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Periodontology or periodontics (from
Ancient Greek Ancient Greek includes the forms of the Greek language used in ancient Greece and the ancient world from around 1500 BC to 300 BC. It is often roughly divided into the following periods: Mycenaean Greek (), Dark Ages (), the Archaic pe ...
, – 'around'; and , – 'tooth', genitive , ) is the specialty of
dentistry Dentistry, also known as dental medicine and oral medicine, is the branch of medicine focused on the teeth, gums, and mouth. It consists of the study, diagnosis, prevention, management, and treatment of diseases, disorders, and conditions of ...
that studies supporting structures of
teeth A tooth ( : teeth) is a hard, calcified structure found in the jaws (or mouths) of many vertebrates and used to break down food. Some animals, particularly carnivores and omnivores, also use teeth to help with capturing or wounding prey, ...
, as well as diseases and conditions that affect them. The supporting tissues are known as the periodontium, which includes the
gingiva The gums or gingiva (plural: ''gingivae'') consist of the mucosal tissue that lies over the mandible and maxilla inside the mouth. Gum health and disease can have an effect on general health. Structure The gums are part of the soft tissue l ...
(gums),
alveolar bone The alveolar process () or alveolar bone is the thickened ridge of bone that contains the tooth sockets on the jaw bones (in humans, the maxilla and the mandible). The structures are covered by gums as part of the oral cavity. The synonymous t ...
,
cementum Cementum is a specialized calcified substance covering the root of a tooth. The cementum is the part of the periodontium that attaches the teeth to the alveolar bone by anchoring the periodontal ligament.Illustrated Dental Embryology, Histology, ...
, and the
periodontal ligament The periodontal ligament, commonly abbreviated as the PDL, is a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which it sits. It inserts into root cementum one side and onto alveolar ...
. A periodontist is a dentist that specializes in the prevention, diagnosis and treatment of
periodontal disease Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main caus ...
and in the placement of dental implants.


The periodontium

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.


Gingivae

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 categorised 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.Clerehugh, V., Tugnait, A., & Genco, R. J. (2009). Periodontology at a glance. Chichester: John Wiley & Sons Ltd


Free gingiva

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 The gingival sulcus is an area of potential space between a tooth and the surrounding gingival tissue and is lined by sulcular epithelium. The depth of the sulcus (Latin for ''groove'') is bounded by two entities: apically by the gingival ...
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 The sulcular epithelium is that epithelium which lines the gingival sulcus.Carranza's Clinical Periodontology, W.B. Saunders, 2002, page 23. It is apically bounded by the junctional epithelium and meets the epithelium of the oral cavity at the h ...
; it begins at the gingival margin and ends at the base of the sulcus where the junctional epithelium and attached gingiva begins.


Attached gingiva

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 specialised protective barrier to microorganisms residing around the gingival sulcus. Collagen fibres bind the attached gingiva tightly to the underlying periodontium including the cementum and alveolar bone and vary in length and width, depending on the location in the oral cavity and on the individual.Newman, M., Takei, H. Klokkevold, P. R., Carranza, F. A. (2015). Carranza’s Clinical Periodontology (12th ed.). St. Louis: Elsevier IncWeinberg, M., Westphal, C., Froum, S. J., Palat, M. P., & Schoor, R. S. (2010). Comprehensive Periodontics for the Dental Hygienist (3rd ed.). Upper Saddle River, N.J.: Pearson Education The attached gingiva lies between the free gingival line or groove and the
mucogingival junction A mucogingival junction is an anatomical feature found on the intraoral mucosa. The mucosa of the cheeks and floor of the mouth are freely moveable and fragile, whereas the mucosa around the teeth and on the palate are firm and keratinized. Wher ...
. The attached gingiva dissipates functional and masticatory stresses placed on the gingival tissues during common activities such as
mastication Chewing or mastication is the process by which food is crushed and ground by teeth. It is the first step of digestion, and it increases the surface area of foods to allow a more efficient break down by enzymes. During the mastication process, ...
, tooth brushing and speaking.Gehrig, J., & Willmann, D. E. (2011). Foundations of Periodontics for the Dental Hygienist (3rd ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health. In health it is typically pale pink or coral pink in colour and may present with surface stippling or racial pigmentation.


Interdental gingiva

The interdental gingiva takes up the space beneath a tooth contact point, between two adjacent teeth. It is normally triangular or pyramidal in shape and is formed by two interdental papillae (lingual and facial). The middle or centre part of the interdental papilla is made up of attached gingiva, whereas the borders and tip are formed by the free gingiva. The central point between the interdental papillae is called the col. It is a valley-like or concave depression that lies directly beneath the contact point, between the facial and lingual papilla. However, the col may be absent if there is gingival recession or if the teeth are not contacting. The main purpose of the interdental gingiva is to prevent food impaction during routine mastication.


Alveolar Mucosa

This area of tissue is non-keratinized and is located beyond the
mucogingival junction A mucogingival junction is an anatomical feature found on the intraoral mucosa. The mucosa of the cheeks and floor of the mouth are freely moveable and fragile, whereas the mucosa around the teeth and on the palate are firm and keratinized. Wher ...
. It is less firmly attached and is redder than attached gingiva. It provides for the movement of cheek and lips.


Periodontal ligament

The
periodontal ligament The periodontal ligament, commonly abbreviated as the PDL, is a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which it sits. It inserts into root cementum one side and onto alveolar ...
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 Sharpey's fibres (bone fibres, or perforating fibres) are a matrix of connective tissue consisting of bundles of strong predominantly type I collagen fibres connecting periosteum to bone. They are part of the outer fibrous layer of periosteum, e ...
. The periodontal ligament is composed mostly of collagen fibres, however it also houses blood vessels and nerves within loose connective tissue. Mechanical loads that are placed on the teeth during mastication and other external forces are absorbed by the periodontal ligament, which therefore protects the teeth within their sockets.


