C

23

Periodontics
OBJECTIVES
The student should strive to meet the following objectives and demonstrate an understanding of the facts and principles presented in this chapter: 1. Describe the scope of periodontics. 2. Identify members of the periodontal team and their roles. 3. Describe the stages of periodontal disease. 4. Explain the diagnostic procedures involved in the patients first visit to the periodontal office. 5. Identify and describe periodontal instruments and their uses. 6. Describe non-surgical procedures and the dental assistants role in each procedure. 7. Explain surgical procedures and dental assisting responsibilities. 8. Identify the types of periodontal dressing and how they are prepared, placed, and removed. 9. Describe periodontal maintenance procedures and the patients role relating to each.

OUTLINE
Introduction The Periodontal Team Periodontal Disease Periodontal Diagnostic Procedures Periodontal Instruments Non-Surgical Periodontal Procedures Surgical Periodontal Procedures Periodontal Dressing Periodontal Maintenance Procedures

KEY TERMS
bone resorption (p. 489) bruxism (p. 485) calculus (p. 484) coronal polish (p. 495) curette (p. 490) electrosurgery (p. 492) frenectomy (p. 499) furcation (p. 485) gingival grafting (p. 498) gingivectomy (p. 496) gingivitis (p. 485) gingivoplasty (p. 496) hoe scaler (p. 490) interdental knives (p. 491) mucogingival surgery (p. 498) occlusal equilibration (p. 488) osseous surgery (p. 498) ostectomy (p. 498) osteoplasty (p. 498) periodontal dressing (p. 498) periodontal flap surgery (p. 498) periodontal knives (p. 491) periodontal pocket (p. 488) periodontal probe (p. 489) periodontal probing (p. 488) periodontitis (p. 485) periodontium (p. 484) periosteal elevators (p. 493) plaque (p. 488) pocket marking pliers (p. 493) prophylaxis (p. 495) recession (p. 488) root planing (p. 495) scaling (p. 495) sickle scalers (p. 490) surgical scalpel (p. 492) tooth mobility (p. 488) ultrasonic instruments (p. 491)

483

484

CHAPTER 23

I NTRODUCTION
The periodontist specializes in diseases of the tissue around the root of the tooth. This specialty deals with symptoms, probable causes, diagnosis, and treatment of periodontal disease.

T HE P ERIODONTAL T EAM
The team in a periodontal office includes the periodontist, dental assistants, dental hygienists, and business office staff. The periodontist coordinates treatment with the general dentist in the overall care of the patient. The periodontist screens the patient, performs the surgical care, and provides continual care according to the patients needs. The dental assistant performs chairside assisting duties and the expanded functions allowed by state dental practice acts, including placing and removing periodontal dressing, removing sutures, and performing coronal polishes. The dental assistant takes radiographs, makes impressions for study models, places sealants, and administers fluoride treatments. The dental assistant also gives pre- and postoperative instructions and prepares the treatment room for surgery. These functions are in addition to treatment room preparation and maintenance and sterilization procedures. The dental assistant is involved in educating and motivating the patient throughout the treatment. In some offices, the dental assistant also may perform laboratory tasks, such as pouring study models or making periodontal splints. The dental hygienist performs traditional hygiene procedures and, depending on the state dental practice act, may also administer local anesthetic. In a periodontal practice, the hygienist often sees patients who have more advanced periodontal disease; therefore, their responsibilities include deep curettage, root planing, and clinical examination procedures.

FIGURE 23-1 View of patient with mild gingivitis.

Periodontal disease involves the periodontium, which represents the tissues that support the teeth and includes the following: GingivaTissues that surround the teeth. Epithelial attachmentArea at the bottom of the sulcus where the gingiva attaches to the tooth. SulcusSpace between the tooth and the free gingiva. In healthy mouths, the sulcus is 1 to 3 mm deep. Periodontal ligaments or membranesFibers of connective tissue that surround the root of the tooth and attach the cementum to the bone. CementumHard surface that covers the dentin on the root of the tooth. Alveolar boneBone that forms the socket that encases the root of the tooth.

Symptoms of Periodontal Disease

The symptoms of periodontal disease include bleeding gums, loose teeth (mobility), inflamed gingiva, abnormal contour of the gingiva, periodontal pocket formation, malocclusion, halitosis, pain and tenderness, and recession and discoloration. All of these symptoms may be present or the symptoms may vary (Figure 23-2A).

P ERIODONTAL D ISEASE
Evidence of periodontal disease has been noted in ancient history studies. Ancient human skulls demonstrate evidence of bone destruction, and early civilizations told of treatment methods such as using wire to tie loose teeth together. According to the American Academy of Periodontology, three out of four adults will experience, to some degree, periodontal problems at some time in their lives. Periodontal disease occurs in children and adolescents with marginal gingivitis and gingival recession, which are the most prevalent conditions (Figure 23-1).

