Periodontology

Field of dentistry

Periodontology or periodontics (from Ancient Greek περί, – 'around'; and ὀδούς, – 'tooth', genitive ὀδόντος, ) is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. A periodontist is a dentist that specializes in the prevention, diagnosis and treatment of periodontal disease and in the placement of dental implants.

The term periodontium is used to describe the group of structures that directly surround, support and protect the teeth. The periodontium is composed largely of the gingival tissue and the supporting bone.

Normal gingiva may range in color from light coral pink to heavily pigmented. The soft tissues and connective fibres that cover and protect the underlying cementum, periodontal ligament and alveolar bone are known as the gingivae. The gingivae are categorized into three anatomical groups: the free, attached and the interdental gingiva. Each of the gingival groups are considered biologically different; however, they are all specifically designed to help protect against mechanical and bacterial destruction.

The tissues that sit above the alveolar bone crest are considered the free gingiva. In healthy periodontium, the gingival margin is the fibrous tissue that encompasses the cemento enamel junction, a line around the circumference of the tooth where the enamel surface of the crown meets the outer cementum layer of the root. A natural space called the gingival sulcus lies apically to the gingival margin, between the tooth and the free gingiva. A non diseased, healthy gingival sulcus is typically 0.5 3mm in depth, however, this measurement can increase in the presence of periodontal disease. The gingival sulcus is lined by a non keratinised layer called the oral sulcular epithelium; it begins at the gingival margin and ends at the base of the sulcus where the junctional epithelium and attached gingiva begins.

The junctional epithelium is a collar like band that lies at the base of the gingival sulcus and surrounds the tooth; it demarcates the areas of separation between the free and attached gingiva. The junctional epithelium provides a specialized protective barrier to microorganisms residing around the gingival sulcus. The attached gingiva lies between the free gingival line or groove and the mucogingival junction. The attached gingiva dissipates functional and masticatory stresses placed on the gingival tissues during common activities such as mastication, tooth brushing and speaking. In health it is typically pale pink or coral pink in colour and may present with surface stippling or racial pigmentation.

The periodontal ligament is the connective tissue that joins the outer layer of the tooth root, being the cementum, to the surrounding alveolar bone. It is composed of several complex fibre groups that run in different directions and which insert into the cementum and bone via Sharpey's fibres.

Cementum is the outer layer of the tooth root; it overlies the dentine layer of the tooth and provides attachment for the collagen fibres of the periodontal ligament. It also protects the dentine and provides a seal for the otherwise exposed ends of the dentinal tubules. It is not as hard as enamel or dentine and is typically a light yellow colour.

Periodontal disease encompasses a number of diseases of the periodontal tissues that result in attachment loss and destruction of alveolar bone. Periodontal diseases take on many different forms but are usually a result of a coalescence of bacterial plaque biofilm accumulation of the red complex bacteria (e. g. P. gingivalis, T. forsythia, and T. denticola) of the gingiva and teeth, combined with host immuno inflammatory mechanisms and other risk factors that can lead to destruction of the supporting bone around natural teeth. Untreated, these diseases can lead to alveolar bone loss and tooth loss. as of 2013, periodontal disease accounted for 70.8% of teeth lost in patients with the disease in South Korea. Periodontal disease is the second most common cause of tooth loss (second to dental caries) in Scotland. Twice daily brushing and flossing are a way to help prevent periodontal diseases. Healthy gingiva can be described as stippled, pale or coral pink in Caucasian people, with various degrees of pigmentation in other races. The gingival margin is located at the cemento enamel junction without the presence of pathology. The gingival pocket between the tooth and the gingival should be no deeper than 1–3mm to be considered healthy. There is also the absence of bleeding on gentle probing. Individual risk factors include: gender, smoking and alcohol consumption, diabetes, obesity and metabolic syndrome, osteoporosis and Vitamin D conditions, stress and genetic factors.

In 2017, the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) together collaborated to revise and adopt a new classification system for periodontal conditions to aid in a more personalized approach to patient care. In 2018 they released an updated classification system which includes a multi dimensional staging and grading system for periodontitis classification, a recategorization of various forms of periodontitis, and the inaugural classification for peri implant diseases and conditions.

Contemporary periodontal treatment is designed based on the trimeric model, and is performed in four phases. These phases are structured to ensure that periodontal therapy is conducted in a logical sequence, consequently improving the prognosis of the patient, in comparison to indecisive treatment plan without a clear goal.

The non surgical phase is the initial phase in the sequence of procedures required for periodontal treatment. Phase I consists of treatment of emergencies, antimicrobial therapy, diet control, patient education and motivation, correction of iatrogenic factors, deep caries, hopeless teeth, preliminary scaling, temporary splinting, occlusal adjustment, minor orthodontic tooth movement and debridement.