Alveolar bone

In periodontal health, the
alveolar bone The alveolar process () or alveolar bone is the thickened ridge of bone that contains the tooth sockets on the jaw bones (in humans, the maxilla and the mandible). The structures are covered by gums as part of the oral cavity. The synonymous t ...
surrounds the teeth and forms the bony socket that supports each tooth. The buccal and lingual plates and lining of the sockets are composed of thin, yet dense compact or cortical bone. Within the cortical plates and dental sockets lies cancellous bone, a spongy or trabecular-type bone which is less dense than compact bone.


Cementum

Cementum Cementum is a specialized calcified substance covering the root of a tooth. The cementum is the part of the periodontium that attaches the teeth to the alveolar bone by anchoring the periodontal ligament.Illustrated Dental Embryology, Histology, ...
is the outer layer of the tooth root; it overlies the
dentine Dentin () (American English) or dentine ( or ) (British English) ( la, substantia eburnea) is a calcified tissue of the body and, along with enamel, cementum, and pulp, is one of the four major components of teeth. It is usually covered by e ...
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.


Gingival diseases

Gingivitis Gingivitis is a non-destructive disease that causes inflammation of the gums. The most common form of gingivitis, and the most common form of periodontal disease overall, is in response to bacterial biofilms (also called plaque) that is attac ...
is a common condition that affects the gingiva or mucosal tissues that surround the teeth. The condition is a form of periodontal disease; however, it is the least devastating, in that it does not involve irreversible damage or changes to the periodontium (gingiva, periodontal ligament, cementum or alveolar bone). It is commonly detected by patients when gingival bleeding occurs spontaneously during brushing or eating. It is also characterised by generalised inflammation, swelling, and redness of the mucosal tissues. Gingivitis is typically painless and is most commonly a result of plaque
biofilm A biofilm comprises any syntrophic consortium of microorganisms in which cells stick to each other and often also to a surface. These adherent cells become embedded within a slimy extracellular matrix that is composed of extracellular po ...
accumulation, in association with reduced or poor
oral hygiene Oral hygiene is the practice of keeping one's mouth clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and cleaning between the teeth. It is important that oral hygiene be carried ou ...
. Other factors may increase a person's risk of gingivitis, including but not limited to systemic conditions such as uncontrolled diabetes mellitus and some medications. The signs and symptoms of gingivitis can be reversed through improved oral hygiene measures and increased plaque disruption. If left untreated, gingivitis has the potential to progress to periodontitis and other related diseases that are more detrimental to periodontal and general health.


Periodontal diseases

Periodontal disease Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main caus ...
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 The red complex is a group of bacteria that are categorized together based on their association with severe forms of periodontal disease. The red complex—among a number of other complexes—were classified by Sigmund Socransky in 1998. The thr ...
bacteria (e.g.,
P. gingivalis ''Porphyromonas gingivalis'' belongs to the phylum ''Bacteroidota'' and is a nonmotile, Gram-negative, rod-shaped, anaerobic, pathogenic bacterium. It forms black colonies on blood agar. It is found in the oral cavity, where it is implicated i ...
,
T. forsythia ''Tannerella forsythia'' is an anaerobic, Gram-negative bacterial species of the Bacteroidota phylum. It has been implicated in periodontal diseases and is a member of the red complex of periodontal pathogens. ''T. forsythia'' was previously na ...
, and
T. denticola ''Treponema denticola'' is a Gram-negative, obligate anaerobic, motile and highly proteolytic spirochete bacterium. It is one of four species of oral spirochetes to be reliably cultured, the others being ''Treponema pectinovorum, Treponema soc ...
) 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 The alveolar process () or alveolar bone is the thickened ridge of bone that contains the tooth sockets on the jaw bones (in humans, the maxilla and the mandible). The structures are covered by gums as part of the oral cavity. The synonymous t ...
loss and tooth loss. , 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 Tooth decay, also known as cavities or caries, is the breakdown of teeth due to acids produced by bacteria. The cavities may be a number of different colors from yellow to black. Symptoms may include pain and difficulty with eating. Complicat ...
) 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. Periodontal diseases can be caused by a variety of factors, the most prominent being dental plaque. Dental plaque forms a bacterial biofilm on the tooth surface; if not adequately removed from the tooth surface in close proximity to the gingiva, a host-microbial interaction gets underway. This results in the imbalance between host and bacterial factors which can in turn result in a change from health to disease. Other local or systemic factors can result in or further progress the manifestation of periodontal disease. Other factors can include age, socio-economic status, oral hygiene education and diet. Systemic factors may include uncontrolled diabetes or tobacco smoking. Signs and symptoms of periodontal disease: bleeding gums,
gingival recession Gingival recession, also known as receding gums, is the exposure in the roots of the teeth caused by a loss of gum tissue and/or retraction of the gingival margin from the crown of the teeth.halitosis Bad breath, also known as halitosis, is a symptom in which a noticeably unpleasant breath odour is present. It can result in anxiety among those affected. It is also associated with depression and symptoms of obsessive compulsive disorder. ...
(bad breath), mobile teeth, ill-fitting dentures and buildup of plaque and
calculus Calculus, originally called infinitesimal calculus or "the calculus of infinitesimals", is the mathematics, mathematical study of continuous change, in the same way that geometry is the study of shape, and algebra is the study of generalizati ...
. Individual risk factors include: gender, smoking and alcohol consumption, diabetes, obesity and
metabolic syndrome Metabolic syndrome is a clustering of at least three of the following five medical conditions: abdominal obesity, high blood pressure, high blood sugar, high serum triglycerides, and low serum high-density lipoprotein (HDL). Metabolic syndro ...
, osteoporosis and Vitamin D conditions, stress and genetic factors. In 1999 the
American Academy of Periodontology The American Academy of Periodontology (AAP) is the non-profit membership association for periodontists-dental professionals specializing in the prevention, diagnosis, and treatment of diseases affecting the gums and supporting structures of the te ...
(AAP) reworked the existing classification of periodontal diseases from 1989 to alter the weaknesses present. The old classification placed too much emphasis on the age of disease onset and rate of progression, which are often difficult to determine. The 1999 classification was published in the Annals of Periodontology. Below is the abbreviated version of the 1999 classification of periodontal diseases and conditions. I. Gingival Diseases
A. Dental plaque-induced gingival diseases
B. Non-plaque-induced gingival lesions II. Chronic Periodontitis
(slight: 1–2 mm CAL; moderate: 3–4 mm CAL; severe: > 5 mm CAL) A. Localised
B. Generalised (> 30% of sites are involved) III. Aggressive Periodontitis
(slight: 1–2 mm CAL; moderate: 3–4 mm CAL; severe: > 5 mm CAL) A. Localised
B. Generalised (> 30% of sites are involved) IV. Periodontitis as a Manifestation of Systemic Diseases
A. Associated with haematological disorders
B. Associated with genetic disorders
C. Not otherwise specified V. Necrotizing Periodontal Diseases
A. Necrotizing ulcerative gingivitis
B. Necrotizing ulcerative periodontitis VI. Abscesses of the Periodontium
A. Gingival abscess
B. Periodontal abscess
C. Pericoronal abscess VII. Periodontitis Associated With Endodontic Lesions
A. Combined periodontic-endodontic lesions
VIII. Developmental or Acquired Deformities and Conditions
A. Localised tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis
B. Mucogingival deformities and conditions around teeth
C. Mucogingival deformities and conditions on edentulous ridges
D. Occlusal trauma In 2018 a new classification of periodontal disease was announced. It was determined that the previous AAP 1999 classification did not cater for the needs of patients with peri-implant diseases and conditions. The new 2018 classification of periodontal and peri-implant diseases and conditions is as follows: Periodontal Health, Gingival Diseases and Conditions:
Periodontal Health and Gingival Health
Gingivitis: Dental-Biofilm Induced
Gingival Diseases: Non-Dental Biofilm-Induced
Periodontitis:
Necrotizing Periodontal Diseases
Periodontitis
Periodontitis as a Manifestation of Systemic Disease
Other Conditions Affecting The Periodontium:
Systemic Diseases or conditions affecting the periodontal supporting tissues
Periodontal Abscesses and Endodontic-Periodontal Lesions
Mucogingival Deformities and Conditions
Traumatic Occlusal Forces
Tooth and Prosthesis Related Factors
Peri-Implant Diseases and Conditions:
Peri-Implant Health
Peri-Implant Mucositis
Peri-implantitis
Peri-Implant Soft and Hard Tissue Deficiencies


