Progression from Gingivitis to Periodontitis

The transition from gingivitis to periodontitis is a critical process in periodontal disease progression. This lecture will outline the key stages involved in this progression, highlighting the changes in microbial composition, host response, and tissue alterations.

Pathway of Progression

1. Establishment and Maturation of Supragingival Plaque:

   • The process begins with the formation of supragingival plaque, which is evident in gingivitis.
   • As this plaque matures, it becomes more complex and can lead to changes in the surrounding tissues.

2. Migration of Periodontopathogenic Bacteria:

   • When the microbial load overwhelms the local host immune response, pathogenic bacteria migrate subgingivally (below the gum line).
   • This migration establishes a subgingival niche that is conducive to the growth of periodontopathogenic bacteria.

Initial Lesion

• Timeline:
  • The initial lesion, characterized by subclinical gingivitis, appears approximately 2 to 4 days after the colonization of the gingival sulcus by bacteria.
• Clinical Manifestations:
  • Vasculitis: Inflammation of blood vessels in the gingival tissue.
  • Exudation of Serous Fluid: Increased flow of gingival crevicular fluid (GCF) from the gingival sulcus.
  • Increased PMN Migration: Polymorphonuclear neutrophils (PMNs) migrate into the sulcus in response to the inflammatory process.
  • Alteration of Junctional Epithelium: Changes occur at the base of the pocket, affecting the integrity of the junctional epithelium.
  • Collagen Dissolution: Perivascular collagen begins to dissolve, contributing to tissue breakdown.

Early Lesion

• Timeline:
  • The early lesion forms within 4 to 7 days after the initial lesion due to the continued accumulation of bacterial plaque.
• Characteristics:
  • Leukocyte Accumulation: There is a significant increase in leukocytes at the site of acute inflammation, indicating an ongoing immune response.
  • Cytopathic Alterations: Resident fibroblasts undergo cytopathic changes, affecting their function and viability.
  • Collagen Loss: Increased collagen loss occurs within the marginal gingiva, contributing to tissue destruction.
  • Proliferation of Basal Cells: The basal cells of the junctional epithelium proliferate in response to the inflammatory environment.

Dimensions of Toothbrushes

Toothbrushes play a crucial role in maintaining oral hygiene, and their design can significantly impact their effectiveness. The American Dental Association (ADA) has established guidelines for the dimensions and characteristics of acceptable toothbrushes. This lecture will outline these specifications and discuss their implications for dental health.

Acceptable Dimensions of Toothbrushes

1. Brushing Surface Dimensions:

   • Length:
     • Acceptable brushing surfaces should measure between 1 to 1.25 inches (25.4 to 31.8 mm) long.
   • Width:
     • The width of the brushing surface should range from 5/16 to 3/8 inch (7.9 to 9.5 mm).
   • Rows of Bristles:
     • Toothbrushes should have 2 to 4 rows of bristles to effectively clean the teeth and gums.
   • Tufts per Row:
     • Each row should contain 5 to 12 tufts of bristles, allowing for adequate coverage and cleaning ability.

2. Filament Diameter:

   • The diameter of the bristles can vary, affecting the stiffness and cleaning effectiveness:
     • Soft Filaments:
       • Diameter of 0.2 mm (0.007 inches). Ideal for sensitive gums and children.
     • Medium Filaments:
       • Diameter of 0.3 mm (0.012 inches). Suitable for most adults.
     • Hard Filaments:
       • Diameter of 0.4 mm (0.014 inches). Generally not recommended for daily use as they can be abrasive to the gums and enamel.

3. Filament Stiffness:

   • The stiffness of the bristles is determined by the diameter relative to the length of the filament. Thicker filaments tend to be stiffer, which can affect the brushing technique and comfort.

Special Considerations for Children's Toothbrushes

• Size:
  • Children's toothbrushes are designed to be smaller to accommodate their smaller mouths and teeth.
• Bristle Thickness:
  • The bristles are thinner, measuring 0.005 inches (0.1 mm) in diameter, making them gentler on sensitive gums.
• Bristle Length:
  • The bristles are shorter, typically around 0.344 inches (8.7 mm), to ensure effective cleaning without causing discomfort.

Clinical Implications

1. Choosing the Right Toothbrush:

   • Dental professionals should guide patients in selecting toothbrushes that meet ADA specifications to ensure effective plaque removal and gum protection.
   • Emphasizing the importance of using soft or medium bristles can help prevent gum recession and enamel wear.

2. Education on Brushing Technique:

   • Proper brushing technique is as important as the toothbrush itself. Patients should be educated on how to use their toothbrush effectively, regardless of the type they choose.

3. Regular Replacement:

   • Patients should be advised to replace their toothbrush every 3 to 4 months or sooner if the bristles become frayed. This ensures optimal cleaning effectiveness.

4. Special Considerations for Children:

   • Parents should be encouraged to choose appropriately sized toothbrushes for their children and to supervise brushing to ensure proper technique and effectiveness.

