2. Overview of Periodontal iDisease.pptx

Overview of Periodontal Disease.pptx Overview of Periodontal Disease.pptx Overview of Periodontal Disease.pptx Overview of Periodontal Disease.pptx Overview of Periodontal Disease.pptx Overview of Periodontal Disease.pptx Overview of Periodontal Disease.pptx Overview of Periodontal Disease.pptx Overview of Periodontal Disease.pptx Overview of Periodontal Disease.pptx

1. Periodontal Disease By: Dr. Abrham J(MD) 1

2. Overview of Periodontal Disease: Causes, Pathogenesis, and Characteristics Periodontal diseases are serious chronic infections that involve destruction of the tooth-supporting apparatus , Although plaque is essential for the initiation of periodontal diseases, the majority of the destructive processes associated with these diseases are due to an excessive host response to the bacterial challenge. 2

3. TYPES OF PERIODONTAL DISEASE Periodontal diseases include two general categories based on whether there is attachment or bone loss: gingivitis and periodontitis . 3

4. Plaque-Induced Gingival Diseases Gingivitis is gingival inflammation associated with plaque and calculus accumulation. It is the most common form of gingival disease. Gingivitis can occur on teeth with no attachment loss; it also occurs in the gingiva of teeth previously treated for periodontitis with no further attachment loss. 4

5. Cont... Dental Plaque Only: The bacterial antigens and their metabolic products (e.g., endotoxin ) stimulate epithelial and connective tissue cells to produce inflammatory mediators that result in a localized inflammatory response recruiting polymorphonuclear leukocytes (PMNLs or neutrophils ) to the site. 5

6. Cont... the clinical signs of gingivitis develop are redness,swelling , and bleeding. The plaque host interaction can be altered by the effects of local factors, systemic factors, or both. 6

7. Cont... Systemic Factors: Systemic hormonal changes associated with puberty, menstrual cycle, or pregnancy , as well as with chronic diseases such as diabetes, can alter the host response to dental plaque. Hormonal changes and certain diseases can upregulate systemic cellular and immunologic function resulting in local severe gingival inflammation, 7

8. Cont... Medications: Medications such as anticonvulsant drugs (e.g., dilantin ), immunosuppressive drugs (e.g., cyclosporine), and calcium channel blockers (e.g., diltiazem ) can cause severe gingival enlargement and pseudo-periodontal pocketing (i.e., increased probing depths with no associated attachment or bone loss). 8

9. Cont... Malnutrition: The host immune system can be diminished when malnutrition develops, resulting in excessive gingival inflammation. Severe ascorbic acid (vitamin C) deficiencies (i.e., scurvy) can produce bright red, swollen, and bleeding gingival tissues. In the case of vitamin C deficiency, gingivitis is associated with a suppressed synthesis of both connective tissue collagens treatment with vitamin C supplements can reverse this condition. 9

10. Nonplaque -Induced Gingival Lesions These types of lesions usually are rare and mainly due to systemic conditions. Bacteria,viruses , or fungi can cause these types of gingival lesions. It is associated with pain and fever, as well as red swollen gingival tissues with bleeding or abscess formation, and can be treated with routine periodontal scaling and root planing in addition to antibiotic therapy. 10

11. Cont... Some of the clinical signs include bleeding on probing, deep pockets,recession , and tooth mobility. Often, this destructive process is silent and continues for long periods of time without being identified. 11

12. Chronic periodontitis Chronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation of the periodontal tissues that is caused by accumulation of profuse amounts of dental plaque. 12

13. Cont... 13

14. Cont... Most prevalent in adults, but can occur in children and adolescents Amount of destruction is consistent with presence of local factors Subgingival calculus is a frequent finding Associated with a variable microbial pattern Slow to moderate rate of progression but may have periods of rapid progression 14

15. Cont... Can be associated with local predisposing factors (e.g. tooth-related or iatrogenic factors) May be modified by and /or associated with systemic diseases (e.g. diabetes mellitus, HIV infection) Can be modified by factors other than systemic disease such as smoking and emotional stress 15

16. Extent and severity Extent: Localized: < 3 0% of sites affected Generalized: > 30% of sites affected Severity: entire dentition or individual teeth/site Slight = 1-2 mm CAL Moderate = 3-4 mm CAL Severe = 5 mm CAL 16

17. Clinical Characteristics Gingival inflammation (color and texture alteration) Bleeding on probing (BOP) Periodontal pocketing Loss of clinical attachment and or loss of alveolar bone Variable pocket depths Horizontal/vertical bone loss 17