Prevention

The most effective prevention method is what can be achieved by the patient at home, for example, using the correct
tooth brushing Tooth brushing is the act of scrubbing teeth with a toothbrush, usually equipped with toothpaste. Interdental cleaning (with floss or an interdental brush) can be useful with tooth brushing, and together these two activities are the primary me ...
technique,
interdental cleaning Interdental cleaning or interproximal cleaning is part of oral hygiene where the aim is to clean the areas in between the teeth, otherwise known as the proximal surfaces of teeth. This is to remove the dental plaque in areas a toothbrush cannot rea ...
aids such as interdental brushes or floss and using a fluoridated
toothpaste Toothpaste is a paste or gel dentifrice used with a toothbrush to clean and maintain the aesthetics and health of teeth. Toothpaste is used to promote oral hygiene: it is an abrasive that aids in removing dental plaque and food from the teeth, ...
. It is also advised that patients receive bi-annual check ups from their dental health provider along with thorough cleaning.


Treatment

Along with specialist periodontist treatment, a general dentist or
dental hygienist A dental hygienist or oral hygienist is a licensed dental professional, registered with a dental association or regulatory body within their country of practice. Prior to completing clinical and written board examinations, registered dental hygien ...
can perform routine scale and cleans using either hand instruments or an ultrasonic scaler (or a combination of both). The practitioner can also prescribe specialised plaque-removal techniques (tooth brushing, interdental cleaning). The practitioner can also perform a plaque index to indicate to the patient areas of plaque they are not removing on their own. This can be removed through the procedure of a dental prophylaxis.


Aetiology

The primary aetiological factor for periodontal disease is plaque biofilm of dental biofilm. A dental biofilm is a community of microorganisms attached to a hard, non-shedding surface. In the oral cavity, hard non-shedding surfaces include teeth, dental restorative materials and fixed or removable dental appliance such dentures. It is this adherence to non-shedding surfaces that allows bacteria in a dental biofilm to have unique characteristics of clinical significance. The stages of biofilm formation: #Formation of an acquired pellicle: involves selective absorption of salivary and GCF molecules through an electrostatic affinity with
hydroxyapatite Hydroxyapatite, also called hydroxylapatite (HA), is a naturally occurring mineral form of calcium apatite with the formula Ca5(PO4)3(OH), but it is usually written Ca10(PO4)6(OH)2 to denote that the crystal unit cell comprises two entities. ...
. #Bacterial transportation: bacteria will readily adhere to the acquired pellicle through
adhesins Adhesins are cell-surface components or appendages of bacteria that facilitate adhesion or adherence to other cells or to surfaces, usually in the host they are infecting or living in. Adhesins are a type of virulence factor. Adherence is an essent ...
, proteins and enzymes within one to two hours. #Reversible interaction: there is electrostatic attraction or hydrophobic interaction between microorganisms and the tooth surface. #Irreversible interaction: bacterial adhesins recognise specific host receptors such as pili and outer membrane proteins. The different species of bacteria bind together and require specific receptors to interact with the pellicle. #Co-adehsion: there is a natural affinity for oral microorganisms to adhere to one another which is termed co‐adhesion. Co-adhesion involves the adherence of planktonic or single culture cells to already attached organisms on a surface. The organisms which make first contact with the surface and allow the platform for later co-adhesion of bacteria are called early colonisers; they facilitate the formation of complex multispecies dental biofilms. #Multiplication: through continued growth and maturation of existing plaque micro-organisms and the further recruitment of later colonisers. #Climax community (homeostasis): after a prolonged period of stability, the bacterial community has sufficient nutrients and protection to survive. These complex biofilms are usually found in hard to cleanse areas. Nutrition is provided from dietary consumption of the host for supra-gingival biofilm organisms and from blood and GCF for the sub gingival biofilm organisms. #Detachment: from one surface to another or within biofilm allows colonisation at remote sites. Bacteria contained within the biofilm are protected by a slimy extracellular polysaccharide matrix which helps to protect them from the outside environment and chemotherapeutics agents. An example of a chemotherapeutic agent is an antiseptic such as chlorhexidine mouth-rinse or antibiotics. Thus, antibiotics are not generally used in the treatment of periodontal disease, unlike other bacterial infections around the body. The most effective way to control the plaque biofilm is via mechanical removal such as toothbrushing, interdental cleaning or periodontal debridement performed by a dental professional.