After post phase I, it is necessary to evaluate the requirement of periodontium for surgery. Debridement is thorough mechanical removal of calculus and dental biofilm from the root surfaces of the tooth. Debridement is the basis of treatment for inflammatory periodontal diseases and remains the golden standard for surgical and non surgical treatment in the initial therapy. It is conducted by hand instrumentation such as curettes or scalers and ultrasonic instrumentation. This requires the patient to be motivated in improving their oral hygiene and requires behaviour change in terms of tooth brushing, interdental cleaning, and other oral hygiene techniques. Personal oral hygiene is often considered an essential aspect of controlling chronic periodontitis. Research has shown that it is important to appreciate the motivation of the patient behaviour changes that have originated from the patient. Oral health therapists are employed by the dental team to share the responsibilities of care. They are an important asset as they have been uniquely and specifically trained in preventative dentistry and risk minimization. This allows the dental team to work more competently and effectively as dentists can manage more complex treatments or significantly medically compromised patients.

A periodontist is a specialist dentist who treats patients for periodontal related diseases and conditions. They are involved in the prevention, diagnosis and treatment of periodontal disease. Periodontists receive further specialist training in periodontics after completing a dental degree. Periodontists provide treatments for patients with severe gingival diseases or complex medical histories. Periodontists offer a wide range of treatments including root scaling and planing, periodontal surgery, implant surgery and other complex periodontal procedures. List of procedures performed by a periodontist: and are a minimum of three years in length and usually culminate with a master (MSc or MDent) degree. Graduates are then eligible to sit for the fellowship exams with the Royal College of Dentists of Canada. Dentistry is a regulated profession. To become a licensed dentist in Canada one must have a BDS, DDS, or DMD degree and be certified by the National Dental Examining Board of Canada.

The American Dental Association (ADA) accredited programs are a minimum of three years in length. According to the American Academy of Periodontology, U. S. trained periodontists are specialists in the prevention, diagnosis and treatment of periodontal diseases and oral inflammation, and in the placement and maintenance of dental implants. Many periodontists also diagnose and treat oral pathology. Historically, periodontics served as the basis for the speciality of oral medicine. Following successful completion of post graduate training a periodontist becomes board eligible for the American Board of Periodontology examination.

After periodontal treatment, whether it be surgical or non surgical, maintenance periodontal therapy is essential for a long term result and stabilization of periodontal disease. There is also a difference in the maintenance of different types of periodontal disease, as there are different types, such as:

The reversible inflammation of the gums is easily prevented by patients. After the removal of the inflammatory product, usually plaque or calculus, this allows the gums room to heal. This is done by patients thoroughly cleaning teeth every day with a soft bristle toothbrush and an interdental aid. This can be floss, interdental brushes, or whatever is preferred by the patient. Without patient compliance and constant removal of plaque and calculus, gingivitis cannot be treated completely and can progress to irreversible periodontitis.

Also acute necrotizing ulcerative gingivitis and necrotizing ulcerative periodontitis, it is a type of periodontal disease different than many other periodontal diseases. Clinical characteristics include gingival necrosis (breakdown of the gums), gingival pain, bleeding, halitosis (bad breath), as well as a grey colour to the gingiva and a punched out appearance. It is treated through debridement, usually under local anaesthetic due to immense pain. To maintain and treat the condition completely, a chlorhexidine mouthwash should be recommended to the patient to use twice daily, oral health instruction should be provided (using a soft bristle toothbrush or electric toothbrush twice a day) and an interdental cleaning aid, such as floss or interdental brushes, which cleans the areas that the toothbrush cannot reach. The patient should also be educated on proper nutrition and diet and healthy fluid intake. Smoking cessation should occur not only to completely eradicate the disease but also for the health of the patient. Pain control can be done through ibuprofen or paracetamol/acetaminophen. In the case of an immunocompromised patient, antibiotics should be prescribed. Assessment of treatment should be done after 24 hours of treatment and continued every 3–6 months until signs and symptoms are resolved and gingival health and function restored.

The inflammation of the gums and irreversible destruction of the alveolar bone and surrounding structures of the teeth, which is usually slow progressing but can have bursts. Local factors explain presence of disease, such as diet, lack of oral hygiene, plaque accumulation, smoking, etc. It is characterized by pocket formation and recession of the gingiva (shrinkage of the gums). Treatment and maintenance are important in stopping disease progression and to resolve the inflammation. Treatment usually consists of scaling and root planning, surgical therapy, and regenerative surgical therapy. After treatment, patient care and regular maintenance check ups are important to completely eradicate the disease and present its recurrence. This is done through plaque control and removal: twice daily toothbrushing and daily interdental cleaning; chlorhexidine mouthwash can also be effective. The patient should also present to a dentist for maintenance check ups at least every three months for an in office check up and if necessary, plaque control.