International Journal of Oral & Maxillofacial Pathology.

2011;2(4):20-23 ISSN 2231 2250

Available online at http://www.journalgateway.com or www.ijomp.org
2011 International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved
Research Article
Cemento-Dentinal Junction in Health and Disease: A Light Microscopic Study
Pratebha B, Sudhakar R, Manoj Raja
Abstract
Background: The ultimate goal of periodontal therapy is periodontal regeneration. For
regeneration to be reasonably predictable, it is necessary that the tooth roots have cementum left
on them after instrumentation as cementum is a better substrate for regeneration. But,
instrumentation results in dentin exposure due to complete removal of cementum. The reason for
this to happen could either be over-zealous root planing or presence of a weakened junctional
tissue - the cemento-dentinal junction that forms a biological and structural link between the
cementum and dentin. Aims and Objectives: The objective of this study was to observe the
cemento-dentinal junction in health and disease under a light microscope, report the differences
and discuss the probable clinical implications of this junction affected with periodontitis. Materials
and Methods: 10 Healthy and 20 periodontitis affected teeth were collected, sectioned into two
halves, demineralized in 10% formic acid, and frozen sections obtained for observation under a
light microscope. Results: Pathologic granules were present in periodontitis affected teeth [roots
exposed to the oral cavity due to periodontitis] and absent in all healthy samples except in one
sample. The unexposed apical thirds of root surfaces of periodontitis affected samples to a large
extent showed absence of granules except in few, where few isolated granules were present.

Keywords: Tooth Abnormalities;Dental Cementum;Tooth Root;Cementodentinal Junction;
Pathologic Granules;Periodontal Regeneration;Scaling.

Pratebha Balu, Sudhakar Ramalingam, Manoj Raja. Cemento-Dentinal Junction in Health and Disease: A
Light Microscopic Study. International Journal of Oral & Maxillofacial Pathology; 2011:2(4):20-23.
International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta
Software Private Limited. All Rights Reserved.

Received on: 14/08/2011 Accepted on: 19/10/2011

Introduction
The cemento-dentinal junction (CDJ)
cements the cementum to dentin and forms
a biological and structural link between
cementum and dentin. This layer was
mistaken to be the intermediate cementum
and the hyaline layer of Hopewell and Smith
in the past.
1,2
But now it is clear that this is a
distinct tissue on its own right.
3
Certain
important proteins crucial to periodontal
regeneration, like bone morphogenic
protein-2 and osteogenin
4
are also reported
to be present in this tissue. Prolonged
exposure of cementum to a microbial
environment during periodontitis causes
structural and compositional changes to
cementum

and the CDJ.
5-7


Many studies have attempted to discuss the
structure and composition of this layer. But
documentation regarding the changes that
occur in periodontitis at the CDJ and
particularly the clinical implications of a
diseased CDJ is still unclear. The aims &
objectives of this study therefore was to
study the structural changes that occur at
CDJ in periodontitis affected teeth and to
report the differences observed in health and
disease as seen under a light microscope.
The probable clinical implications of
periodontitis affected CDJ have also been
discussed.

Materials and Methods
Ten healthy and 20 periodontitis teeth were
collected and processed for observing under
a light microscope. Inclusion criteria for
healthy samples comprised of teeth that
were extracted for orthodontic reasons
[premolars], prior to commencement of
orthodontic treatment and also included
impacted molars and canines. Inclusion
criteria for periodontitis samples comprised
of teeth that had hopeless prognosis and
extracted from patients with either chronic
(or) aggressive periodontitis [graded as
severe in terms of disease severity]. It was
also ensured that patients did not have
history of prior dental treatment (or) any kind
of periodontal therapy. The collected
samples were preserved in 10% formalin
and sectioned into 2 halves. One half was
processed for light microscopy and the other
half processed for scanning electron
microscopy. The light microscopic
observations alone have been discussed in
this study.

The samples were demineralized in 10%
formic acid for a period of 1 month. Extent of
ISSN 2231 2250 Cemento-Dentinal J unction in Health and Disease: A..... 21
demineralization was checked
radiographically. After adequate
demineralization was confirmed, frozen
sections of samples were made. The
temperature of cryostat was set at -20
o
C and
10-12m sections were obtained. One best
section from each sample was taken up for
observation, evaluation and interpretation.
8


Results
Frozen sections of 10 healthy and 20
periodontitis samples were viewed under
light microscope. In the healthy samples,
dentin showed presence of dentinal tubules
as numerous pin point openings; cementum
thickness appeared notably constant in most
of the samples where periodontal ligament
fibers could be appreciated; Pathologic
granules were absent in all healthy samples
(Fig 1a) except in one sample, where few
isolated granules were present in the
coronal thirds of root surface.