Pathogenesis

An individual's host response plays an important role in the
pathogenesis Pathogenesis is the process by which a disease or disorder develops. It can include factors which contribute not only to the onset of the disease or disorder, but also to its progression and maintenance. The word comes from Greek πάθος ''pat ...
of periodontal disease. Even in a mouth where the gingiva appear healthy, there is constant low-level inflammatory response facilitated by the host to manage the constant bacterial load of plaque micro-organisms. Leukocytes and neutrophils are the main cells that phagocytose bacteria found in the gingival crevice or pocket. They migrate from the tissues in a specialised exudate called gingival crevicular fluid also known as GCF. Neutrophils are recruited to the gingival crevice area as they are signalled to by molecules released by plaque microorganisms. Damage to epithelial cells releases cytokines which attract leukocytes to assist with the inflammatory response. The balance between normal cell responses and the beginning of gingival disease is when there is too much plaque bacteria for the neutrophils to phagocytose and they degranulate, releasing toxic enzymes that cause tissue damage. This appears in the mouth as red, swollen and inflamed gingiva which may bleed when probed clinically or during tooth brushing. These changes are due to increased capillary permeability and an influx of inflammatory cells into the gingival tissues. When gingival disease remains established and the aetiology is not removed, there is further recruitment of cells such as macrophages, which assist with the phagocytic digestion of bacteria, and lymphocytes, which begin to initiate an immune response. Pro-inflammatory cytokines are produced inside the gingival tissues and further escalate inflammation, which impacts the progression of chronic systemic inflammation and disease. The result is collagen breakdown, infiltrate accumulation as well as collagen breakdown in the periodontal ligament and alveolar bone resorption. At this stage, the disease has progressed from gingivitis to periodontitis and the loss of supporting periodontium structure is irreversible.


