Third Edition

A Comprehensive
TEXTBOOK OF
PERIODONTOLOGY

T.R. Gururaja Rao

All India Publishers and Distributors

About the book
T. R. Gururaja Rao

Third edition of A Comprehensive Text Book of Periodontology is written in thirteen sections. There is a detailed
history of Evolution of Global Periodontology in general and the development of Periodontology in India in
particular.

The overview of Periodontology has been the most important introduction to a student to provide the significance
of studying the subject at the third year B.D.S. level. Very briefly the entire Periodontology has been described
as the student has to directly treat the patients with his limited knowledge of pathology, anatomy, physiology
pathology, microbiology and surgical sciences.

Later the Biology of Periodontal tissues has been dealt elaborately .The etiopathogenesis of periodontal diseases
comprises of systematic narration of the various causative local and systemic factors.

The prevalence and incidence of periodontal diseases in the world in general and in India in particular has been
described in a unique manner

It is interesting to note that Necrotizing Ulcerative Gingivitis has been revised by Jacob Kaimenyi .Candida
infections of Periodontium is an unique presentation from Lakshman Samaranayake and Fawad Javed. The chapter
on occlusion has been re written. As far as Periodontics is concerned the concept of diagnosis, treatment planning,
use of advanced diagnostic aids has firmly been dealt at both undergraduate and post graduate levels. The periodontal
instruments, instrumentation, sterilization of instruments is a novel masterpiece

The various non surgical modalities of periodontal therapy is described with an input of latest knowledge and
postgraduate consideration. The surgical and advanced surgical methods in Periodontics are the lifeline .There has
been all the information projected to make the procedures easily understood. There are thirty contributors from,
Hong Kong, Saudi Arabia, Australia, United States, Libya, and Kenya apart from Indians. The editor expresses his
gratitude and respects to all the contributors for their role.

The editor has made the contents more short and applicable to the Indian post graduate and undergraduate students
and it is beyond the scope of the book to incorporate the references provided by the contributors. The editor
also acknowledges the pictures provided from different Dental Colleges regarding histology, pathology, surgical
procedures especially from KLE Society Institute of Dental Sciences, Bangalore Karnataka. The book has several
diagrams and figures presented which has been drawn by students of JCD Dental College Sirsa ,Haryana namely
Poonam Arora, Dhahiya, Jay Tiwari. Art of communication, Seminars, Publications, dissertation has been the hall
mark of this book as it is devoted to the post graduate students since English is not the spoken language of Indians
and many Asian and African countries

As a revision to the students, a question bank of over five hundred questions has been provided on various
chapters will help to make the students learn better. This book will certainly find a place for both post graduate and
undergraduate students of Periodontology.
 i

A Comprehensive

Textbook of Periodontology
Third Edition
ii

Let all the people be healthy

Let there be no disease
Let everyone be prosperous
Let no one suffer from pain
 iii

A Comprehensive

Textbook of Periodontology
Third Edition

Prof. T.R. Gururaja Rao

M.A., M.D.S., M.Sc., (London) F.I.O.M.P.
Formerly, Professor & Head Department of Periodontology and Vice Principal College of Dental Surgery
Kasturba Medical College, Manipal

Senior Professor, Head and Chairman

Department of Periodontics
SDM College of Dental Sciences, Dharwad

Professor and Head, Department of Periodontology and Oral Pathology

V.S. Dental College & Hospital, Bangalore

Principal, Professor & Head, Department of Periodontology,

Dayananda Sagar College of Dental Science, Bangalore

Professor & Head, Department of Oral & Maxillo Facial Pathology & Microbiology,
Oxford Dental College & Hospital, Bangalore

Professor & Head, Department of Periodontology Post Graduate Guide

AME Dental College & Hospital, Raichur, Karnataka State.

Professor & Head, Department of Periodontics & Director, Academic Affairs

JCD Dental College, Sirsa, Haryana

Presently Principal, Professor & Head, Department of Community Dentistry

AME Dental College & Hospital, Raichur, Karnataka State.

All India Publishers & Distributors

4380/4B, Ansari Road, Daryaganj,
New Delhi - 110002
iv

A COMPREHENSIVE TEXTBOOK OF PERIODONTOLOGY - Third Edition

Copyright 2014 Author & Publisher

All rights reserved, No part of this publication may be replaced, reproduced, stored in retrieval system
or transmitted by any means, electronic, mechanical, photocopying or otherwise without the prior written permission
of the publisher.

(Text, illustrations, diagrams, layout, structure, presentation etc., and also illustrations through figures, drawings
and charts quality of protection as artistic works).

First Edition : 1997

Second Edition : 2001

Revised Second Edition : 2007

Third Edition : 2014

I.S.B.N. : 81-8004-

Published by Rajender K. Arya

All India Publishers & Distributors
4380/4B, Ansari Road,
Daryaganj, New Delhi - 110002
Ph : 011-23244429; email: [email protected]

B.O.: 113, Poonamallee High Road,

Chennai - 600084.
Ph.: 044-28360804

This book has been published in good faith that the material provided by the author/contributors is original.
Every effort is made to ensure the accuracy of material, but the author/contributors, printer and publisher will not
be held responsible for any inadvertent error(s). In case of any dispute all legal matters are to be settled under Delhi
Jurisdiction only.

Composed by Sheila Sudheendra at Bangalore, India.

Printed at R.S. Offsets, New Delhi.

 v

To our Beloved
Patients : To enable them to learn the art and science prevent
dental diseases.

Students : To study the state of art and science in the

principles and practice of periodontology

Teachers : For bestowing knowledge, skill and ability to

combat the largest diseases of the mankind.

Book and Journals : Which expanded the ocean of knowledge.

The Almighty Creator : Many thanks to Him, who created us, this
universe and the environment.
vi
Contents at a Glance

Foreword xv Section 7 497-573

Introduction xvi Outline in Infection Control

Section 8 575-638
History of Periodontology liii
Non Surgical Periodontal Therapy
Section 1 1-28
Section 9 639-686
Overview of clinical
Periodontology
Surgical Periodontal Therapy
Section 2 29-118
Section 10 687-789
Biology of Periodontol
Advanced Periodontal Therapy
Tissues

Section 3 119-256 Section 11 790-816

Etiology of Periodontal Diseases Communication Skills

Section 4 257-295 Section 12 817-832

Epidemiology and research methodology in peri- Line diagrams

odontics
Section 13 833-882
Section 5 297-449
Color Atlas
Periodontal Pathology Index

Section 6 451-496

Periodontal Diagnosis and

Treatment Planning
viii
 ix

Contents
Section 1 1-28

Overview of Clinical Periodontology T. R. Gururaja Rao 1-28

Section 2 29-118

Biology of Periodontal Tissues

2.1 Gingiva T. R. Gururaja Rao 31-63

2.2 Cementum Geetha Vijay 65-71
2.3 Alveolar Bone Veena H. R. 73-85
2.4 Periodontal ligament Veena H. R. 87-98
2.5 Effects of Aging on Periodontal Tissues Ashwin Prabhu 99-103
2.6 Gingival Fluid T. R. Gururaja Rao 105-107
2.7 Applied Anatomy & Physiology of
Periodontal Tissues T. R. Gururaja Rao 109-118

Section 3 119-256

Etiology of Periodontal Diseases

3.1 Dental Plaque (Biofilm) and Microbiology Sudhir Patil and

of Periodontal Diseases T R Gururaja Rao 121-137
3.2 Dental Calculus Sudhir Patil 139-142
3.3 Iatrogenic Factors Lalit Mathur 143-146
3.4 Host Response in Periodontal Diseases,
Inflammation and Immunity Suresh Bindhumadhav 147-159
3.5 Polymorphonuclear Leukocytes T.R.Gururaja Rao 161-169
3.6 Markers of Periodontal Diseases T. R. Gururaja Rao 171-175
3.7 Endocrinal Disorders Selva Kumar 177-188
3.8 Effect of Nutritional and Psychosomatic
Factors on Periodontal Tissues T R Gururaja Rao 189-192
3.9 Role of Steroids and AIDS on
Periodontal Tissues T. R. Gururaja Rao 193-195
3.10 Haematological Influences on the Periodontium Selva Kumar 197-209
3.11 Genotype Polymorphism in Periodontitis T R Gururaja Rao 211-213
3.12 Periodontal Medicine Swargajyoti Das 215-227
x Contents

3.13 Risk Factors In Periodontal Diseases P P Marawar 229-246

3.14 Periodontitis in Children and Adolescents T R Gururaja Rao 247-256

Section 4 257-295

Epidemiology and Research Methodology in Periodontics

4.1 Epidemiology of Periodontal Diseases P. K. Baskar 259-271

4.2 Research Related to Periodontitis in Animals T. R. Gururaja Rao 273-274
4.3 Scientific Writing and Research Methodology T. R. Gururaja Rao 275-279
4.4 Review of Epidemiology of Periodontal Diseases
in India and Abroad T. R. Gururaja Rao 281-295

Section 5 297-449

Periodontal Pathology

A. Classification of Periodontal Diseases

5.1 Classification of Gingival and Periodontal
Diseases T. R. Gururaja Rao 299-304

B. Periodontal Diseases
5.2 Gingival Diseases Suresh Bindhumadhav 305-327
5.3 Acute Gingival Lesions: Acute
Necrotizing Gingivitis Jacob T Kaimenyi 329-339
5.4 Candidal Infections - Periodontium Lakshman Samaranayaka 341-354
& Fawad Javad

C. Chronic Periodontitis
5.5 Periodontitis T. R. Gururaja Rao 355-364
5.6 Pocket Amit Garg 365-373
5.7 Ossesous Defects Amit Garg 375-378
5.8 Mobility Amit Garg 379-384
5.9 Halitosis Amit Garg 385-389

D. Aggressive Periodontitis
5.10 Aggressive Periodontitis Vijay Chava 391-395

E. Perio-Endo Relationship
5.11 Perio-Endo Relationship
Interdisciplinary Periodontics P. P. Marawar and
Sangeeta Aggarwal 397-415
 Contents xi