The dentin in periodontitis samples
appeared similar to healthy samples, but the
thickness of cementum was not constant.
Areas of thinning denoted areas of
resorption of cementum on the root surface.
All periodontitis samples showed presence
of pathologic granules in exposed root
surface (Fig 1b). In few samples even in
unexposed apical thirds, few granules were
spotted which were circular to ovoid in
shape. The granules were always present
either as aggregates of granules (Fig 2a);
isolated single granules spaced throughout
cementum (Fig 2b); or as long chain-like
clusters (Fig 2c). The pathologic granules
were always present in exposed root
surfaces and absent in the unexposed apical
thirds. In the outermost layers of cementum,
in almost all the samples, few isolated
granules were present. But the highest
concentration of granules was always
observed near the CDJ. There was no
variation in granule patterns observed
between chronic and aggressive
periodontitis samples.


Figure 1: Healthy sample showing total absence of granules at high power view (a) and presence
of both exposed (E) and unexposed (UE) areas (b). Arrows show presence of granules only in
exposed areas. Granules were absent in unexposed areas (X200).


Figure 2: Arrows show presence of granules in clusters (a), Arrows show presence of numerous
isolated pathologic granules (b) and Arrows show presence of granules in long chain like clusters
(c) *- Artifact
22 Pratebha B et al ISSN 2231 - 2250
Discussion
In periodontitis, the destruction caused by
bacteria and its products can be traced right
from the surface of cementum through CDJ
and at times, beyond the CDJ till dentin. The
effects of damage on cemental surface may
be seen as areas of hypo or
hypermineralisation and areas of resorption
due to alterations in organic and inorganic
components.
6,7
The bacterial toxin traverses
cementum, reaches CDJ and causes
destruction of the unmineralised collagen
which is present in abundance at CDJ.
8-10

Collagen at the cemento-dentinal junction is
particularly susceptible to denaturation
because this interface is rich in
unmineralised collagen. The area of
destruction where collagen is lost appears
as vacuoles under the microscope and is
known as pathologic granules.
9


The results of our study are in agreement
with those of Armitage et al.
9,10
in that, the
maximum concentration of pathologic
granules was found at CDJ. In healthy
samples the granules were usually absent.
Based on the results of our study, we
propose that the destruction of fibres at CDJ
could cause weakening of the cemento-
dentinal junction in periodontitis affected
teeth, and that a weakened junctional tissue
may not withstand mechanical periodontal
therapeutic procedures like root planing
resulting in complete removal of cementum,
thus exposing dentin.

Cementum removal deprives us of important
cementum attachment proteins such as
osteopontin, fibronectin and vitronectin that
are crucial to periodontal regeneration
11
and
the feasibility of regeneration is more
predictable on cementum compared to
dentin.
12
Root planing aims to remove
altered cementum and provide a healthier
cemental surface more suitable for
regeneration.
13
In periodontitis affected teeth
where the cemento-dentinal junction could
either be rendered weak or detached due to
disease, root planing is likely to result in
complete cemental removal exposing dentin
which is not suited for periodontal
regeneration. Studies on root planing
suggest the optimal pressure required for
root planning and the number of strokes

adequate to remove altered cementum.
14-16


But the pressure generated during root
planing is subjective and varies from one
person to the other and we do not have
pressure indicating armamentarium for root
planing. How can optimal root planing be
ensured? The shear strength of the
cemento-dentinal junction that can withstand
the impact of root planing needs to be
ascertained. These queries may have to be
addressed in order to prevent unnecessary
removal of healthy cementum and to
safeguard cemento-dentinal junction as they
are crucial to periodontal regeneration. We
therefore want to emphasize the need to
revisit and re-evaluate the impact of clinical
procedures like root planing on periodontitis
affected root surfaces that probably have
weakened cemento-dentinal junctions.

Author Affiliations
1. Dr. Pratebha Balu, Reader, Department. of
Periodontics and Implantology, 2. Dr. Sudhakar
Ramalingam, Reader, Department of Oral &
Maxillofacial Pathology, 3. Dr. Manoj Raja, Senior
Lecturer, Department. of Periodontics and
Implantology, Karpaga Vinayaga Institute of
Dental Sciences, GST Road, Palayanoor PO.
Chinna Kolambakkam, Kanchipuram Dist.,
Tamilnadu, India.

Acknowledgement
We would like to thank all the staff members of
Department of Oral Pathology and Microbiology
for their support.

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Corresponding Author
Dr. Sudhakar R,
Department of Oral & Maxillofacial
Pathology,
Karpaga Vinayaga Institute of Dental
Sciences,
GST Road, Palayanoor PO.
Chinna Kolambakkam
Kanchipuram Dist, India.
Ph: 09894360512
Email:dcprodent@gmail.com





Source of Support: Nil, Conflict of Interest: None Declared.