Risk factors

A risk factor is a variable that in health can be defined as "a characteristic associated with an increased rate of a subsequently occurring disease". Risk factors are variables that contribute to disease, rather than being factors that induce disease. Risk factors may be seen as modifiable and non-modifiable. Modifiable risk factors are often behavioural in nature and can be changed by the individual or environmental circumstances, whereas non-modifiable factors are usually intrinsic to an individual's genetics and cannot be changed. To determine risk factors for a disease, evidence-based research and studies are needed for evidence, with longitudinal studies giving the most statistically significant outcomes and the best reliability for determining risk factors. Risk factors often coexist with other variables, rarely acting alone to contribute to a disease. Risk factors can be genetic, environmental, behavioural, psychological, and demographic in nature. There are many risk factors that contribute to placing an individual at higher risk for developing gingival and periodontal diseases. However, the only aetiological factor for periodontal disease is bacterial plaque, or biofilm. Identification of one's risk factors plays an important role in the diagnosis, treatment and management of periodontal diseases. It was previously believed that each human being had the same risk of developing periodontal diseases, but through the identification and classification of risk factors, it has become well understood that each individual will have a differing array of risk factors that generate susceptibility and contribute to severity of periodontal disease. Individual, modifiable risk factors include: *
Tobacco smoking Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is beli ...
: tobacco smoking is firmly established as a major risk factor for periodontal disease, with the relationship between smoking exposure and periodontal tissue destruction being supported strongly by various research papers. Smoking decreases the healing abilities of the oral tissues by destroying blood vessels and supply and preventing essential immune-defence organisms from penetrating the tissues. Therefore, pathogenic bacteria are able to destruct the periodontal tissues more rapidly and escalate the severity of disease. Although the clinical signs of inflammation are less pronounced, smokers have a larger portion of sites with deep pocketing depths and loss of clinical attachment when compared with nonsmokers. Smoking cessation and counselling is an integral part of a dental professional's work with periodontal disease patients. Smoking cessation has been proven to prevent progression of periodontal disease and to return the oral microflora to a less pathogenic microbial state. * Alcohol consumption: more research needs to be conducted in the form of longitudinal studies on the effects of alcohol on the periodontal tissues. However, current studies suggest that alcohol consumption moderately increases one's risk for progression of periodontal disease. *
Diabetes Mellitus Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
: diabetes falls under the category of modifiable risk factors as although it cannot be cured, it can be controlled, which greatly helps periodontal disease control. A clear two-way relationship has been established with blood glucose control directly affecting periodontal disease severity and progression, and vice versa. Periodontal disease patients with diabetes mellitus also have poorer healing abilities than those without diabetes, and hence are at an increased risk for more severe diseases if blood glucose control is poor and when healing abilities are affected by systemic disease. *
Obesity Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's ...
and
vitamin D deficiency Vitamin D deficiency or hypovitaminosis D is a vitamin D level that is below normal. It most commonly occurs in people when they have inadequate exposure to sunlight, particularly sunlight with adequate ultraviolet B rays (UVB). Vitamin D defic ...
are both risk factors for periodontal disease that go hand in hand. Obesity is generally associated with a decreased consumption of fruits and vegetables, with an increase in foods high in fat, salt and sugar. Having a poor diet not only contributes to obesity but also results in a lack of essential nutrients, including vitamin C, D, and calcium, which all play important roles in ensuring a healthy immune system and healthy oral tissues and bone. * Poor
oral hygiene Oral hygiene is the practice of keeping one's mouth clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and cleaning between the teeth. It is important that oral hygiene be carried ou ...
: as plaque is the only aetiological factor for periodontal disease, poor oral hygiene is the most prominent risk factor in initiating, progressing and determining severity of disease. Performing brushing and interdental cleaning is perhaps one of the most effective ways at removing dental plaque biofilm and prevention of periodontal diseases. *
Cardiovascular disease Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, hea ...
: not only does poor oral hygiene have a clear relationship with an increased risk of developing cardiovascular disease, high concentrations of cholesterol and the mechanisms of oral bacteria in the process of atherosclerosis may increase in individuals with chronic periodontitis. *
Stress Stress may refer to: Science and medicine * Stress (biology), an organism's response to a stressor such as an environmental condition * Stress (linguistics), relative emphasis or prominence given to a syllable in a word, or to a word in a phrase ...
: various studies have demonstrated that individuals under psychological, ongoing chronic stress are more likely to have clinical attachment loss and decreased levels of alveolar bone due to periodontal destruction. This is due to the increased production of certain immune cells and interleukins, which decrease the defensive mechanisms against pathogenic bacteria, therefore increasing chances of developing periodontal disease. *
Pregnancy Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but ...
: studies have shown that the oral tissues are affected and altered during pregnancy due to a decreased immune response and increased vascular blood supply and volume systemically. it is important to note that pregnancy does not cause gingival and periodontal diseases but may exacerbate the inflammatory response to a pre-existing disease. It is also important to note that pregnancy does not detract minerals from the oral tissues or teeth as previously thought and heard in old wives' tales. Existing disease often presents during pregnancy due to an altered oral environment, and not merely due to pregnancy causing disease. These effects can be prevented by good oral hygiene through toothbrushing and interdental cleaning. Non-modifiable risk factors include: *
Genetics Genetics is the study of genes, genetic variation, and heredity in organisms.Hartl D, Jones E (2005) It is an important branch in biology because heredity is vital to organisms' evolution. Gregor Mendel, a Moravian Augustinian friar work ...
and the host response have been shown to play an important role in periodontal disease development in studies on identical twins and isolated indigenous populations. Periodontal disease also may result due to an abnormal or decreased immune response, rather than aggressive properties of bacterial pathogens. *
Osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone a ...
: in individuals with osteoporosis, studies have shown that alveolar bone is less dense than in a healthy adult. However, this does not demonstrate a relationship with periodontal pathogens or clinical attachment loss, therefore more research is needed to investigate if osteoporosis is a true risk factor for periodontal disease. * Drug-induced disorders: many drugs and medications can have an adverse effect on the periodontal tissues, through contributing to various oral conditions such as dry mouth and
gingival hyperplasia Gingival enlargement is an increase in the size of the gingiva (gums). It is a common feature of gingival disease. Gingival enlargement can be caused by a number of factors, including inflammatory conditions and the side effects of certain medica ...
. It is crucial that dental professionals ensure that poly-pharmacy patients have medical history reviewed at each visit to correctly evaluate the patient's risk and determine appropriate course of action for dental treatment. * Haematological disorders: important cells and nutrients carried in the blood to the periodontal tissues are crucial for the tissues' defence mechanisms and response to toxins and pathogens, gas exchange and efficient hemostasis. Therefore, red blood cells have a pivotal role in maintaining the health of the periodontium, meaning haematological disorders can have profound detriment to the periodontal tissues and the onset of disease. Risk characteristics must be considered in conjunction with risk factors as variables that may also contribute to increasing or decreasing one's chances of developing periodontal disease. Numerous studies show that age,
gender Gender is the range of characteristics pertaining to femininity and masculinity and differentiating between them. Depending on the context, this may include sex-based social structures (i.e. gender roles) and gender identity. Most culture ...
, race,
socioeconomic status Socioeconomic status (SES) is an economic and sociological combined total measure of a person's work experience and of an individual's or family's economic access to resources and social position in relation to others. When analyzing a family's ...
,
education Education is a purposeful activity directed at achieving certain aims, such as transmitting knowledge or fostering skills and character traits. These aims may include the development of understanding, rationality, kindness, and honesty ...
and
genetics Genetics is the study of genes, genetic variation, and heredity in organisms.Hartl D, Jones E (2005) It is an important branch in biology because heredity is vital to organisms' evolution. Gregor Mendel, a Moravian Augustinian friar work ...
also have strong relationships on influencing periodontal disease. Periodontal disease is multifactorial, requiring dental and oral health professionals to have a clear and thorough understanding of the risk factors and their mechanisms in order to implement effective disease management in clinical practice.


Diagnosis

Periodontitis and associated conditions are recognised as a wide range of inflammatory diseases that have unique symptoms and varying consequences. In order to identify disease, classification systems have been used to categorise periodontal and gingival diseases based on their severity,
aetiology Etiology (pronounced ; alternatively: aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek (''aitiología'') "giving a reason for" (, ''aitía'', "cause"); and ('' -logía''). More completely, e ...
and treatments. Having a system of classification is necessary to enable dental professionals to give a label to a patient's condition and make a ''periodontal diagnosis.'' A diagnosis is reached by firstly undertaking thorough examination of the patient's medical, dental and social histories, to note any predisposing risk factors (see above) or underlying systemic conditions. Then, this is combined with findings from a thorough intra and extra oral examination. Indices such as the periodontal screening record (PSR) and the Community Periodontal Index of Treatment Needs (CPITN) are also used in making a diagnosis and to order or classify the severity of disease. If disease is identified through this process, then a full periodontal analysis is performed, often by dental hygienists, oral health therapists or specialist periodontists. This involves full mouth periodontal probing and taking measurements of pocket depths, clinical attachment loss and recession. Along with this other relevant parameters such as plaque, bleeding, furcation involvement and mobility are measured to gain an overall understanding of the level of disease.
Radiographs Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...
may also be performed to assess alveolar bone levels and levels of destruction.


Treatment


Phases of periodontal therapy

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 Prognosis ( Greek: πρόγνωσις "fore-knowing, foreseeing") is a medical term for predicting the likely or expected development of a disease, including whether the signs and symptoms will improve or worsen (and how quickly) or remain sta ...
of the patient, in comparison to indecisive treatment plan without a clear goal.