F. Trauma from Occlusion

5.13 Trauma From Occlusion S.M.Joshi and Lalit Mathur 417-430

G Orthodontic Periodontic Interrelationship

5.14 Orthodontic-Periodontics Interrelationship Amitabh Kallury,Neeraj Aggarwal 431-449

Section 6 451-496

Periodontal Diagnosis & Treatment Planning

6.1 Outline for Examination, Case History T. R. Gururaja Rao 453-458

6.2 Periodontal Diagnosis T. R. Gururaja Rao 459-464
6.3 Radiography In Periodontics T. R. Gururaja Rao 465-468
6.4 Computers in Periodontics Ashwin Prabhu 471-477
6.5 Advanced Diagnostic Aids Anoop Bhushan 479-496

Section 7 497-573

Basics of Periodontal Therapy

7.1 Outline in Infection Control Raghunath Puttaiah 499-523

7.2 Objectives of Periodontal Therapy T. R. Gururaja Rao 525-527
7.3 Rationale for Periodontal Therapy T. R. Gururaja Rao 529-530
7.4 Factors that may Affect or Modify
Periodontal Therapy T. R. Gururaja Rao 531-534
7.5 Instrumentarium T. R. Gururaja Rao 535-562
7.6 Sutures and Suturing Techniques T. R. Gururaja Rao 563-569
7.7 Periodontal Dressings T. R. Gururaja Rao 571-573

Section 8 575-638

Non Surgical Periodontal Therapy

8.1 Oral Hygiene Methods in India T. R. Gururaja Rao 577-579

8.2 Oral Physiotherapy Mechanical
Methods of Plaque Control Jacob T. Kaimenyi 581-595
8.3 Chemical Methods of Plaque Control T. R. Gururaja Rao 597-604
8.4 Drugs in Periodontology T. R. Gururaja Rao 605-624
8.5 Resolution of Inflammation by Lipoxins Ashish Jain 625-630
8.6 Supportive Periodontal Therapy T. R. Gururaja Rao 631-638
xii Contents

Section 9 639-686

Surgical Periodontal Therapy

9.1 Objectives and Principles of

Periodontal Surgery T. R. Gururaja Rao 641-648
9.2 Rationale for Root Surface Treatment T. R. Gururaja Rao 649-656
9.3 Root Planing & Gingival Curettage
Periodontal Splints T. R. Gururaja Rao 657-662
9.4 Periodontal Flap Surgery T. R. Gururaja Rao 663-668
9.5 Regenerative Osseous Procedures T. K. Pal 669-677
9.6 Osseous Resective Surgery T. R. Gururaja Rao 679-686

Section 10 687-789

Advanced Periodontal Therapy

10.1 Recent Advances in Periodontal

Surgical Technology A. Kumaraswamy 689-692
10.2 Periodontal Plastic Surgery T. R. Gururaja Rao 693-697
10.3 Periodontal Aesthetics T. R. Gururaja Rao 699-715
10.4 Guided Tissue Regeneration T. R. Gururaja Rao 717-726
10.5 The Role of Growth Factors in Healing T. R. Gururaja Rao 727-729
10.6 Stem Cells Research in Periodontics Ashish Jain 731-735
10.7 Tissue Engineering K. Nanda Kumar 737-747
10.8 Bone Morphogentic Proteins T. R. Gururaja Rao 749-754
10.9 Host Modulation & Photodynamic
Therapy Suresh Bindhumadhav 755-756
10.10 Pre-Prosthetic Surgery T. R. Gururaja Rao 757-766
10.11 Lasers in Periodontics T. R. Gururaja Rao 767-770
10.12 Dental Implants T. R. Gururaja Rao, Amit Garg 771-789
& Anshuman Dwivedi

Section 11 790-816

Communication Skills V. L. Pattankar 792-816

 Contents xiii

Section 12 817-832

Line Diagrams

1. Biology of Periodontal Tissues 818

2. Classification of Subgingival Plaque 819
3. Stages of Gingivitis 820
4. Immune Reactions 821
5. Periodontal Pockets 822
6. Types of alveolar bone destruction 823
7. Bony Defects 824
8. Trauma from occlusion 825
9. Classification of Endontic/Periodontal Problems 826
10. Advanced Diagnostic Methods 827
11. Periodontal Instruments and design 828
12. Periodontal Splints 829
13. Periodontal Surgical Techniques 830
14. Papilla preservation flap technique 831
15. Different suturing techniques in Periodontal Surgery 832

Section 13 833-882

Color Atlas

1. Gingiva in Health and Disease 834

2. Gingiva 835
3. Gingival Enlargements 836
4. Cementum 837
5. Periodontal Ligament 838
6. Bone Remodelling 839
7. Plaque Microbiota 840
8. Sub Gingival Plaque and host tissue Interaction 841
9. Acute Ulcerative Gingivitis 842
10. The Healthy gingiva and the changes occurring in the gingiva as result of
inflammation leading to pocket formation, mobility 843
11. The (a) adult periodontitis patient (b) Juvenile periodontitis. note the lesion is bilaterally
symmetrical in the female patient aged 19 years. 844
xiv Contents

12. Fungal Infections of Periodontium 845

13. The Advanced Diagnostic Instruments 846
14. Periodontal Diagnostic Instruments 847
15. Periodontal Diagnostic Instruments 848
16. Effect of oral prophylaxis, patient education on the gingiva and periodontium 849
17. Orthodontics and Oral Hygiene 850
18. Showing the modified Widman flap surgery as pocket eradication\ method 851
19. Guided Tissue Regeneration with Non-absorbable membrane 852
20. Surgical Procedures 853
21. Free Mucosal Autograft 854
22. Reconstructive mucosal grafts 855
23. Periodontal surgery 856
24. Periodontal surgery 857
25. Two Stage Free Mucosal Graft Procedure 858
26. Coronally Advanced Flaps 859
27. Periodontal Aesthetics 860
28. Periodontal Aesthetics 861
29. Laser Cases 862
30. Laser Cases 863
31. Radiographic feature of alveolar bone loss in periodontitis 864
32. Radiographic features of Pulpal Periodontal Problems 865
33. Radiographic features of Pulpal Periodontal Problems 866

Index 867
 Foreword xv

Foreword
Prof.Newell Johnson

CMG, FMedSci, MDSc, PhD, FDSRCS (Eng), FRACDS, FRCPAth (UK), FFOP(RCPA), FILT (UK), FICD.

Emeritus Professor of Oral Health Sciences,Kings College London.,Adjunct Professor,Charles Sturt University,
New South Wales, Australia.,Honorary Professor,The Tamil Nadu Dr MGR Medical University, India.,

Professor of Dental Research, Griffith Health Institute[Population and Social Health Research Programme - Lead
for Population Oral Health; Infectious Diseases and Cancer Research Groups]Building GO5, Room 3.22A.,Gold
Coast Campus.Griffith University.Queensland 4222.,Australiahttp://www.griffith.edu.au/health/griffith-health-
instituteTelephone +61 (0)7 555 29306.,Mobile phone +61 (0)448 954 344

I t is a pleasure to write a Foreword to this edition of

the now-established A Comprehensive Textbook
of Periodontology master-minded by my long-term
all members of the dental and oral health professions,
therefore, to understand these diseases well. You will all
have patients who need your interventionist care. But
friend Professor T.R.Gururaja Rao. please remember that severe periodontal disease affects
a minority of the population predominantly those
The coverage is comprehensive and the individual with inherited susceptibility factors. Most members
topics selected wisely: Indeed one might use the title of society can prevent any significant destructive
Textbook of Periodontology and Periodontics - or periodontitis by good nutrition, and a reasonable [but
even The Indian Textbook of Periodontology and not excessive] level of oral hygiene.
Periodontics for a substantial number of distinguished
Indian colleagues make up the authorship, and the Understand your patients: understand the society from
material is apposite to the epidemiology of this family which they come; their family situation; the interplay of
of diseases in the Sub-continent, and to the special risk factors which will be different for every individual;
genetic, cultural and environmental factors which the inseparability of oral health and disease from the
influence periodontal diseases amongst Indian peoples. rest of the body: treat the patient and his/her family, not
the tooth.
Damage to the supporting tissues of teeth resulting
from one or other of the forms of periodontitis are the I wish this great book, and everyone of its readers,
major cause of tooth loss amongst adults. It behoves success in a noble health care profession, and your
patients improved quality of life.

Prof. Newell Johnson

xvi Introduction

Introduction
Prof P.K.Baskar

Professor Emeritus., Tamil Nadu Dental College Dental College and Hospital., MGR Medical University
Past President,Indian Society of Peiodontology.

Past President., Founder member of Indian Society of Dental Research., (Now International Association of Dental
Research, India Section)

Director., Viveka Institute of Dental Health, (Chennai)

I have great pleasure to write this introduction

to this book A Comprehensive Text Book of
Periodontology Authored by Prof. T.R.Gururaja Rao
diagrams, which will help the reader to benefit without
any fatigue. The sections have been contributed by
thirty eminent academicians from India and abroad
who has laboured a great deal to churn all his experience with many innovative ideas. Questions at the end of
as a teacher, academician, researcher, clinician and an each section is another hall mark off the book for the
administrator. He had earlier authored two textbooks reader to remember and reinforce the topics.
viz Text Book of Periodontology and Text Book
of Community Dentistry. Both the books have been My association with Prof T.R.Gururaja Rao as a
of great use to both undergraduate and post graduate colleague, co examiner runs for many decades. Our
students. It has become popular at several countries roles at the Indian Society of Periodontology,and
abroad as well . Indian Society of Dental Research have strengthened
my confidence in recommending this book to all those
The present book Comprehensive Text Book of who are interested in Periodontology.
Periodontology has been carefully divided into
thirteen sections, with apt subtitles, tables and I convey my congratulations to Prof.T.R.Gurururaja
Rao and his team for their hard work in publishing the
book

Prof. P.K. Baskar

 About the Author xvii

About the Author

Prof T.R. Gururaja Rao

M.A., M.D.S., M.Sc., (London) F.I.C.D., F.I.A.O.M.P.,

Principal AME Dental College Hospital, Raichur, Karnataka State.