Sutures for Periodontal Flaps

Suturing is a critical aspect of periodontal surgery, particularly when managing periodontal flaps. The choice of suture material can significantly influence healing, tissue adaptation, and overall surgical outcomes.

1. Nonabsorbable Sutures

Nonabsorbable sutures are designed to remain in the tissue until they are manually removed. They are often used in situations where long-term support is needed.

A. Types of Nonabsorbable Sutures

1. Silk (Braided)

   • Characteristics:
     • Excellent handling properties and knot security.
     • Provides good tissue approximation.
   • Applications: Commonly used in periodontal surgeries due to its ease of use and reliability.

2. Nylon (Monofilament) (Ethilon)

   • Characteristics:
     • Strong and resistant to stretching.
     • Less tissue reactivity compared to silk.
   • Applications: Ideal for delicate tissues and areas requiring minimal tissue trauma.

3. ePTFE (Monofilament) (Gore-Tex)

   • Characteristics:
     • Biocompatible and non-reactive.
     • Excellent tensile strength and flexibility.
   • Applications: Often used in guided tissue regeneration procedures and in areas where long-term support is needed.

4. Polyester (Braided) (Ethibond)

   • Characteristics:
     • High tensile strength and good knot security.
     • Less pliable than silk.
   • Applications: Used in situations requiring strong sutures, such as in flap stabilization.

2. Absorbable Sutures

Absorbable sutures are designed to be broken down by the body over time, eliminating the need for removal. They are often used in periodontal surgeries where temporary support is sufficient.

A. Types of Absorbable Sutures

1. Surgical Gut

   • Plain Gut (Monofilament)

     • Absorption Time: Approximately 30 days.
     • Characteristics: Made from sheep or cow intestines; provides good tensile strength initially but loses strength quickly.
     • Applications: Suitable for soft tissue approximation where rapid absorption is desired.

   • Chromic Gut (Monofilament)

     • Absorption Time: Approximately 45 to 60 days.
     • Characteristics: Treated with chromium salts to delay absorption; retains strength longer than plain gut.
     • Applications: Used in areas where a longer healing time is expected.

2. Synthetic Absorbable Sutures

   • Polyglycolic Acid (Braided) (Vicryl, Ethicon)

     • Absorption Time: Approximately 16 to 20 days.
     • Characteristics: Provides good tensile strength and is absorbed predictably.
     • Applications: Commonly used in periodontal and oral surgeries due to its handling properties.

   • Dexon (Davis & Geck)

     • Characteristics: Similar to Vicryl; made from polyglycolic acid.
     • Applications: Used in soft tissue approximation and ligation.

   • Polyglycaprone (Monofilament) (Maxon)

     • Absorption Time: Similar to Vicryl.
     • Characteristics: Offers excellent tensile strength and is absorbed more slowly than other synthetic options.
     • Applications: Ideal for areas requiring longer support during healing.

Gracey Curettes

Gracey curettes are specialized instruments designed for periodontal therapy, particularly for subgingival scaling and root planing. Their unique design allows for optimal adaptation to the complex anatomy of the teeth and surrounding tissues. This lecture will cover the characteristics, specific uses, and advantages of Gracey curettes in periodontal practice.

• Gracey curettes are area-specific curettes that come in a set of instruments, each designed and angled to adapt to specific anatomical areas of the dentition.

• Purpose: They are considered some of the best instruments for subgingival scaling and root planing due to their ability to provide excellent adaptation to complex root anatomy.

Specific Gracey Curette Designs and Uses

1. Gracey 1/2 and 3/4:

   • Indication: Designed for use on anterior teeth.
   • Application: Effective for scaling and root planing in the anterior region, allowing for precise access to the root surfaces.

2. Gracey 5/6:

   • Indication: Suitable for anterior teeth and premolars.
   • Application: Versatile for both anterior and premolar areas, providing effective scaling in these regions.

3. Gracey 7/8 and 9/10:

   • Indication: Designed for posterior teeth, specifically for facial and lingual surfaces.
   • Application: Ideal for accessing the buccal and lingual surfaces of posterior teeth, ensuring thorough cleaning.

4. Gracey 11/12:

   • Indication: Specifically designed for the mesial surfaces of posterior teeth.
   • Application: Allows for effective scaling of the mesial aspects of molars and premolars.

5. Gracey 13/14:

   • Indication: Designed for the distal surfaces of posterior teeth.
   • Application: Facilitates access to the distal surfaces of molars and premolars, ensuring comprehensive treatment.

Key Features of Gracey Curettes

• Area-Specific Design: Each Gracey curette is tailored for specific areas of the dentition, allowing for better access and adaptation to the unique contours of the teeth.

• Offset Blade: Unlike universal curettes, the blade of a Gracey curette is not positioned at a 90-degree angle to the lower shank. Instead, the blade is angled approximately 60 to 70 degrees from the lower shank, which is referred to as an "offset blade." This design enhances the instrument's ability to adapt to the tooth surface and root anatomy.

Advantages of Gracey Curettes

1. Optimal Adaptation: The area-specific design and offset blade allow for better adaptation to the complex anatomy of the roots, making them highly effective for subgingival scaling and root planing.