Phase I therapy (initial therapy – disease control phase)


=Non-surgical phase

= The non-surgical phase is the initial phase in the sequence of procedures required for periodontal treatment. This phase aims to reduce and eliminate any gingival inflammation by removing
dental plaque Dental plaque is a biofilm of microorganisms (mostly bacteria, but also fungi) that grows on surfaces within the mouth. It is a sticky colorless deposit at first, but when it forms tartar, it is often brown or pale yellow. It is commonly found be ...
and
calculus Calculus, originally called infinitesimal calculus or "the calculus of infinitesimals", is the mathematics, mathematical study of continuous change, in the same way that geometry is the study of shape, and algebra is the study of generalizati ...
, restoration of
tooth decay Tooth decay, also known as cavities or caries, is the breakdown of teeth due to acids produced by bacteria. The cavities may be a number of different colors from yellow to black. Symptoms may include pain and difficulty with eating. Complicatio ...
and correction of defective restoration, as these all contribute to gingival inflammation, also known as
gingivitis Gingivitis is a non-destructive disease that causes inflammation of the gums. The most common form of gingivitis, and the most common form of periodontal disease overall, is in response to bacterial biofilms (also called plaque) that is attac ...
. Phase I consists of treatment of emergencies, antimicrobial therapy, diet control, patient education and motivation, correction of
iatrogenic Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence. "Iatrogenic", ''Merriam-Webster.com'', Merriam-Webster, Inc., accessed 27 ...
factors, deep
caries Tooth decay, also known as cavities or caries, is the breakdown of teeth due to acids produced by bacteria. The cavities may be a number of different colors from yellow to black. Symptoms may include pain and difficulty with eating. Complicati ...
, hopeless teeth, preliminary scaling, temporary splinting, occlusal adjustment, minor
orthodontic Orthodontics is a dentistry specialty that addresses the diagnosis, prevention, management, and correction of mal-positioned teeth and jaws, and misaligned bite patterns. It may also address the modification of facial growth, known as dentofacial ...
tooth movement and
debridement Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy. I ...
.


=Re-evaluation phase

= During this phase, patients are seen 3–6 weeks after initial therapy; it is required to re-evaluate the steps carried out after the phase I therapy. Usually 3–6 week re-evaluation is crucial in severe cases of periodontal disease. The elements which are required to be re-evaluated are the results of initial therapy (phase I therapy),
oral hygiene Oral hygiene is the practice of keeping one's mouth clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and cleaning between the teeth. It is important that oral hygiene be carried ou ...
and status, bleeding and plaque scores and a review of
diagnosis Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine "cause and effect". In systems engin ...
and
prognosis Prognosis ( Greek: πρόγνωσις "fore-knowing, foreseeing") is a medical term for predicting the likely or expected development of a disease, including whether the signs and symptoms will improve or worsen (and how quickly) or remain sta ...
and modification of the whole treatment plan if necessary.


Phase II therapy (surgical phase)

After post-phase I, it is necessary to evaluate the requirement of periodontium for surgery. Factors identifying if the surgical phase is required are:
periodontal pocket Gingival and periodontal pockets (also informally referred to as gum pockets) are dental terms indicating the presence of an abnormal depth of the gingival sulcus near the point at which the gingival tissue contacts the tooth. Tooth gingival inte ...
management in specific situations, irregular bony contours or deep craters, areas of suspected incomplete removal of local deposits, degree II and III furcation involvements,
distal Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position pro ...
areas of last molars with expected
mucogingival junction A mucogingival junction is an anatomical feature found on the intraoral mucosa. The mucosa of the cheeks and floor of the mouth are freely moveable and fragile, whereas the mucosa around the teeth and on the palate are firm and keratinized. Wher ...
problems, persistent inflammation, root coverage and removal of gingival enlargement.


Phase III therapy (restorative phase)

During this phase, any defects need to be restored with removable or fixed through dental prosthesis, prosthodontics, or other restoration processes.


Phase IV therapy (maintenance phase)

The last phase of periodontal therapy requires the preservation of periodontal health. In this phase, patients are required to re-visit through a scheduled plan for maintenance care to prevent any re-occurrence of the disease. The maintenance phase constitutes the long-term success for periodontal treatment, thus contributing to a long relationship between the
oral health therapist A dental hygienist or oral hygienist is a licensed dental professional, registered with a dental association or regulatory body within their country of practice. Prior to completing clinical and written board examinations, registered dental hygien ...
/
dentist A dentist, also known as a dental surgeon, is a health care professional who specializes in dentistry (the diagnosis, prevention, management, and treatment of diseases and conditions of the oral cavity and other aspects of the craniofacial c ...
/
periodontist Periodontology or periodontics (from Ancient Greek , – 'around'; and , – 'tooth', genitive , ) is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting ...
and the
patient A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other heal ...
.


Periodontal and restorative interface

The
prognosis Prognosis ( Greek: πρόγνωσις "fore-knowing, foreseeing") is a medical term for predicting the likely or expected development of a disease, including whether the signs and symptoms will improve or worsen (and how quickly) or remain sta ...
of the restorative treatment is determined by the periodontal health. The goals for establishing periodontal health prior to restorative treatment are as follows: # Periodontal treatment should be managed to assure the establishment of firm gingival margin prior to tooth preparation for restoration. Absence of bleeding tissue during restorative manipulation provides accessibility and aesthetic outcome. # Certain periodontal treatment is formulated to increase sufficient tooth length for retention. Failure to accomplish these methods prior restorations can lead to the complexity or risk of failure of treatment such as impression making, tooth preparation and restoration. # Periodontal therapy should follow restorative method as the resolution of gingival inflammation may result in the repositioning of teeth or in soft tissue and mucosal changes.