A recipient of prestigious Commonwealth Senior

Medical Scholarship to United Kingdom for
Masters in Oral Pathology in 1984 from University of
Founder Principal Dayananda Sagar College of Dental
Sciences, Bengaluru. He was also instrumental for
starting Post Graduate Education in Periodontics and
London, he has been actively teaching Periodontics, Oral Pathology at several institutions. A veteran of
Oral Pathology and Community Dentistry. He was attending over 125 conferences all over the world, he
President of Indian Society of Periodontology, Indian has several publications of international repute to his
Association of Oral and (Maxillo Facial) Pathologists credit.
and Indian Society of Dental Research, and Vice
President of Indian Dental Association Head office. An author of Text Book of Periodontology and
He is a fellow of the Indian Association of Dental Text book of Community Dentistry, he has been an
Research, Indian Association of Oral and Maxillofacial examiner for Oral Pathology, Community Dentistry
Pathologists, International College of Dentists, and and Periodontics for many Universities at the
Academy of General Education. undergraduate and post graduate levels in India and
abroad. He is also a referee for Journal of Indian
With over four decades of experience and after being a Society of Periodontology, International Journal of
guide for over thirty post graduate students, he has held Oral and Maxillo Facial Pathology, Indian Dental
senior teaching positions at different levels. He was the Association. He is member of the American Academy
Vice Principal at College of Dental Surgery Manipal, of Periodontology, International Association of
Dental Research, International Association of Oral
Pathologists. A former Director for Academic Affairs
at JCD Dental College, Sirsa, Haryana. Presently he
is the Principal of AMEs Dental College, Raichur,
Karnataka.
xviii Contributors

A Comprehensive Textbook of Periodontology (2014 - 3rd Edition)

Contributors
1. N.W.Johnson 8. Selva kumar.
M.D.Sc.,Ph.D.,FDS, RCS., FRAC,DS., FRC(Path), M.D.S, Department of Periodontics, Sree
Professor of Dental Research, Dean, Dental School, Venkateshwara Dental College and Hospital,
Griffith University, Gold Coast, Queensland, Navallur, Thalabur.,Kanchipuram district Tamil
Australia. Nadu.

2. J.T.Kaimenyi 9. K. Nandakumar
M.D.S.,Ph.D, Prof of Periodontology, Deputy Vice M.D.S, Professor and Head Department of
Chancellor, University of Nairobi,Kenya. Periodontics and Principal,Azeeya Dental College
and Hopsital, Meyyanur,Kollam,Thiruvanthapu
3. Vijay Chava ram district, Former Prof and Head Department
M.D.S, Professor and Head Dept of Periodontics, of Periodontics, Government Dental College and
Narayana Dental College and Hospital, Hospital, Thiruvanthapuram, Kerala.
Nellore,Andhra Pradesh.
10. Amitabh Kallury
4. P.K.Baskar M.D.S. F.D.R.S, RCS(Glasgow), Professor and
M.D.S.,F.I.C.D. Emeritus Professor, Tamil Nadu Head Department of Orthodontics, Peoples Dental
Dr M.G.R. Medical University, Director,and former Academy,Bhanpur, Bhopal, Madhya Pradesh.
Principal V.M.S. Dental College Salem, Former
Additional Professor Department of Periodontics, 11. Sudhir R Patil
Madras Dental College, Chennai Tamil Nadu. M.D.S., Professor and Head Department of
Periodontics, Vice Principal, KLE Societys
5. Tamal Kanti Pal Institute of Dental Sciences,Tumkur Road,
M.D.S.,PhD, Professor and Head, Department Bangalore.
of Periodontics,Guru Nanak Institute of Dental
Sciences and Research, Kolkatta West Bengal. 12. Sangeeta Aggarwal
M.D.S. Department of Conservative Dentistry
6. Subhash. M.Joshi and Endodontics, Government Dental College and
M.D.S, Prof and Head, Department of Hospital, Amritsar,Punjab.
Prosthodontics, Former Principal Bharati
Vidyapeeth, Dental College, Pune Maharashtra. 13. Swarga Jyoti Das
M.D.S.,Ph.D(University of London), Professor and
7. Shashikant.A.Kale Head Department of Periodontics. Regional Dental
M.D.S.,D.D.P.H, Prof and Head Department of College and Hospital, Guwahati, Assam.
Periodontics, Dean Govt Dental College and
Hospital,Mumbai, Joint Director, Government of 14. Anoop Bhushan.
Maharashtra. M.D.S. Prof and Head Department of Periodontics,
Santosh Dental College and Hospital, Ghaziabad
(Uttar Pradesh).
 Contributors xix

15. Ashish Jain. 22. Amit Garg.

M.D.S. Professor and Head Department of Reader, M.D.S. Department of Periodontics, JCD
Periodontics and Incharge Principal, Dr HST Dental College, Sirsa Haryana.
Institute of Dental Sciences, Punjab University
Sector-25, Chandigarh-Punjab. 23. T. R. Gururaja Rao.
M.A., M.D.S.,M.Sc(University of London).F.I
16. Raghunath Puttaiah. .C.D.,(USA).,F.I.A.O.M.P, Professor and Head
B.D.S. M.P.H., Professor Baylor college of Department of Periodontics, Director,Academic
Dentistry, Dallas, Texas USA. Affairs, JCD Dental College Sirsa Haryana;
Presently Principal AMEs Dental College,
17. Veena. H.R. Raichur, Karnataka.
M.D.S. Reader Department of Periodontics,
KLESocietys Institute of Dental Sciences, 24. V. L. Pattankar.
Bangalore. M.B.B.S.,M.D., Emeritus Professor Department of
Pathology, KBNIMS, Gulbarga, Karnataka.
18. Lakshman Samaranayaka,
B.D.S.,Hon D.Sc.,Hon FDS., RCS., 25. Ashwin Prabhu,
D.D.S(Glasgow),FRC (Path.,FHK(Pth)., FCD, M.D.S. Reader,Department of Periodontics, KLES
SHK., FHKAM (Path)., FHKAM (D.Surgery), Societys Institute of Dental Sciences, Bangalore.
Dean of Dentistry Tam Wah Chung Professor in
Dental Sciences, Chair of Microbiology,University 26. P. P. Marawar,
of Hong Kong, King James IV Professor The M.D.S., Prof and Head Department of
Royal College of Surgeons of Edinburgh UK. Periodontology, Rural Dental College and Hospital,
Director,The Prince Philip Dental Hospital,Hong Loni(Pravara), Maharashtra.
Kong.
27. Fawad Javed,
19. Geetha Vijay. B.D.S., PhD(Sweden), Research Associate and
M.D.S. Professor and Head Department of Eng A.B. Research chair for Growth Factors and
Periodontics, Vaidehi Institute of Dental Sciences Bone regeneration College of Applied Medical
and Research, Bangalore. Sciences, King Saud University, Riyadh (Kingdom
of Saudi Arabia).
20. Lalit M.Mathur.
M.D.S. Professor and Head Dept. of Periodontics 28. Neeraj Aggarwal,
and Principal,Pacific Dental College and Hospital, M.D.S., Reader, Department of Periodontology,
Udaipur, Rajasthan. Peoples Dental Academy, Bhopal, Madhya
Pradesh.
21. Suresh Bindhumadhav.
M.D.S.,M.F.D.R.C.S (Ireland), Assistant Professor, 29. Prof A.Kumaraswamy,
Department of Periodontics, University of Tripoli, M.D.S, Visitng Professor StonyBrook University
College of Dental and Oral Medicine and Surgery, NewYork Practising Periodontologist,Implantoloist,
Tripoli, Libya. Specialist in Esthetic and Cosmetic Dentistry

30. Dr. Anshuman Dwivedi.

B.D.S, Cert in Implantology(Paris)., (Madrid).,
Oral Implantologist
xx About the Author

About the
CAbout
o n tthe
r iAuthor
butors
Dr. T. R. Gururaja Rao completed BDS from the Association. He is member of the American Academy
first batch of Government Dental College and Hospital of Periodontology, International Association of
Nagpur in 1972, and MDS from Government Dental Dental Research, International Association of Oral
College and Hospital Bangalore in 1977 in Periodontics. Pathologists. A former Director for Academic Affairs
at JCD Dental College, Sirsa, Haryana. Presently he
A recipient of prestigious Commonwealth Senior is the Principal of AMEs Dental College, Raichur,
Medical Scholarship to United Kingdom for Masters Karnataka.
in Oral Pathology in 1984 from University of London,
he has been actively teaching Periodontics, Oral Dr. Anoop Bhushan is Professor and Head of
Pathology and Community Dentistry. He was President Department of Periodontics and Oral Implantology,
of Indian Society of Periodontology, Indian Association Santosh Dental College, Ghaziabad, is a Graduate
of Oral and (Maxillo Facial) Pathologists and Indian and Post Graduate in Periodontics from the renowned
Society of Dental Research, and Vice President of Faculty of Dental Sciences, KG Medical College,
Indian Dental Association Head office. He is a fellow Lucknow. He is very actively involved in Graduate
of the Indian Association of Dental Research, Indian and Postgraduate Teaching with fields of keen interest
Association of Oral and Maxillofacial Pathologists, being The Application of the Modern Periodontology
International College of Dentists, and Academy of in Current Practice of Periodontics and Tissue friendly
General Education. Implantology. He is the Technical Advisor to Union
Public Service Commission of India. To his credit are
With over four decades of experience and after being a several international/national publications including
guide for over thirty post graduate students, he has held a pioneer research publication on Plaque Tenacity
senior teaching positions at different levels. He was the in Journal of Periodontal Research. He has been
Vice Principal at College of Dental Surgery Manipal, Keynote/Guest Speaker to national and international
Founder Principal Dayananda Sagar College of Dental conferences including few deliberations in the Medical
Sciences, Bengaluru. He was also instrumental for Conferences also. He has extensively spoken on the
starting Post Graduate Education in Periodontics and recent advances in Periodontics and their relevance in
Oral Pathology at several institutions. A veteran of the Indian Context. He has been the Chief Guide to
attending over 125 conferences all over the world, he Several Dissertations and also External Examiner to a
has several publications of international repute to his Number of Medical Universities.
credit.
He is the Dental Advisor, Centre of Agrarian Research,
An author of Text Book of Periodontology and Training & Education, and Ghaziabad. In the past he
Text book of Community Dentistry, he has been an has held the post of Joint Editor, Clinical Society, and
examiner for Oral Pathology, Community Dentistry K.G. Medical College, Lucknow. He is an Active
and Periodontics for many Universities at the International Member of American Academy of
undergraduate and post graduate levels in India and Periodontology.
abroad. He is also a referee for Journal of Indian
Society of Periodontology, International Journal of
Oral and Maxillo Facial Pathology, Indian Dental
 About the Author xxi