18. Cont... 18

19. Microbiology Strong evidence for etiology Porphyromonas gingivalis , Bacteriodes forsythus and treponema denticola Moderate evidence Campylobacter rectus, Eubacterium nodatum , Fusobacterium nucleatum , Prevotella intermedia / nigrescens , Peptostreptococcus micros, Streptococcus intermedius -complex and Treponema denticola . 19

20. CP diagnosis Radiographic features: horizontal bone loss 20

21. CP Treatment and prognosis: Remove local etiologic factors (scaling and root planning) , education, control of associated factors 21

22. Aggressive Periodontitis This form of periodontitis was previously categorized as Juvenile Periodontitis . Common features include rapid attachment loss and bone destruction in the absence of significant accumulations of plaque and calculus. These forms of periodontitis usually affect young individuals, often during puberty,from 10 to 30 years of age, with a genetic predisposition. The bacteria most often associated with aggressive periodontitis are Actinobacillus actinomycetemcomitans . 22

23. Cont... Aggressive periodontitis can be further characterized as localized and generalized forms. The localized form usually affects first molar and incisor sites. The generalized form usually involves at least three teeth other than first molars and incisors. 23

24. LOCALIZED AGGRESSIVE PERIODONTITIS Clinical Characteristics age of onset around puberty . interproximal attachment loss on at least two permanent teeth, one of which is a first molar, and involving no more than two teeth other than first molars and incisors. 24

25. Cont... lack of clinical inflammation despite the presence of deep periodontal pockets Furthermore, in many cases the amount of plaque on the affected teeth is minimal, the quantity of plaque may be limited, it often contains elevated levels of A. actinomycetemcomitans , and in some patients, Porphyromonas gingivalis . 25

26. Cont... progresses rapidly. Evidence suggests that the rate of bone loss is about three to four times faster than in chronic periodontitis . robust antibody response to the pathogens present. 26

27. GENERALIZED AGGRESSIVE PERIODONTITIS Clinical Characteristics usually affects individuals under the age of 30, but older patients also may be affected. In contrast to localized aggressive periodontitis , a poor antibody response to the pathogens present. is characterized by "generalized interproximal attachment loss affecting at least three permanent teeth other than first molars and incisors" 27

28. Cont... often have small amounts of bacterial plaque associated with the affected teeth . P. gingivalis , A. actinomycetemcomitans, and Bacteriodes forsythus frequently are detected in the plaque that is present. a severe, acutely inflamed tissue , often proliferating, ulcerated,and bleeding may occur spontaneously or with slight stimulation. deep pockets can be demonstrated by probing. 28

29. treatment Mechanical therapy (non surgical or surgical debridement) in conjunction with antibiotics. Tetracycline seems affecting A.a better (250mg 3 times daily for 2wks). Or Some studies suggest the use of metrondazole 400mg and amoxicillin 250mg 4 times daily for 1wk in severe cases. Root planning and maintaining good oral hygiene is required and periodontal surgery to gain more access to the roots. 29

30. Necrotizing Periodontal Diseases The most severe inflammatory disorders caused by plaque bacteria Usually run an acute course , therefore it included in diagnoses They are rapidly destructive and debilitating Appear to represent various stages of the same disease process 30

31. Cont... Necrotizing ulcerative gingivitis (NUG) Necrotizing ulcerative periodontitis (NUP) C. Necrotizing ulcerative stomatitis (NUS) 31

32. Cont... In NUG there is a rapid destruction of gums tissue In NUP there is rapid destruction of hard (alveolar bone) tissues. It has not been determined whether or not NUG and NUP are the same or unique entities, and both are classified as NUP diseases. Both have similarities in the microbial profile NUP is a marker of severe immune suppression . 32

33. Clinical characteristics of NUG NUG is an inflammatory gingival condition characterized by ulcerated and necrotic gingival papillae (punched-out appearance) Ulcers are covered by yellowish-white or grayish slough ( pseudomembrane ) Removal of pseudomembrane leads to bleeding 33

34. NUP Interproximal ulceration, necrosis and cratering Foetor ex ore is often present Pain (severe, deep, localized in jaw) Spontaneous bleeding Soft tissue necrosis and rapid perio -destruction 34

35. Cont... Prominent changes in gingival contour are associated with tissue necrosis and loss of periodontal attachment and bone 35

36. Microbiology of necrotizing lesions Treponema sp., Selenomonas sp., Fusobactrum sp., Provetella melaninogenicus Provetella intermedia 36