2. Improved Access: The angled blades enable clinicians to access difficult-to-reach areas, such as furcations and concavities, which are often challenging with standard instruments.

3. Enhanced Efficiency: The design of Gracey curettes allows for more efficient removal of calculus and biofilm from root surfaces, contributing to improved periodontal health.

4. Reduced Tissue Trauma: The precise design minimizes trauma to the surrounding soft tissues, promoting better healing and patient comfort.

Plaque Formation

Dental plaque is a biofilm that forms on the surfaces of teeth and is a key factor in the development of dental caries and periodontal disease. The process of plaque formation can be divided into three major phases:

1. Formation of Pellicle on the Tooth Surface

• Definition: The pellicle is a thin, acellular film that forms on the tooth surface shortly after cleaning.
• Composition: It is primarily composed of salivary glycoproteins and other proteins that are adsorbed onto the enamel surface.
• Function:
  • The pellicle serves as a protective barrier for the tooth surface.
  • It provides a substrate for bacterial adhesion, facilitating the subsequent stages of plaque formation.

2. Initial Adhesion & Attachment of Bacteria

• Mechanism:
  • Bacteria in the oral cavity begin to adhere to the pellicle-coated tooth surface.
  • This initial adhesion is mediated by specific interactions between bacterial adhesins (surface proteins) and the components of the pellicle.
• Key Bacterial Species:
  • Primary colonizers, such as Streptococcus sanguis and Actinomyces viscosus, are among the first to attach.
• Importance:
  • Successful adhesion is crucial for the establishment of plaque, as it allows for the accumulation of additional bacteria.

3. Colonization & Plaque Maturation

• Colonization:
  • Once initial bacteria have adhered, they proliferate and create a more complex community.
  • Secondary colonizers, including gram-negative anaerobic bacteria, begin to join the biofilm.
• Plaque Maturation:
  • As the plaque matures, it develops a three-dimensional structure, with different bacterial species occupying specific niches within the biofilm.
  • The matrix of extracellular polysaccharides and salivary glycoproteins becomes more pronounced, providing structural integrity to the plaque.
• Coaggregation:
  • Different bacterial species can adhere to one another through coaggregation, enhancing the complexity of the plaque community.

Composition of Plaque

• Matrix Composition:
  • Plaque is primarily composed of bacteria embedded in a matrix of salivary glycoproteins and extracellular polysaccharides.
• Implications for Removal:
  • The dense and cohesive nature of this matrix makes it difficult to remove plaque through simple rinsing or the use of sprays.
  • Effective plaque removal typically requires mechanical means, such as brushing and flossing, to disrupt the biofilm structure.

Classification of Periodontal Pockets

Periodontal pockets are an important aspect of periodontal disease, reflecting the health of the supporting structures of the teeth. Understanding the classification of these pockets is essential for diagnosis, treatment planning, and management of periodontal conditions.

Classification of Pockets

1. Gingival Pocket:

   • Also Known As: Pseudo-pocket.
   • Formation:
     • Formed by gingival enlargement without destruction of the underlying periodontal tissues.
     • The sulcus is deepened due to the increased bulk of the gingiva.
   • Characteristics:
     • There is no destruction of the supporting periodontal tissues.
     • Typically associated with conditions such as gingival hyperplasia or inflammation.

2. Periodontal Pocket:

   • Definition: A pocket that results in the destruction of the supporting periodontal tissues, leading to the loosening and potential exfoliation of teeth.
   • Classification Based on Location:
     • Suprabony Pocket:
       • The base of the pocket is coronal to the alveolar bone.
       • The pattern of bone destruction is horizontal.
       • The transseptal fibers are arranged horizontally in the space between the base of the pocket and the alveolar bone.
     • Infrabony Pocket:
       • The base of the pocket is apical to the alveolar bone, meaning the pocket wall lies between the bone and the tooth.
       • The pattern of bone destruction is vertical.
       • The transseptal fibers are oblique rather than horizontal.

Classification of Periodontal Pockets

1. Suprabony Pocket (Supracrestal or Supraalveolar):

   • Location: Base of the pocket is coronal to the alveolar bone.
   • Bone Destruction: Horizontal pattern of bone loss.
   • Transseptal Fibers: Arranged horizontally.

2. Infrabony Pocket (Intrabony, Subcrestal, or Intraalveolar):

   • Location: Base of the pocket is apical to the alveolar bone.
   • Bone Destruction: Vertical pattern of bone loss.
   • Transseptal Fibers: Arranged obliquely.

Classification of Pockets According to Involved Tooth Surfaces

1. Simple Pocket:

   • Definition: Involves only one tooth surface.
   • Example: A pocket that is present only on the buccal surface of a tooth.

2. Compound Pocket:

   • Definition: A pocket present on two or more surfaces of a tooth.
   • Example: A pocket that involves both the buccal and lingual surfaces.

3. Spiral Pocket:

   • Definition: Originates on one tooth surface and twists around the tooth to involve one or more additional surfaces.
   • Example: A pocket that starts on the mesial surface and wraps around to the distal surface.