Dr Amit Garg is a Reader at the Department of He has 14 international and national publications to
Periodontics at JCD Dental College, Sirsa, Haryana. his credit. He has presented several scientific papers at
He has done his BDS from the prestigious institute of national levels.
Manipal College of Dental Sciences, Manipal in 2002.
Then he did his Masters in the field of Periodontology Prof Swarga Jyoti Das is the Professor and Head
in 2007. He completed his one year course in advanced of the Department of Periodontics in the Regional
Aesthetic Dentistry in the same year. He also worked as Dental College, Guwahati. She is also engaged as
a faculty in the Department of Periodontics in MCODS, the Dean of Faculty of Dentistry under Srimanta
Manipal. He has also participated and presented Sankardeva University of Health Sciences, Assam. She
scientific papers in various national and international is a recognized PhD guide of Guwahati University,
conferences. He has also many publications to his Assam and Srimanta Sankardeva University of Health
credit . Sciences, Assam. She has completed BDS (1984) and
MDS (1987) in Periodontology from King Georges
Dr Sangeeta Aggarwal did her BDS from Government Medical College, Lucknow. She was nominated by
Dental College and Hospital Patiala and did her MDS the Ministry of Human Resource, Govt of India for
in Conservative Dentistry and Endodontics from the Commonwealth Scholarship Plan 1998 to pursue
Government Dental College and Hospital Amritsar, PhD Degree and obtained the degree from the Eastman
Punjab. She is actively involved in clinical Endodontics Dental Institute for Oral Health Care, University
and is working as a lecturer at the Government Dental College London, UK in 2001. The subject of her
College and Hospital Amritsar for the last seven years research work was Role of Keratinocytes Growth
Factor and its Receptor in Drug-induced Gingival
Dr J. Selva Kumar is a Periodontist and Implantologist, Enlargement.
working presently as an Associate Professor at Sri
Venkateshwara Dental College, Chennai. He has She has presented a number of papers in national
done his BDS in 1994 and M.D.S (Periodontics) from and international conference held at Washington DC,
Meenaskshi Ammal Dental College and completed his Glasgow, Leeds and San Diego. A list of publications
Post Graduate Diploma in Clinical Research. He is both in the national and international journals is to
associated with various organizations and is presently her credit. Recently, she has published a book titled,
the Vice President of Indian Society of Dental Research MCQs in Periodontology with Explanation. She is
a Life member of the Indian Society of Periodontology
Prof Amitabh Kallury is presently working as and Pierre Fauchard Academy.
Professor and Head at the Department of Orthodontics
and Dento facial Orthopaedics, Peoples Dental Prof Lalit Kumar Mathur completed his BDS
Academy, Bhopal. He did his BDS from Bapuji Dental from Government Dental College and Hospital,
College and Hospital Davanagere in 1995 and MDS Tiruvanthapuram in 1974 and M.D.S from Government
from S.D.M College of Dental Sciences Dharwad, in Dental College and Hospital, Ahmedabad from Gujarat
1999. University in 1977.

He has ten international and national publications to He served the Government of Rajasthan at various
his credit and has attended various conferences and capacities till 2004 when he took voluntary retirement
workshops. as a senior professor there. In 2005, he joined Darshan
Dental College Udaipur as Professor and Head at the
Dr Neeraj Aggarwal is a Reader at the Department Department of Periodontics and presently, he is the
of Periodontics, Peoples Dental Academy, Bhopal. Principal at Pacific Dental College at Udaipur. He has
He did his B.D.S from King George Medical College been conferred the Fellow of International College
Dental College, Lucknow in 2003 and M.D.S. from R of Dentists, Pierre Fauchard Academy and was the
Ahmed Dental College and Hospital Kolkata in 2007. President of Indian Society of Periodontology.
xxii About the Author

Dr Veena H. R completed her BDS from J.S.S Dental He has been awarded Excellence in Performance and
College and hospital Mysore in 1999 and MDS from Distinguished Researcher of the Year by GFBR King
J.S.S. Dental College and Hospital Mysore in 2006. Saud University. His interest includes oral oncology,
Presently, she has been working at KLE Societys connection between oral inflammatory disorders and
Institute of Dental Sciences, Bangalore as Reader systemic conditions particularly diabetes mellitus,
at the Department of Periodontics. She has several impact of smoking and use of smokeless tobacco on
publications to her credit oral health. He has many original and review articles.

Prof Suresh Bindhumadhav BDS, MDS, MFDRCS Prof P. P. Marawar did his BDS from Government
(IRE) obtained his BDS as well as MDS from the Dental College and Hospital Nagpur in 1972, M.D.S,
prestigious Tamil Nadu Government Dental College from University of Bombay in 1975 in Periodontics
and Hospital, Chennai, India and, MFDRCS from from Government Dental College and Hospital,
the Royal College of Surgeons in Ireland, Dublin. Bombay. He has 31 years of teaching experience; and
He has worked in various capacities, both clinical as has eleven papers published in national and international
well as academic, in India and countries such as the journals. Presently he is working as Professor and Head
Kingdom of Saudi Arabia and Libya, where he worked Department of Periodontics at Rural Dental College,
as Assistant Professor in the Faculty of Dental and Oral Loni (Maharashtra).
Medicine and Surgery, Al-Fateh University, Tripoli.
He has delivered lectures and participated actively in Prof Sudhir R. Patil did his BDS, and MDS, from
conferences and seminars both in India and abroad. Government Dental College and Hospital Bengaluru.
He has over 20 years of teaching experience in
Prof Jacob T. Kaimenyi obtained his MDS from undergraduate and postgraduate levels. He was the
Mysore University in 1982 and PhD in Periodontology former Principal and Head Department of Periodontics
from UK. He is Professor of Periodontology and Deputy at P.M.N.M. Dental College and Hospital Bagalkot. He
Vice Chancellor (Academic Affairs), University of was former editor of newsletter of GDC, Bengaluru
Nairobi. Alumni association. At present he is the Professor and
Head Department of Periodontics and Vice Principal
He has held several positions such as President, East at the KLE Societys Institute of Dental Sciences,
and Southern Africa section of IADR, President of Bengaluru.
Commonwealth Dental Association. He has served
on the editorial board of four international journals. His interest includes periodontal microbiology,
He was awarded the Diploma for 2000 outstanding preventive periodontics, halitosis, regenerative and
intellectuals of 21st century. He was awarded the aesthetic periodontics, medical law & ethics and basic
honorary fellowship of International Congress of research. He is a reviewer of several journals. He
Oral Implantologist and Master of Implant Prosthetic has presented and published several scientific papers
section. He has sixty publications, twenty seven guest and given guest lectures and an examiner to various
lectures and over 28 papers at conferences at different universities.
levels.
Prof Geetha Vijay did her BDS from Government
Dr Fawad Javed (BDS, PhD) got his doctoral Dental College and Hospital, Bengaluru and MDS from
education and post doctoral training from Department College of Dental Surgery at Manipal. She worked
of Dental Medicine, Karolinska Institutet Stockholm, at Manipal for over seven years and moved over to
Sweden. Presently, he is a Research Associate at the Benghazi, Libya, where she worked at the Department
Eng A. B. Research Chair for Growth Factors and Bone of Periodontics for another eight years. She continued
Regeneration (GFBR) College of Applied Sciences, imparting her teaching skills at Ajman University
King Saud University Riyadh, Saudi Arabia. for another five years before she finally returned to
Bengaluru. Presently, she is the Professor and Head
 About the Author xxiii

of Department of Aerodonetics at Vydehi Institute of Dr Raghunath Puttaiah did his BDS from Bapuji
Dental Sciences and Research Centre, Bengaluru. She Dental College and Hospital, Davangere in 1983;
has been an examiner for various universities in India obtained his MPH and Dental Public Health, Residency
and abroad. She is also the member Board of Studies of from University of Alabama at Birmingham and was
Rajiv Gandhi University of Health Sciences Karnataka the first recipient of Johnson and Johnson Medical Inc
and has several publications penned to her credit. Post Doctoral Fellowship in Infectious Disease control
in Dentistry at UTHSC-SA Dental School.
Prof Lakshman Samaranayaka Hon DSc, Hon
FDSRCS (Edin), DDS (Glas), FRCPath (UK), He is tenured Associate Professor at the Texas A &
FHKAM(Path),FHKAM(D. Surg) is the Dean and M University System Health Science Centre, Baylor
Chair Professor of Oral Microbiology and Tam Wah- College of Dentistry. He has crafted the Dental Safety
Ching Endowed Professor in Dental Sciences at the Standards for India. He has numerous research projects
University of Hong Kong, as well as the Director of the funded by the dental industry and NIH/NIDCR Grants.
Prince Philip Dental Hospital Hong Kong. He has over 100 abstracts, book chapters, and scientific
publications. He has done lectures extensively all over
In 2001 he received the King James IV Professorship the world.
from the Royal College of Surgeons of Edinburgh, UK
for his outstanding contributions to advance in surgical He has presently developed a program for the dental
science-the first Asian to be awarded the coveted infection control and occupational safety and has
honour. He is also the first from Asia to receive the developed an online CD/DVD Program and Video
Distinguished Scientist Award from the International Pod casts for handheld devices on the website www.
Association of Dental Research, Washington USA. dentalsafety.net.
At the University Of Hong Kong he has been honoured
with the Outstanding Researcher Award, Outstanding Prof. Krishnankutty Nandakumar completed his
Research student Supervisor Award and Research BDS from Government Dental College and Hospital,
Output Award (2009, 2010 and 2011). Tiruvanthapuram in 1973 and MDS from College
of Dental Surgery in 1979 in Periodontics. He has
He is the editor-in-chief of the Journal of Investigative also attended the courses in Oral Implantology,
and Clinical Dentistry (Wiley Blackwell) and the Regenerative Periodontal Surgical Techniques and
author of more than 400 publications and five books, Hospital Administrative Management. He has worked
some translated into five languages. He has been invited at the Government Dental College in Kerala for 32 years
as an esteemed speaker in more than 35 countries on and was working at the Al Arab Medical University
varied aspects of oral infections, dental education and at Benghazi, Libya for four years. Presently he is the
Problem Based Learning, for which he has served as a Principal and Head of the Department of Periodontics
World Bank Technical Consultant in Asia. at Azzeezia College of Dental Sciences and Research,
Meeyyanoor, Kollam Kerala. As an academician he
Dr Ashwin Prabhu did his BDS from Government chaired as Dean, Faculty of Dentistry, University of
Dental College and Hospital, Bengaluru, MDS from Kerala, Member Board of Studies, Member Dental
Bapuji Dental College and Hospital, Davangere. He Council of India, Vice President Indian Dental
is Reader at the KLE Societys Institute of Dental Association, President Indian Dental Association
Sciences, Bengaluru. His research interests include Kerala State Branch, and President Indian Society of
computer and their application in dentistry, and basic Periodontology.
research. He has several papers to his credit and is a good
speaker of repute. He is involved in the development of He was awarded the Best Doctor Award from the
voice-based periodontal charting applications for smart Government of Kerala. He was also a post doctoral
phones and digital recording, archiving and transfer of and post graduate guide for several dental students;
patient data using cloud-based technology. and was also was an examiner to several universities
xxiv About the Author