37. Management of NUG Local debridement, scaling and root planing , and irrigation of affected areas with either povidine iodine 10% or chlorhexidine gluconate 0.12-0.2%. Povidine iodine provides some analgesic properties. Daily rinses with antimicrobial Chlorhexidine gluconate mouth 0.12% 1 Listerine Antiseptic  2 37

38. Cont... Frequent (daily or every-other-day) follow up for 7-10 days, repeating scaling and debridement as necessary Reevaluation 1 mo following resolution of acute symptoms 38

39. Cont... Systemic antibiotics Metronidazole (250mg tid , 7-10 days) When necessary, should administered concurrently with topical clotrimazole troches or nystatin vaginal tablets and, in severe immunosuppression , systemic antifungal medication fluconazole Reevaluation 1 mo following resolution of acute symptoms 39

40. Management of NUP Local debridement, scaling and root planing , and irrigation of affected areas with either povidine iodine 10% or chlorhexidine gluconate 0.12-0.2%. 40

41. Cont... Daily rinses with antimicrobial Chlorhexidine gluconate mouth 0.12% Listerine Antiseptic  Frequent (daily or every-other-day) follow up for 7-10 days, repeating scaling and debridement as necessary 41

42. Cont... Systemic antibiotics Metronidazole (250mg tid , 7-10 days; (Robinson et al.,1998) Consideration should also be given to the prophylactic administration 42

43. Cont... Topical application of clotrimazole troches or nystatin vaginal tablets In severe immunosuppression , systemic antifungal medication fluconazole 100mg, 7 to 10 days 43

44. Cont... Reevaluation 1 mo following resolution of acute symptoms 3 mo supportive periodontal maintenance 30% of patients experience recurrence in 2 years History of NUP predisposes to Necrotizing Ulcerative Stomatitis (Robinson, 2002) 44

45. Management of NUS Debridement of affected areas Daily rinses with antimicrobial Chlorhexidine gluconate mouth rinse 0.12% Listerine Antiseptic  45

46. Cont... Daily (or every-other-day) follow up for the first week, repeating debridement at each visit Systemic antibiotics (e.g., metronidazole 250 tid , 7-10 days). 46

47. Cont... Consideration should also be given to the prophylactic administration of an antifungal medication ( fluconazole 100mg,or Itraconazole 200mg; for 7 to 10 days) Reevaluation 1 mo following resolution of acute symptoms 47

48. Periodontal abscess Classification of Periodontal abscess Periodontal abscess can be: Chronic or acute Single or multiple Gingival abscess or periodontal abscess 48

49. Multiple periodontal abscess 49

50. Periodontal abscess Gingival abscess is a localized purulent infection that involves the marginal gingiva or interdental papilla. Periodontal abscess is a localized purulent infection within the tissues adjacent to the periodontal pocket that may lead to the destruction of periodontal ligament and alveolar bone . 50

51. Periodontal abscess 51

52. Classification of periodontal abscess Depending on the cause of infection: Periodontitis -related abscess ( subgingival biofilm ) Non- periodontitis -related abscess (foreign body) 52

53. Clinical features of GA Clinical features may include combinations of the following signs and symptoms: A localized area of swelling in the marginal gingiva or interdental papillae , with a red, smooth, shiny surface. The lesion may be painful and appear pointed. A purulent exudate may be present. 53

54. Gingival abscess 54

55. Clinical features of PA Clinical features may include combinations of the following signs and symptoms: a Smooth, shiny swelling of the gingiva ; pain, in the area of swelling Tender to touch; a purulent exudate ; 55

56. Periodontal abscess 56

57. Acute Periodontal Abscess 57

58. Clinical features of PA 4. Increase in probing depth . The tooth may be sensitive to horizontal percussion and may be mobile. 5. Rapid loss of periodontal attachment may occur. 6. A periodontal abscess may be associated with Endodontics pathosis 58

59. Signs and symptoms Swelling that usually occurs at sites with pre-existing periodontitis Pain is more continuous, less intense and easier to localize than an endo abscess May not respond to percussion, heat, cold Rule out contribution from non-vital teeth 59

60. Microbiology PA Approximately 60% of bacteria are strict anaerobes Bacterial isolates similar to chronic periodontitis 60

61. Steps in Treatment of Periodontal Abscesses Establish drainage Debride the pocket and root plane the affected tooth Rx antibiotics for aggressive infections Evaluate resolution of the abscess within 1 week 61

62. Cont... 62