Causes of Periodontal Disease

Local irritants are a significant cause of periodontal disease. One irritant, bacterial plaque, is a common cause of the inflammation of the gingival tissues. The bacterial plaque forms around the margin of the gingiva and, if left undisturbed, mineralizes and appears as a yellow or brown deposit on the teeth. This hard deposit is called calculus (tartar) (Figure 23-2B). If plaque and calculus

486

CHAPTER 23

TABLE 23-1

CLASSIFICATION OF PERIODONTAL DISEASE

Characteristics Contributing Factors

Classifications Gingivitis common forms Chronic gingivitis

Common in adults and children. Redness, gingival bleeding, changes in the contour of the gingiva, edema, enlargement, loss of tissue tone. No radiographic changes are detected in the periodontium in gingivitis. People aged sixteen to thirty are mainly affected. Severe inflammation of the marginal gingiva, bleeding, acute pain, necrosis and ulceration of the interdental papilla, foul breath, and craterlike depressions in the crest of the interdental papilla. Sudden onset. Gingival inflammation, enlargement of the papillae, and bleeding.

Predominately caused by plaque accumulation.

Necrotizing ulcerative gingivitis (also known as NUG, acute necrotizing ulcerative gingivitis [ANUG])

Poor oral hygiene, stress, poor diet, and smoking.

Gingivitis associated with hormonal changes (e.g., pregnancy, puberty, steroid therapy, or birth control medication). Gingivitis attributed to the effects of certain drugs (e.g., phenytoin and cyclosporin). Linear gingival erythema (HIV-G or now known as LGE)

Results from an exaggerated response to bacterial plaque. Response to elevated levels of hormones or steroids. Link between bacterial plaque and drug-induced gingival overgrowth. Immunodeficiency virus.

Gingival overgrowth or hyperplasia. Changes in size and contour of the gingiva lead to increased plaque accumulation and inflammation. Patients with AIDS. Severe erythema (redness and inflammation along the marginal gingiva. Extends to the attached gingiva. Some bleeding and pain.

Periodontitis Adult periodontitis Onset in mid-twenties. Slow progression. Gingival inflammation, periodontal pockets, bone loss, and eventual tooth mobility. Classified as early, moderate, or advanced depending on the degree or severity of bone loss. Treatment includes non-surgical and surgical procedures followed by regular maintenance therapy. Rare occurrence. Prepubertal periodontitis affects the primary or mixed dentition. Severe gingival inflammation, rapid bone loss, mobility, and tooth loss. Juvenile periodontitis occurs around puberty. Females are affected more than males. Severe and rapid bone loss that begins with the incisors and first molars. Sparse plaque and calculus buildup for degree of destruction. Poor oral hygiene, genetic factors, malpositioned teeth, and stress.

Early-onset periodontitis, such as prepubertal periodontitis and juvenile periodontitis

Usually genetic basis.

gingivitis are inflamed gingiva, metallic taste, bad breath, pain, and hemorrhage of the tissues. This condition is also known as Vincents disease and trench

mouth. It appears in individuals in the same unhealthy state and frequently occurs in college students around the time of final examinations (because of stress).

486

CHAPTER 23

TABLE 23-1

CLASSIFICATION OF PERIODONTAL DISEASE

Characteristics Contributing Factors

Classifications Gingivitis common forms Chronic gingivitis

Common in adults and children. Redness, gingival bleeding, changes in the contour of the gingiva, edema, enlargement, loss of tissue tone. No radiographic changes are detected in the periodontium in gingivitis. People aged sixteen to thirty are mainly affected. Severe inflammation of the marginal gingiva, bleeding, acute pain, necrosis and ulceration of the interdental papilla, foul breath, and craterlike depressions in the crest of the interdental papilla. Sudden onset. Gingival inflammation, enlargement of the papillae, and bleeding.

Predominately caused by plaque accumulation.

Necrotizing ulcerative gingivitis (also known as NUG, acute necrotizing ulcerative gingivitis [ANUG])

Poor oral hygiene, stress, poor diet, and smoking.

Gingivitis associated with hormonal changes (e.g., pregnancy, puberty, steroid therapy, or birth control medication). Gingivitis attributed to the effects of certain drugs (e.g., phenytoin and cyclosporin). Linear gingival erythema (HIV-G or now known as LGE)

Results from an exaggerated response to bacterial plaque. Response to elevated levels of hormones or steroids. Link between bacterial plaque and drug-induced gingival overgrowth. Immunodeficiency virus.

Gingival overgrowth or hyperplasia. Changes in size and contour of the gingiva lead to increased plaque accumulation and inflammation. Patients with AIDS. Severe erythema (redness and inflammation along the marginal gingiva. Extends to the attached gingiva. Some bleeding and pain.

Periodontitis Adult periodontitis Onset in mid-twenties. Slow progression. Gingival inflammation, periodontal pockets, bone loss, and eventual tooth mobility. Classified as early, moderate, or advanced depending on the degree or severity of bone loss. Treatment includes non-surgical and surgical procedures followed by regular maintenance therapy. Rare occurrence. Prepubertal periodontitis affects the primary or mixed dentition. Severe gingival inflammation, rapid bone loss, mobility, and tooth loss. Juvenile periodontitis occurs around puberty. Females are affected more than males. Severe and rapid bone loss that begins with the incisors and first molars. Sparse plaque and calculus buildup for degree of destruction. Poor oral hygiene, genetic factors, malpositioned teeth, and stress.

Early-onset periodontitis, such as prepubertal periodontitis and juvenile periodontitis

Usually genetic basis.

gingivitis are inflamed gingiva, metallic taste, bad breath, pain, and hemorrhage of the tissues. This condition is also known as Vincents disease and trench

mouth. It appears in individuals in the same unhealthy state and frequently occurs in college students around the time of final examinations (because of stress).