in India and abroad. Most Interesting is his passion Prof A. Kumaraswamy MDS did his BDS and
for innovative talent in collaboration with Sree Chitra MDS from Government Dental College and Hospital,
Thirunal Institute of Medical Sciences and Technology Mumbai. He is attached to Stony Brook University,
(SCTIMST) he contributed to the manufacture of bone New York USA as Professor. He has been a great
regenerative materials and Collagen membrane. organiser and a well-known Faculty in the field of
Aesthetic Dentistry, Cosmetics and Implantology.
Dr Ashish Jain did his BDS from DAV Dental College,
Yamunanagar. He did his MDS from Nair Hospital Dr Anshuman Dwivedi BDS, Cert Implantology
Dental College, Mumbai in 1998. Thereafter, he did his (Paris), Madrid), is a renowned implantologist and is
research in Inflammation and Resolution at Goldman a Faculty Director for Implantology courses in India
School of Dental Medicine, Boston University for two and abroad.
years; and followed it up with another year of research
in Implants at Harvard University. Prof. S.A. Kale was a Professor and Head, Department
of Periodontology and Dean, Government Dental
He has over 35 International & National publications College and Hospital, Mumbai. He was a former
to his credit. Presently he is officiating as Principal of Joint Director of Medical Education, Government
Dr Harvansh Singh Judge Institute of Dental Sciences, of Maharashtra. He has been a very reputed teacher,
Punjab University, Chandigarh. A strict disciplinarian, who has provided several post
graduate students to the country. He was helpful in
Prof. P.K. Baskar is a former additional professor preparation of the earlier editions of the present text
(Dept. of Periodontology) Tamilnadu Dental College book.
and Hospital (Chennai), Professor Emirites MGR
Health University. He was advisor/consultant to Prof. S.M Joshi was a Professor and Head, Department
Vinayaka Mission Foundation Dental College Hospital of Prosthodontics at Government Dental College and
and Research Centre (Salem). He is a past President of Hospital, Mumbai and Nagpur. With over four decades
Indian Society of Periodontology and Founder Member of teaching Prosthodontics he has provided several
of Indian Society of Dental Research - Presently known post graduates in this field. He was the founder, Dean
as International Association of Dental Research, India of Bharathi Vidya Peeth, Dental College and Hospital,
Section. A teacher of high repute and has over 45 years Pune. He was a coordinator for Simhgad institutions
of teaching experience an author of several books, he at Pune for a brief period he also worked as a Post
has great reverence and respect in periodontics and Graduate teacher at SDM Dental College and Hospital,
periodontology. Dharwad.

Prof. T K Pal MDS, PhD, is a recipient of the National Prof. V. L. Pattankar Prof. & Head of Department
Republic Day Scientist Award (1998). He did his BDS, of Pathology KBNIMS, Gulbarga did his MBBS
from R Ahmed Dental College and Hospital, Kolkata; (1970) from KIMS Hubli MD (Pathology) from
MDS, from King George Medical College Dental PGIMER Chandigarh (1976) with distinction.
Hospital, Lucknow. He did his Ph.D., from Jadhavpur Having worked at PGIMER Chandigarh, SCTIMST,
University. He has worked at R Ahmed Dental College Thiruvananthapuram, M.R. Medical College, Gulbarga
and Hospital, Kolkata and has been the professor and has forty three years of teaching with thirty six Post
Head in the Department of Periodontics. He has been Graduate students 116 papers for State and National
an active post graduate teacher and innovative research Conferences. Has several projects under ICMR and
scientist for Regenerative Osseous Materials and Karnataka State Science Technology. Has contributed
Implants. for two text books.

Presently, he is working at the Guru Nanak Institute of

Dental Sciences, Kolkata as Professor and Head.
 Milestones xxv
of the Book

Milestones of the book

Preface to the Third Edition

E ver since the second edition of the Textbook of Ms. Sheila Sudheendra for editing and proof reading
Periodontology was released by Prof P. D. Miller the book; and Mr. Narendra Morching for the design
at Pune in 2006, the book has been far reaching all and layout. I am also thankful to Mr. Nikhil Gupta for
over India, South East Asia, and African countries as recreating few line diagrams in multi-color.
well. The desire to have the third edition took roots
in December 2011 at the International College of The book has been printed and published by All India
Dentists meeting, since there was a great demand for Publishers and Distributors [Regd] New Delhi. My
a comprehensive book suitable for undergraduate and association with Mr. Rajender Arya has been over two
Post graduate students on periodontology. decades. I would like to place on record the gesture
by the academic faculty of JCD Dental College Sirsa,
I was supported by a few periodontists who were Haryana , and KLE Society Institute of Dental Sciences
willing to contribute to this unique venture. It has been Bengaluru for encouraging me and also taking the
amazing experience for me to coordinate with more responsibility to contribute a few chapters and provide
than twenty-eight contributors from India and abroad, their valuable suggestions and inputs.
including Hong Kong, USA, Saudi Arabia, Libya,
Kenya, UK, and Australia for the new book. It is an This magnum opus is dedicated to the elite and pioneer
exhilarating experience to inform readers that several teachers of Periodontology in India, Profs. G. B.
chapters have been re-written, pictures drawn, and we Shankhwalkar, Tehmi M. Ginwalla and T. N. Chawla,
have projected information to the best of our ability. who were the tridents of the Indian peninsula and also
the founding bastion of Periodontology.
The book has been foreworded by my Prof Newell
Johnson who is presently the Dean at Dental School at Sir Isaac Newton once said, If we are today, it is
Griffith University Gold Coast Australia. The keying of because we are sitting on the shoulder of the giants.
the content has been done skillfully and painstakingly No wonder, but for our teachers, we would not have
by Mr. R. C. Nagaraja Rao, a gifted software exponent learnt to teach the younger generation! We have to give
from Bengaluru. Again, graciously acknowledged are back what we have taken.

T. R. Gururaja Rao
xxvi Milestones
of the Book

Milestones of the book

PREFACE TO THE REVISED SECOND
EDITION

A fter successful attempt in providing comprehensive U.S.A, Prof. Mark Bartold, Australia, Prof. Isao
version of the first Text Book of Periodontology Ishikawa, Japan, Prof. Chung Kong Mun, Singapore,
written by an Indian author, there was over whelming Prof. Regina Morales, Philipines, Capt. Amrender
response. All over India and abroad the book was Vadivelu, Chennai during International congresses and
appreciated for lucid description of various chapters. several suggestions were offered to me in updating the
book.
Presently, in this revised edition, fifteen chapters
have been included namely Periodontal Medicine, Another interesting aspect of the book is brief
Polymorphonuclear leukocytes, Lipoxins - Resolution of introduction on communication skills, dissertation,
inflammation, Genotype polymorphism in periodontitis, seminar and journal clubs. There are no books which
Periodontal disease in children and adolescents, National tells the students how to read, remember, write, and how
Survey of Periodontal Diseases, Advanced Diagnostic to present. Here, in this book a unique attempt has been
Techniques, Instrumentarium, Suture and Suturing made to provide the important art of communication.
Technique, Recent advances in Periodontal, Surgical A list of 98 seminar topics have been included for the
Technology, Periodontal Esthetics, Pre Prosthetic students to prepare for postgraduate studies. A model
Surgery in Periodontics, Stem Cell Research, Bone of case history, syllabus of Post graduate program is
Morphogenetic Proteins, Communication skills, journal also given.
clubs and dissertation.
I am sure that this book will surely find a place for
There has been several interactions with eminent Post graduate students as well as the under graduate
Periodontologists of world namely Prof. Van Dyke students. The ultimate goal of the book is to provide
all the details of the subject of Periodontology in one
book. I look forward to your suggestion and criticisms.
Please do not hesitate to provide me necessary inputs.