Standard of periodontal treatment

Non-surgical therapy is the golden standard of periodontal therapy which consists of
debridement Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy. I ...
with a combination of
oral hygiene Oral hygiene is the practice of keeping one's mouth clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and cleaning between the teeth. It is important that oral hygiene be carried ou ...
instructions and patient motivation. It mainly focuses on the elimination and reduction of putative
pathogens In biology, a pathogen ( el, πάθος, "suffering", "passion" and , "producer of") in the oldest and broadest sense, is any organism or agent that can produce disease. A pathogen may also be referred to as an infectious agent, or simply a ger ...
and shifting the microbial flora to a favourable environment to stabilise periodontal disease. 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. It requires a few appointments, depending on time and clinician skills, for effective removal of supragingival and subgingival calculus, when
periodontal pockets Periodontology or periodontics (from Ancient Greek , – 'around'; and , – 'tooth', genitive , ) is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supportin ...
are involved. It can assist in periodontal healing and reduce periodontal pocketing by changing the subgingival ecological environment. Prevention of periodontal disease and maintenance of the periodontal tissues following initial treatment requires the patient's ability to perform and maintain effective dental plaque removal. This requires the patient to be motivated in improving their oral hygiene and requires behaviour change in terms of
tooth brushing Tooth brushing is the act of scrubbing teeth with a toothbrush, usually equipped with toothpaste. Interdental cleaning (with floss or an interdental brush) can be useful with tooth brushing, and together these two activities are the primary me ...
, interdental cleaning, and other oral hygiene techniques. Personal oral hygiene is often considered an essential aspect of controlling
chronic periodontitis Chronic periodontitis is one of the seven categories of periodontitis as defined by the American Academy of Periodontology 1999 classification system. Chronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation ...
. Research has shown that it is important to appreciate the motivation of the patient behaviour changes that have originated from the patient. Patients must want to improve their oral hygiene and feel confident that they have the skills to do so. It is crucial for the clinician to encourage patient changes and to educate the patient appropriately.
Motivational interviewing Motivational interviewing (MI) is a counseling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick. It is a directive, client-centered counseling style for eliciting behavior change by helping clients to e ...
is a good technique to ask open-ended questions and express empathy towards the patient.


Role of the oral health therapist

An
oral health therapist A dental hygienist or oral hygienist is a licensed dental professional, registered with a dental association or regulatory body within their country of practice. Prior to completing clinical and written board examinations, registered dental hygien ...
is a member of the dental team who is dual-qualified as a
dental hygienist A dental hygienist or oral hygienist is a licensed dental professional, registered with a dental association or regulatory body within their country of practice. Prior to completing clinical and written board examinations, registered dental hygien ...
and dental therapist. They work closely with dentists and a number of dental specialists including Periodontists. It is common for the oral health therapist to be involved in the treatment of gingival and periodontal diseases for patients. Their scope of practice in this area includes oral health assessment, diagnosis, treatment and maintenance and referral where necessary. They also have expertise in providing oral health education and promotion to support the patient to maintain their at-home oral care. 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 minimisation. This allows the dental team to work more competently and effectively as dentists can manage more complex treatments or significantly medically compromised patients.


Periodontist

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 Periodontal surgery is a form of dental surgery that prevents or corrects anatomical, traumatic, developmental, or plaque-induced defects in the bone, gingiva, or alveolar mucosa. The objectives of this surgery include accessibility of instruments ...
, implant surgery and other complex periodontal procedures.American Academy of Periodontology. (2019). What is a periodontist?. Retrieved from https://www.perio.org/consumer/what-is-a-periodontist List of procedures performed by a periodontist: * non-surgical treatments * gum graft surgery * laser treatment * regenerative procedures * dental crown lengthening * dental implants * pocket reduction procedures * plastic surgery procedures


Training

Before applying to any postgraduate training program in periodontology, one must first complete a dental degree.


Australia

Australian programs are accredited by the Australian Dental Council (ADC) and are three years in length and culminate with either a
master's degree A master's degree (from Latin ) is an academic degree awarded by universities or colleges upon completion of a course of study demonstrating mastery or a high-order overview of a specific field of study or area of professional practice.
(MDS) or a Doctor of Clinical Dentistry degree (DClinDent). Fellowship can then be obtained with the
Royal Australasian College of Dental Surgeons The Royal Australasian College of Dental Surgeons (RACDS) is a postgraduate professional education body established in 1965 to provide a broad range of activities to enhance the professional development of both general and specialist dentists thr ...
, FRACDS (Perio).


Canada

Canadian programs are accredited by the Commission on Dental Accreditation of Canada 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. To further specialise into periodontics, accredited dentists are required to undertake a specialty core knowledge examination and complete a postgraduate degree.


Europe

Although each European country has its own independent system, an umbrella organisation—the European Federation of Periodontology (EFP)—has the ability to accredit post-graduate programs according to specific guidelines. The EFP awards a certificate of specialized training in periodontology, periodontics and implant dentistry to every successful European candidate after three years of full-time training in an accredited post-graduate program. The graduate programs that have been approved are the following: ,
University of Bern The University of Bern (german: Universität Bern, french: Université de Berne, la, Universitas Bernensis) is a university in the Swiss capital of Bern and was founded in 1834. It is regulated and financed by the Canton of Bern. It is a compreh ...
,
Sahlgrenska University Hospital The Sahlgrenska University Hospital ( Swedish: ''Sahlgrenska Universitetssjukhuset'') is a hospital network associated with the Sahlgrenska Academy at the University of Gothenburg in Gothenburg, Sweden. With 17,000 employees the hospital is the ...
, Institute for Postgraduate Dental Education Jönköping, UCL Eastman Dental Institute,
University of Louvain A university () is an institution of higher (or tertiary) education and research which awards academic degrees in several academic disciplines. Universities typically offer both undergraduate and postgraduate programs. In the United States, the ...
(UCLouvain), University Complutense in Madrid,
Trinity College Dublin , name_Latin = Collegium Sanctae et Individuae Trinitatis Reginae Elizabethae juxta Dublin , motto = ''Perpetuis futuris temporibus duraturam'' (Latin) , motto_lang = la , motto_English = It will last i ...
,
University of Strasbourg The University of Strasbourg (french: Université de Strasbourg, Unistra) is a public research university located in Strasbourg, Alsace, France, with over 52,000 students and 3,300 researchers. The French university traces its history to the ea ...
in
France France (), officially the French Republic ( ), is a country primarily located in Western Europe. It also comprises of Overseas France, overseas regions and territories in the Americas and the Atlantic Ocean, Atlantic, Pacific Ocean, Pac ...
, Paris Diderot University at Rothschild hospital.


