • Periodontitis is a biofilm-induced inflammatory disease modified by host response and risk factors.
  • Gingivitis is reversible; periodontitis involves attachment and bone loss.
  • Probing depth alone is not enough; clinical attachment level is essential.
  • Bleeding on probing is a useful sign of inflammation.
  • Smoking and diabetes strongly affect periodontal prognosis.
  • Treatment must begin with patient education and plaque control.
  • Scaling and root planing is foundational, but not always sufficient.
  • Re-evaluation determines the need for surgery.
  • Periodontal maintenance is necessary for long-term success.
  • Implant health depends on periodontal principles.
  • A patient with periodontitis remains at risk for life and requires ongoing monitoring.

Clinical checklist for periodontal evaluation[edit]

Step Clinical task
1 Review medical, dental, medication, and smoking history
2 Assess chief complaint and patient goals
3 Evaluate plaque and calculus
4 Record probing depths at six sites per tooth
5 Record bleeding on probing and suppuration
6 Measure gingival recession and clinical attachment level
7 Assess mobility, fremitus, and furcation involvement
8 Evaluate occlusion and tooth migration
9 Review radiographs for bone loss pattern
10 Assign diagnosis, stage, grade, extent, and risk factors
11 Develop treatment plan and maintenance schedule

Common periodontal terms[edit]

Term Meaning
Gingiva Gum tissue surrounding the teeth
Periodontium Supporting tissues of the teeth
Periodontal ligament Connective tissue attaching cementum to alveolar bone
Cementum Calcified tissue covering the tooth root
Alveolar bone Bone supporting the teeth
Gingivitis Inflammation of gingiva without attachment loss
Periodontitis Inflammatory destruction of periodontal ligament and alveolar bone
Periodontal pocket Pathologically deepened gingival sulcus
Clinical attachment loss Loss of periodontal attachment measured from the cementoenamel junction
Scaling and root planing Non-surgical removal of plaque and calculus from tooth and root surfaces
Furcation involvement Bone loss between roots of multirooted teeth
Peri-implantitis Inflammatory bone loss around a dental implant

Common periodontal conditions[edit]

Condition Main feature Typical management
Gingivitis Gingival inflammation without attachment loss Oral hygiene instruction and professional cleaning
Periodontitis Attachment loss and bone loss Risk control, scaling and root planing, possible surgery, maintenance
Periodontal abscess Localized purulent infection Drainage, debridement, possible antibiotics if systemic signs are present
Gingival recession Root exposure Plaque control, desensitizing therapy, grafting when indicated
Necrotizing gingivitis Necrotic papillae, pain, bleeding Debridement, antiseptics, risk factor management, antibiotics when indicated
Peri-implant mucositis Soft tissue inflammation around implant Biofilm control and professional debridement
Peri-implantitis Inflammation with progressive implant bone loss Non-surgical and/or surgical therapy, implant surface decontamination, maintenance

Complications of untreated periodontitis[edit]

Untreated periodontitis may lead to:

  • Progressive attachment loss
  • Alveolar bone loss
  • Gingival recession
  • Tooth mobility
  • Furcation involvement
  • Periodontal abscess
  • Pathologic tooth migration
  • Occlusal instability
  • Tooth loss
  • Reduced chewing ability
  • Aesthetic problems
  • Halitosis
  • Increased complexity of dental treatment

See also[edit]

External links[edit]


Dentistry
Specialties
Dental surgery
Organisations


Dentistry involving supporting structures of teeth (Periodontology)
Anatomy
Disease
Diagnoses
Infection
Other
Treatment and prevention
Treatment




Oral health
General Topics
Diseases and Conditions
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This oral health-related article is a stub.


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References[edit]

  1. "2017 Classification of Periodontal and Peri-implant
  1. ↑ American Academy of Periodontology. 2017 Classification of Periodontal and Peri-Implant Diseases and Conditions. https://www.perio.org/research-science/2017-classification-of-periodontal-and-peri-implant-diseases-and-conditions/
  2. ↑ Papapanou PN, Sanz M, Buduneli N, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop. Journal of Clinical Periodontology. 2018. https://pubmed.ncbi.nlm.nih.gov/29926951/
  3. ↑ Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal. Journal of Periodontology. 2018. https://pubmed.ncbi.nlm.nih.gov/29926952/
  4. ↑ Sanz M, Herrera D, Kebschull M, et al. Treatment of stage I-III periodontitis: The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology. 2020. https://pubmed.ncbi.nlm.nih.gov/32383274/

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