T. R. Gururaja Rao
 Milestones xxvii
of the Book

Milestones of the book

PREFACE TO THE SECOND EDITION

I must place on record my appreciation to the comments

of Prof. K.L. Banerjee former professor and Head.
Department of Periodontology, Dr. R. Ahmed Dental
the success of the book. I herewith acknowledge with
gratitude to these eminent teachers. This book has been
introduced by Professor C. Bhasker Rao, Principal
College and Hospital, Calcutta. Prof. N.W. Johnson. S.D.M. College of Dental Sciences, Dharwad.
Nuffield. Professor of Dental Sciences. Kings College
School of Medicine and Dentistry. Dental School, I would like to acknowledge him with thanks for
Caldicot Road. London, Dr. Andy Shahani 650. South providing me the necessary permission to go through
First Avenue. Covina. California, U.S.A. the library books, journals and dissertations facilities
during my period of tenure at SDM Dental Collie and
In providing this book it was the hard work of several Hospital. Dharwad. I also thank him for writing a few
persons to whom I would like to acknowledge. At words for this book.
the out set my gratitude goes to beloved teacher late
Dr. K.R. Devanath. former professor and head of the In this edition of the book, attempts have been
department of periodontology. Government Dental made to provide recent advances in several fields
College and Hospital, Bangalore. and Principals of namely biology of the periodontal tissues, pathology,
several dental colleges in the state of Karnataka. He microbiology of periodontal diseases, diagnostic
had been my guide, philosopher, and mentor who had aids, osseous regenerative procedures, computers,
encouraged me towards my achievements. This book radiography in periodontics. implants-periimplants.
has been contributed by several co-authors. Professor AIDS, on infection control. There are over twenty two
Newell Johnson. London, Professor Jacob T. Kaimenyi. plates with over one hundred twenty five photographs,
Nairobi, Professor P.K. Basker. Chennai. Professor T.K. eight line diagrams and four X-ray plates.
Pal. Kolkutta, Professor S.A. Kale, Mumbai. Professor
S.M. Joshi. Pune. Dr. Vijay Chava, Dharwad. I have I would like to acknowledge the efforts of Ms.
also to place on record and acknowledge our beloved Anandhi. Chennai for the excellent typesetting,
Teacher Dr. S.A. Kale, M.D.S.. D.D.P.H., Former Mr. Anil, Bangalore. Mr. Madhukar. Dharwad for
Dean. Government Dental College and Hospital, their photography. It was my good fortune to have
Mumbai, Former Joint Director for Medical Education. Mr. Rajender K. Arya of All India Publishers and
Government of Maharashtra. in providing me guidance Distributors, Chennai who helped me to print, publish
and accepting to do the proofreading. I would like to the second edition. I acknowledge with thanks for his
sincerely thank all of them for their part in providing total efforts for bringing this book.
necessary suggestion, alterations, contributions for

T. R. Gururaja Rao
xxviii Milestones
of the Book

Milestones of the book

PREFACE TO THE FIRST
EDITION

P eriodontal diseases have been ubiquitous in nature. evolved. With consorted efforts, this book has come
No race is free from it. No Human being is without into existence after three editions in cyclostyled prints.
this dreadful disease. Possibly it an old scourge on the
mankind. It is regarded as number two disease which The book has been written in three parts. In the first part
afflicts mankind after common cold according to there is a brief introduction and resume of anatomy,
Guinness Book of World Records. pathology of periodontal tissues, methodology of
treatment and prevention. The second part of the book
Periodontal diseases are known from the earliest gives an account of detailed answers to the relevant
civilization of 3000 B.C. Babylonian and Egyptian topics. The third part provides special information to
aptly studied the diseases in those days. Today the the reader about the applied aspects of basic sciences.
awareness of the need for a more scientific approach
has been emerging. Scientists with sophisticated tools I am sure it will be useful for the students of third and
have brought periodontology into the main stream of final B.D.S. students who are taking periodontology.
biological sciences. Tremendous progress has been This preparation is also helpful for students who
made in the anatomy of periodontal tissues, nature of are taking post graduate entrance examinations in
periodontal diseases, in its treatment and prevention. periodontology. My efforts would have failed if I
will not acknowledge the hard work of printing the
There was a need to provide a detailed account of text by Mr. Pradeep Saldhana,to the Printers Mr.
knowledge with respect to the periodontal tissues, its Raghavendra of Swantanra Mudranalaya, Bangalore,
diseases, treatment, and prevention in Indian context. and to Mr.Ramalinge Gowda for cover design. A special
So far no attempt had been made. The preparation of gratitude is owed to my parents who have encouraged
this book goes back as early as in 1980 when a few me through out. My work is all due to sacrifices made
students were entrusted to provide short but relevant by my wife in tolerating the long hours spent In writing
answers to the questions. Eventually as a teacher in the book.
periodontology, now an attempt to provide a book

T. R. Gururaja Rao
 Inception xxix
of the Book

Inception of the book

Periodontology and Periodontics Third (cyclostyled ) Edition April

By Dr T.R.Gururaja Rao .M.D.S., M.Sc(London) 1987.
Vice Principal, Prof and Head Department of
Periodontology ,College of Dental Surgery, Manipal Introduction:
Manipal ,576119.
Periodontal diseases have been ubiquitous in nature.
First Edition April 1982 No race is free from it; no human being is without this
dreadful disease. Possibly it is an old scourge on the
Foreword mankind.
It has been a pleasure to go through this book .I am
sure this unique method of presenting the subject of Periodontal diseases are known from the earliest
periodontology to the students who have to study civilization of 3000.B.C. The disease was aptly studied
for their B.D.S Examination will greatly benefit. I by Babylonians, Egyptians in those days. So said R.
congratulate Dr T. R. Gururaja Rao who have taken the W. Bunting just about 50 years ago Pyorrhoea is
trouble for this book definitely a preventable disease and a great majority of
cases which are not hopelessly affected be stopped, the
Dr. S. S. Khera, M.S.D. lesions healed, and the disease permanently controlled
10th April 1982 by simple and rational form of treatment.
Ex Professor and Head Department of Oral and
Maxillo facial Surgery, Government Dental College Awareness of the need for a more scientific approach
and Hospital, Mumbai has been emerging in the scientists and sophisticated
Ex Director Dental Studies College of Dental Surgery tools have brought periodontology into the main stream
, Manipal 576119, KLE Society Dental College and of biological sciences. Tremendous progress has been
Hospital, Belgaum(Karnataka ) made in the anatomy of periodontal tissues, nature of
--------------------------------------------------------------- periodontal disease, and in its treatment and prevention.

Since the pertinent field of periodontology has been

dealt to a large extent to the best of the available
literature and period still there are a few topics which
have remained untouched. It is the opinion of the
author that this attempt to present dental profession
an appraisal of the current status of science and art of
Periodontology would merely be an analogy.
xxx Inception
of the Book

Preface to the Third (cyclostyled) First Printed book

Edition
Principles and Practice of Periodontology
It is my pleasure to present the third edition of this
book to you. After a series of repeated introspective Introduction:
healthy criticism I have been encouraged to add several Books in all fields in Dentistry are needed especially so
chapters into the new book. in the field of periodontology as periodontal diseases
are a major dental health hazard in our country.
I wish to thank the 150 students who have read it
with interest. My efforts would have failed if I would The book Principles and Practice of Periodontology
not have got stenographer Mr Umesh Nayak for has a lot of information which has been updated and
transcription and Mr Krishnarajan for his hard work of presented in a concise form .It provides a very useful
typing, cyclostyling and binding and selling. and interesting reading for both senior dental students
and also for practitioners in dentistry.
Once again,I have been pleased with success due to my
revered Principal Dr K. S. Bhat who had permitted me Dr K. R. Devanath, M.B.B.S., M.D.S., Cert in Perio
to use the department for the secretarial work. I hope (USA)
the readers would find it more interesting to go through Ex Prof and Head Department of Periodontology,
the latest text. Government Dental College and Hospital, Bangalore
560002
Your criticism is solicited at all times
Ex Principal, Bapuji Dental College and Hospital,
Manipal Davanagere, Ex Principal Ramaiah Dental College
4th May 1987 T.R.GURURAJA RAO and Hospital, Bangalore
---------------------------------------------------------------
 M.D.S Course in xxxi
Periodontics

M.D.S Course in Periodontology and

Oral Implantology

Objectives reach to the public to motivate and educate

regarding periodontal disease, its prevention and
The following objectives are laid out to achieve the consequences of not treated
goals of the course: Plan out epidemiological survey to assess prevalence
and incidence of aggressive periodontitis and adult
Knowledge periodontitis in India population (Region wise)
Discuss historical perspective to advancement in the Shall develop knowledge, skill in the science and
subject proper and related topics: practice of Oral Implantology
Describe etiology, pathogenesis, diagnosis and Shall develop teaching skill in the field
management of common periodontal diseases with Periodontology and Oral Implantology skills
emphasis on Indian population
Familiarize with the biochemical, microbiologic Skills
and immunologic genetic aspects of periodontal
pathology Take a proper clinical history, through examination
Describe various preventive periodontal measures of intra oral, extra oral, medical history evaluation,
Describe various treatment modalities of periodontal advice essential diagnostic procedures and interpret
disease from historical aspect to currently available them to come to a reasonable diagnosis
ones Effective motivation and education regarding
Describe interrelationship between periodontal periodontal disease maintenance, after the treatment
disease and various systemic conditions Perform both non-surgical & education regarding
Describe periodontal hazards due to iatrogenic periodontal disease maintenance after the treatment
caused and deleterious habits and prevention of it Perform both non-surgical and surgical procedures
Identify rarities in periodontal disease and independently
environmental/Emotional determinants in a given Provide Basic Life Support Service (BSL)
case recognizes the need for and advance life support
Recognize conditions that may be outside the area and does the immediate need for that Human values,
of his Speciality/competence and refer them to an ethical practice and communication abilities
appropriate Specialist Adopt ethical principles in all aspects of treatment
Decide regarding non-surgical or surgical modalities. Professional honesty and integrity are to
management of the case be fostered. Develop communication skills to make
Update him by attending course, conferences awareness regarding periodontal disease. Apply
and seminars relevant to periodontics or by self- high moral and ethical standards while carrying out
learning process human or animal research. Be humble, accept the
Plan out/carry out research activity both basic and limitations in knowledge and skill, and ask for help
clinical aspects with the aim of publishing his work from colleagues when needed. Respect patients
in scientific journals rights and privileges, including patients right to
information and right to seek a second opinion.
xxxii M.D.S Course in
Periodontics