India

Periodontics is offered as a specialization field of dentistry in India. Periodontists attend a Master of Dental Surgery (M.D.S.) program affiliated with dental schools in India. The minimum qualification required for the M.D.S. degree is a Bachelor of Dental Surgery. A majority of dental schools in India offer M.D.S. degrees specializing in periodontology. The course is three years and students are trained for
implantology A dental implant (also known as an endosseous implant or fixture) is a prosthesis that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown, bridge, denture, or facial prosthesis or to act as an orthodont ...
as well as diagnosis and treatment of peri-implant diseases along with periodontology.


United Kingdom

The British Society of Periodontology exists to promote the art and science of periodontology. Their membership includes specialist practitioners, periodontists, general dentists, consultants and trainees in restorative dentistry, clinical academics, dental hygienists and therapists, specialist trainees in periodontology and many others. Specialist training in periodontics in the UK is either a three-year full-time program or four years at three days per week. At the end of the training, candidates are awarded a Master of Clinical Dentistry (MClinDent) before being entered on the specialist list held by the
General Dental Council The General Dental Council (GDC) is an organisation which regulates dental professionals in the United Kingdom. It keeps an up-to-date register of all qualified dentists and other dental care professionals such as: dental hygienists, dental thera ...
.


United States

The
American Dental Association The American Dental Association (ADA) is an American professional association established in 1859 which has more than 161,000 members. Based in the American Dental Association Building in the Near North Side of Chicago, the ADA is the world's ...
(ADA)-accredited programs are a minimum of three years in length. According to the
American Academy of Periodontology The American Academy of Periodontology (AAP) is the non-profit membership association for periodontists-dental professionals specializing in the prevention, diagnosis, and treatment of diseases affecting the gums and supporting structures of the te ...
, 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 specialty of
oral medicine An oral medicine or stomatology doctor (or stomatologist) has received additional specialized training and experience in the diagnosis and management of oral mucosal abnormalities (growths, ulcers, infection, allergies, immune-mediated and autoim ...
. Following successful completion of post-graduate training a periodontist becomes board-eligible for the American Board of Periodontology examination. Successful completion of board certification results in Diplomate status in the American Board of Periodontology.


Maintenance

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:


Gingivitis

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.


Necrotising ulcerative gingivitis (NUG)

Also acute necrotising ulcerative gingivitis and necrotising 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 Chlorhexidine (CHX) (commonly known by the salt forms chlorhexidine gluconate and chlorhexidine digluconate (CHG) or chlorhexidine acetate) is a disinfectant and antiseptic that is used for skin disinfection before surgery and to sterilize surgi ...
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.


Chronic periodontitis

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 characterised 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.


Aggressive periodontitis

Aggressive periodontitis involves inflammation of the gingiva and rapid and severe destruction of the periodontal ligament, alveolar bone and surrounding structures. Unlike chronic periodontitis, it often occurs in patients with good oral health and plaque control and can be genetic. Patients generally appear clinically healthy. It can be localised, which generally has a circumpubertal onset, or generalised, which usually occurs in individuals above the age of 35. Treatment is determined on the severity of the disease and the age of the patient. Supragingival (above gums) and subgingival (under gums) debridement and antibiotics are sometimes necessary. To maintain the treatment and prevent reoccurrence of disease, patient care is necessary. This involves good oral hygiene like for all other forms of periodontitis and gingivitis. Brushing twice a day and interdental cleaning are necessary in maintaining a healthy periodontium and preventing the continuation of periodontal destruction. Regular periodontal check ups are also necessary every 3–6 months.


Periodontitis as a manifestation of systemic disease

Periodontitis may be caused by systemic disease. There are currently at least 16 systemic diseases that have been linked with periodontal disease, such as diabetes mellitus, haematological disorders such as acquired neutropenia and leukemia,
Down syndrome Down syndrome or Down's syndrome, also known as trisomy 21, is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. It is usually associated with physical growth delays, mild to moderate intellectual d ...
, etc. Treatment and prevention are very important concepts in the management and maintenance of periodontitis as a manifestation of systemic disease. Treatment can consist of either surgical or non-surgical treatment depending on severity. After treatment, patient compliance is important, which includes oral hygiene: tooth brushing twice a day and interdental brushing at least once a day; chlorohexidine mouthwash may also be helpful.


See also

*
Bone grafting Bone grafting is a surgical procedure that replaces missing bone in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly. Some small or acute fractures can be cured wit ...
*
Chronic periodontitis Chronic periodontitis is one of the seven categories of periodontitis as defined by the American Academy of Periodontology 1999 classification system. Chronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation ...
*
Dental implant A dental implant (also known as an endosseous implant or fixture) is a prosthesis that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown, bridge, denture, or facial prosthesis or to act as an orthodo ...
*
Gingival graft Gingival grafting, also called gum grafting or periodontal plastic surgery, is a generic term for the performance of any of a number of periodontal surgical procedures in which the gum tissue is grafted. The aim may be to cover exposed root sur ...
*
Gingival recession Gingival recession, also known as receding gums, is the exposure in the roots of the teeth caused by a loss of gum tissue and/or retraction of the gingival margin from the crown of the teeth.Journal of Periodontology The ''Journal of Periodontology'' is the academic journal An academic journal or scholarly journal is a periodical publication in which scholarship relating to a particular academic discipline is published. Academic journals serve as permanent ...
'' *
Periodontitis Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main cau ...
*
Scaling and root planing Scaling and root planing, also known as conventional periodontal therapy, non-surgical periodontal therapy or deep cleaning, is a procedure involving removal of dental plaque and calculus (scaling or debridement) and then smoothing, or planing, o ...
*
Sinus lift Maxillary sinus floor augmentation (also termed sinus lift, sinus graft, sinus augmentation or sinus procedure) is a surgical procedure which aims to increase the amount of bone in the posterior maxilla (upper jaw bone), in the area of the prem ...


References


External links


AAP Directory of Periodontists

American Academy of Periodontology's (AAP) article on Periodontal Disease

British Society of Periodontology

Canadian Academy directory of Periodontists

Dental Council of India

European Federation of Periodontology

The National Institute of Cranialfacial Research's article on Periodontal Disease

South African Society for Periodontology
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