Course Contents Pathology

1. Cell structure and metabolism
Paper I 2. Inflammation and repair, necrosis and degeneration
Applied Anatomy: 3. Immunity and hypersensitivity
1. Development of the periodontium 4. Circulatory disturbances - edema, hemorrhage,
2. Micro and Macro structural anatomy and biology shock, thrombosis, embolism, infarction
of the periodontal tissues and hypertension.
3. Age changes in the periodontal tissue 5. Disturbances of nutrition
4. Anatomy of the Periodontium 6. Diabetes mellitus
Macroscopic and microscopic anatomy 7. Cellular growth and differentiation, regulation
Blood supply of the Periodontium 8. Lab investigations
Lymphatic system of the Periodontium 9. Blood
Nerves of the Periodontium
5. Temporomandibular joint, Maxillae and mandible Microbiology
6. Cranial nerves (5, 7, 9, 11, 12) 1. General bacteriology
7. Tongue, oropharynx a. Identification of bacteria
8. Muscles of mastication b. Culture media and methods
c. Sterilization and disinfection
Physiology 2. Immunology and infection
1. Blood 3. Systemic bacteriology with special emphasis on oral
2. Respiratory system - Acknowledge of the respiratory microbiology - staphylococci genus actinomyces
diseases which are a cause of periodontal diseases and other filamentous bacteria and actinobacillus
(periodontal Medicine) actinomycetumcomitans porphyromonas species.
3. Cardiovascular system 4. Virology
(i) Blood pressure a. General properties of viruses
(ii) Normal ECG b. Herpes, Hepatitis, virus, HIV virus
(iii) Shock 5. Mycology
4. Endocrinology - hormonal influences on a. Candidiasis
Periodontium 6. Applied microbiology
5. Gastrointestinal system 7. Diagnostic microbiology and immunology, hospital
a. Salivary secretion - Composition, function & infections and management.
regulation
b. Reproductive physiology Pharmacology
i. Hormones - Actions and regulations, role 1. General pharmacology
in periodontal disease a. Definitions - Pharmcokinetics with clinical
ii. family planning methods applications, routes of administration
6. Nervous system Including local drug delivery in Periodontics
a. Pain pathways b. Adverse drug reactions and drug interactions
b. Taste - Taste buds, primary taste sensation & 2. Detailed pharmacology of
pathways for sensation a. Analgesics - opiod and nonopiod
b. Local anesthetics
Biochemistry c. Haematinics and coagulants, Anticoagulants
1. Basics of carbohydrates, lipids, vitamins, proteins, d. Vit D and Calcium preparations
enzymes and minerals e. Antidiabetics drugs
2. Diet and nutrition and periodontium f. Steroids
3. Biochemical tests and their significance g. Antibiotics
4. Calcium and phosphorus h. Antihypertensive
i. Immunosuppressive drugs and their effects on
oral tissues
 M.D.S Course in xxxiii
Periodontics

j. Antiepileptic drugs 5. Basic concepts of inflammation and immunity

3. Brief pharmacology, dental use and adverse effects 6. Microbial interactions with the host in periodontal
of diseases
a. General anesthetics 7. Pathogenesis of plaque associated periodontal
b. Antypsychotics diseases
c. Antidepressants 8. Dental calculus
d. Anxiolytic drugs 9. Role of iatrogenic and other local factors
e. Sedatives 10. Genetic factors associated with periodontal diseases
f. Antiepileptics 11. Influence of systemic diseases and disorders of the
g. Antihypertensives Periodontium
h. Antianginal drugs 12. Role of environmental factors in the etiology of
i. Diuretics periodontal disease
j. Hormones 13. Stress and periodontal diseases
k. Pre-anesthetic medications 14. Occlusion and periodontal diseases
4. Drugs used in Bronchial asthma, cough 15. Smoking and tobacco in the etiology of periodontal
5. Drug therapy of diseases
a. Emergencies 16. AIDS and periodontium
b. Seizures 17. Periodontal medicine
c. Anaphylaxis 18. Dentinal hypersensitivity
d. Bleeding
e. Shock Paper III
f. Diabetic ketoacidosis
g. Acute addisonian crisis Clinical and Therapeutic Periodontology and
6. Dental Pharmacology Oral implantology
a. Antiseptics Please note:
b. Astringents Clinical periodontology includes gingival diseases,
c. Sialogogues periodontal disease, periodontal instrumentation,
d. Disclosing agents diagnosis, prognosis and treatment of periodontal
e. Antiplaque agents diseases
7. Fluoride pharmacology
I. Gingival Diseases
Biostatistics 1. Gingival inflammation
1. Introduction, definition and branches of biostatistics 2. Clinical features of gingivitis
2. Collection of data, sampling, types, bias and errors 3. Gingival enlargement
3. Compiling data-graphs and charts 4. Acute gingival infections
4. Measures of central tendency (mean, median and 5. Desquamative gingivitis and oral mucous
mode), standard deviation and variability membrane diseases
5. Tests of significance (chi square test t test and Z - 6. Gingival diseases in the childhood
test)
6. Null hypothesis II. Periodontal diseases
1. Periodontal pocket
Paper II 2. Bone loss and patterns of bone destruction
3. Periodontal response to external forces
Etiopathogenesis 4. Masticatory system disorders
1. Classification of periodontal diseases and 5. Chronic periodontitis
conditions 6. Aggressive periodontitis
2. Epidemiology of gingival and periodontal diseases 7. Necrotising ulcerative periodontitis
3. Defense mechanisms of gingiva 8. Interdisciplinary approaches
4. Periodontal microbiology - Orthodontic
xxxiv M.D.S Course in
Periodontics

- Endodontic 6. Periodontal flap

9. Periodontic considerations in periodontal therapy 7. Osseous surgery (resective and regenerative)
8. Furcation; Problem and its management
III. Treatment of periodontal diseases 9. The periodontic - endodontic continuum
A. History, examination, diagnosis, prognosis and 10. Periodontic plastic and esthetic surgery
treatment planning 11. Recent advances in surgical techniques
1. Clinical diagnosis
2. Radiographic and other aids in the diagnosis of E. Future directions and controversial questions in
periodontal diseases periodontal therapy
3. Advanced diagnostic techniques 1. Future directions for infection control
4. Risk assessment 2. Research directions in regenerative therapy
5. Determination of prognosis 3. Future directions in anti-inflammatory therapy
6. Treatment plan 4. Future directions in measurement of periodontal
7. Rationale for periodontal treatment diseases
8. General principles of anti-infective therapy with
special emphasis on infection control in F. Periodontal maintenance phase
periodontal practice 1. Supportive periodontal treatment
9. Halitosis and its treatment 2. Result of periodontal treatment
10. Bruxism and its treatment
IV. Oral implantology
B. Periodontal instrumentation 1. Introduction and historical review
1. Instrumentation 2. Biological, clinical and surgical aspects of dental
2. Principles of periodontal instrumentation implants
3. Instruments used in different parts of the mouth 3. Diagnosis and treatment planning
4. Implant surgery
C. Periodontal therapy 5. Prosthetic aspects of dental implants
1. Preparation of tooth surface 6. Diagnosis and treatment of Peri implant
2. Plaque control complications
3.Anti microbial and other drugs used in periodontal 7. Special emphasis on plaque control measures
therapy and wasting diseases of teeth implant patients
4. Periodontal management of HIV infected patients 8. Maintenance phase
5. Occlusal evaluation and therapy in the management
of periodontal diseases V. Management of Medical Emergencies in
6. Role of orthodontics as an adjunct to periodontal Periodontal practice
therapy
7. Special emphasis on precautions and treatment for Teaching / Learning Activities
medically compromised Seminars :- A minimum of 15 seminars to be
patients presented by each student during the
8. Periodontal splints P.G. course (Atleast 5 seminar per year)
9. Management of dentinal hypersensitivity Journal clubs :- A minimum of 25 journal articles
to be reviewed by each student
D. Periodontal surgical phase - special emphasis on during the P.G course
drug prescription Interdepartmental Seminars :- Each P.G. student
1. General principles of periodontal surgery should present at least 1 seminar in an
2. Surgical anatomy of periodontium and related interdepartmental meeting during the P.G. course.
structures Such meeting may be held at least once
3. Gingival curettage every month
4. Gingivectomy technique Library Assignment :- One to be presented at the
5. Treatment of gingival enlargements end of 18 months of the course
 M.D.S Course in xxxv
Periodontics

Academic Activities: Second year

1. Clinical Work 10 Cases
I year 2. Case history and treatment planning 5 Cases
Submission of synopsis for Dissertation - within 6 3. Local Drug Delivery techniques
months from the start of the course 4. Periodontal surgical procedures
- Pocket therapy
Library Assignment I - to be submitted at the end of the - Muco-gingival surgeries
I year - Implants (2 implants)
- Management of perio endo problems
II year 5. Occlusal adjustments 10 Cases
Library Assignment II - to be submitted at the end of 6. Perio splints 10 Cases
the II year
Third year
Scientific Paper presentation at the conferences Clinical work
1. Regenerative techniques
III year - Using various graft and barrier membranes
Scientific paper/Poster presentation at conferences 2. Record, maintenance and follow up of all treated
cases including implants
Submission of Dissertation - 6 months before
completion of III year Assessment examinations :- In addition to the regular
evaluation , log book etc., assessment examination
Skills should be conducted once every six months & progress
of the student monitored
First year - Pre - Clinical work
Dental Note : The number of cases mentioned are minimum
1. Practice of incisions and suturing techniques on the number to be performed by each candidate.
typhodont models
2. Fabrication of bite guards and splints Submission of Synopsis for Dissertation should be done
3. Occlusal adjustments on the casts mounted on the within 6 months of the commencement of the course.
articulator
4. X - Ray techniques and interpretation Submission of two copies of Library Assignments at
5. Local anesthetic techniques the end of 1 and 2 year.
Medical
1. Basic diagnostic microbiology and immunology, Submission of pre-clinical work as scheduled.
collection and handling of sample,
culture techniques Submission of Dissertation - 6 months before
2. Basic understanding of immunological diseases completion of III year.
3. Interpretation of various biochemical investigations
4. Practical training and handling medical emergencies Maintenance of Work Diary/Log book.
and basic life support devices
5. Basic Biostatistics - Surveying and data analysis Monitoring Learning Progress
Clinical work
1. Applied periodontal indices 10 Cases It is essential to monitor the learning progress to each
2. Scaling and root planning (SRP) candidate through continuous appraisal and regular
a. Hand 15 Cases assessment. It not only helps teachers to evaluate
b. Ultrasonic 15 Cases students, but also students to evaluate themselves. The
3. Curettage 10 Cases monitoring to be done by the staff of the department
4. Gingivectomy 20 Cases based on participation of students in various teaching/
5. Gingivoplasty 10 Cases
xxxvi M.D.S Course in
Periodontics

learning activities. It may be structured and assessment 1st day

be done using checklists that assess various aspects.
Case discussion
Scheme of Examination Long case - One
A. Theory : 400 Marks Short cases - Two
Written examination shall consist of four question
papers each of three hours duration. Total marks for Periodontal surgery - Periodontal flap surgery on a
each paper will be 100. Paper I, II and III shall consist previously prepared case in one quadrant on the mouth
of two long questions carrying 20 marks each and 6 after getting approval from the examiners
short essay questions each carrying 10 marks. Paper IV
will be on Essay. Question on recent advances may be 2nd day
asked in any of the papers. Distribution of topics for
each paper will be as follow: Post - surgical review and discussion of the case treated
on the 1st day
Paper I : Applied Basic Sciences : Applied Anatomy,
Physiology & Biochemistry, Pathology, Microbiology, Presentation of dissertation & discussion
Pharmacology, Research Methodology and Biostatistics All the examiners shall participate in all the aspects
Paper II : Normal Periodontal structure, Etiology & of clinical examinations / Viva Voce Distribution of
Pathogenesis of Periodontal diseases, epidemiology as Marks for Clinical examination (recommended)
related to Periodontics a) Long Case discussion 50
Paper III : Periodontal diagnosis, therapy & Oral b) 2 short cases 25 2 = 50
implantology c) Periodontal surgery 75
Paper IV : Essay (with emphasis on recent advances in Post - operative review 25
periodontics) Total 200
* The topics assigned to the different papers are
generally evaluated under those sections. However C. Viva Voce 100 Marks
a strict division of the subject may not be possible i. Viva - Voce examination: 80 marks
and some overlapping of topics is inevitable. All examiners will conduct viva - voce conjointly
Students should be prepared to answer overlapping on candidates comprehension, analytical approach,
topics. expression, interpretation of data and communication
B. Practical / Clinical Examination : 200 marks skills. It includes all components of course contents.
The clinical examination shall be of two days duration It includes presentation and discussion on dissertation
also.

ii. Pedagogy : 20 marks

A topic be given to each candidate in the beginning
of clinical examination. He/she is asked to make a
presentation on the topic for 8 - 10 minutes.
 Department of xxxvii
Periodontology

Department of Periodontology

POST GRADUATE CASE HISTORY RECORD

Students name

Case No. :

Supervisors Name

Treatment:

Started on:

Completed on:

Case Analysis:
xxxviii Department of
Periodontology

Completed on:

I, aged S/O or D/O

residing at consciously and willingly give my consent for diagnostic
Examination, Biopsy, transfusion or operation under any type or anesthesia and agree that no responsibility will be
borne by surgeon or hospital staff and the risk has been explained to me in my own language and will follow the
instructions given by the concerned doctor and come for the future follow-ups as and when necessary.

Signature of the patient _______________________

Date ______________________________________

Witness ___________________________________

NAME DATE

AGE OPD NO

SEX ADDRESS

OCCUPATION PHONE NO

CHIEF COMPLAINT :

PRESENT DENTAL HISTORY:

PAST DENTAL HISTORY:

MEDICAL HISTORY:

MEDICATION:

Oral Hygiene Habits:

Type of brush
Dentifrice
Frequency
Direction / technique
Others
Dietary habits
 Department of xxxix
Periodontology

General examination
Extra oral examination
Symmetry of face
Lymph glands
TMJ
Lip seal

Intra oral examination

Buccal Mucosa:
Labial Mucosa:
Tongue:
Floor of the mouth
Hard Palate
Adverse Habits:
Tobacco:
Pan Chewing:
Betel nut Chewing:
Smoking:
Parafunctional:
Any other habits:

Oral Hygiene Status:

A) O.H.I-S (Green & Vermillion)
Debris Index

6 1 6

Total DI-Score
Calculus Index

6 1 6

Total CI-Score
Total OHI-S Score per person DI - S + CI - S

B) Status of Oral Hygiene:

Good:
Fair:
xl Department of
Periodontology

Poor:

C) Halitosis:
Gingival status

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37
Color:
Consistency:-
Position:-
Contour:-
Stillmans Clefts
Mc calls Festoons:
Size
Surface Texture
Bleeding on Probing:
Exudation:

Gingival Index (Loe & Silness)

 Department of xli
Periodontology

Mobility Grade
Furcation Grade
Pathological Migration/Drifting
Pockets

Pockets
Pathological Migration/Drifting
Furcation Grade
Mobility Grade

Mucogingival Problems:
Recession:
Width of Attached Gingiva: Adequate: Inadequate:
Depth of Vestibule:
Shallow; Adequate:
Frenal attachment: Mucosal attachment
Gingival attachment
Papillary attachment
Papilla - penetrating
Tension test:

Periodontal status assessment:

Russells periodontal index:

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

P. I score per person = sum of individual scores / no. of teeth present

Dental status:
No. of teeth Present:
Unreplaced Missing Teeth:
xlii Department of
Periodontology

Extrusion:
Restorations:
Plunger Cusp:
Tooth Anatomy
Malposition:
Food Impaction:
Hypersensitivity:
Wasting Disease:
Attrition:
Abrasion:
Erosion:
Occlusal Analysis:

Type of Malocclusion:
Overbite:
Overjet:
Cross bite:
Open Contacts:
Crowding:
Wear Pattern (facets)
Trauma from Occlusion (Fremitus Test)
Prematurities:

Laboratory Investigation:-

1. Complete Haemogram
a) RBC Count:
b) WBC Count. (TC):
c) Differential Count:
d) Haemoglobin:
e) Platelet Count:
f) Bleeding Time:
g) Clotting Time:
h) E.S.R.
i) Others:

2. Blood Sugar Analysis

i) Fasting blood Sugar:
ii) Postprandial blood Sugar
iii) Random Blood Sugar

3) Urine analysism
i) Sugar
ii) Albumin.

4) Microbiological analysis:-

5) Serological Test:
 Department of xliii
Periodontology

6) Biopsy :

7) Roentgenographic Findings
Extra oral
Intra oral
OPG
cephalogram

Diagnosis:

Differential diagnosis

Prognosis:
Overall:
Individual:

Study Models :
Pre-Operative

Post-Operative

Photographs:
Pre-Operative
Post-Operative

Treatment Plan:
Preliminary Phase;
Phase I Therapy -ETIOTROPHIC PHASE:

Evaluation of response to phase - I:

Phase II therapy - Surgical phase:

Phase III therapy - Restorative phase:

Phase IV therapy - Maintenance phase:

xliv Pre-operative
Examination chart

Pre - operative Examination Chart

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

Lingual

R AB L

Maxillary
Facial

A
B

Facial

R AB L

Mandibular
Lingual

A
B

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

KEY TO CHARTING

A. Marginal gingiva - N Normal, E edematous. F Mobility - record (1), (2), (3), on crown
fibrotic, B Interdental gingiva - same also C crater Drifting - indicate with an arrow in direction of
Missing teeth - Black out, if replaced black out only movement.
root Plunger cusp - indicate with an arrow.
Gingival margin - draw using CEJ as guide Clasped tooth - draw oblique line through crown.
Pocket - measure in 3 places and colour red. Muscle attachement - V
Mucogingival Junction - draw blue line. Extruded tooth -
Abnormalities in crown or root form - draw. Bifurcation or trifurcation - X in area
Malposed teeth - draw in position. Infrabony pocket - I.F.P -(1), (2), (3), WALLS.
Deficient contacts - draw 2 vertical parallel lines Facets outline on occlusal surface.
through the contact.
 Pre-operative xlv
Examination chart

CASE ANALYSIS

RECALLS

DATE WORK DONE REMARKS SIGN

xlvi Post-operative
Examination chart

Post - operative Examination Chart

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

Lingual

R AB L

Maxillary
Facial

A
B

Facial

R AB L

Mandibular
Lingual

A
B

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

KEY TO CHARTING

A. Marginal gingiva - N Normal, E edematous. F Drifting - indicate with an arrow in direction of

fibrotic, B Interdental gingiva - same also C crater movement.
Missing teeth - Black out, if replaced black out only Plunger cusp - indicate with an arrow.
root Clasped tooth - draw oblique line through crown.
Gingival margin - draw using CEJ as guide Muscle attachement - V
Pocket- measure in 3 places and colour red. Extruded tooth -
Mucogingival Junction - draw blue line. Bifurcation or trifurcation - X in area
Abnormalities in crown or root form - draw. Infrabony pocket - I.F.P -(1), (2), (3), WALLS.
Malposed teeth - draw in position. Facets outline on occlusal surface.
Deficient contacts - draw 2 vertical parallel lines
through the contact.
Mobility - record (1), (2), (3), on crown
 List of xlvii
Seminar Topics

List of seminar topics

1. Epithelium in health with special reference to 28. Lymphatic drainage of head and neck
junctional epithelium and in disease with Special 29. Advanced diagnostic methods in periodontics -
reference to keratinization microbiological aspects
2. Ultrastructure and microcirculation of Gingiva, 30. Cranial nerves - Trigeminal and Facial nerve
Histochemistry of gingiva 31. psychosomatic influence on oral mucosa
3. Collagen 32. gingival enlargements
4. Alveolar bone in health and disease 33. prosthetic procedures in managements of
5. Cementum in health and disease periodontal diseases
6. Periodontal Ligament, age changes in periodontium 34. Connective tissue in health and diseases
7. Diagnosis and treatment planning 35. Trauma from occlusion
8. Gingival fluid in health and disease 36. SRP, Root planing and Biomodificaiton of root
9. Ultra structure of cell surface
10. Anatomy of maxilla and its development 37. History of Flap designs, classification and its
11. Role of Dental Plaque in etiology of periodontal importance
diseases and bacterial products. 38. osseous regenerative procedures in periodontics
12. Chemical mediators and inflammation. 39. osseous resective procedures in periodontics
13. Anatomy of mandible and its development 40. Animal models in periodontics
14. Muscles of mastication 41. Nutritional influence on periodontal health
15. Role of systemic factors in etiology of periodontal 42. Endocrinological influence on periodontal tissues
diseases. 43. hematological influence on periodontium
16. Host responses in periodontal diseases 44. Dermatological lesions and its influence on
17. Cultural media employed for oral bacteria, methods periodontium
of identification with emphasis to Actinobacillus 45. Physics behind periodontal instrumentation
actinomycetamcommitans, porphyromonas 46. Periodontal splints and its role in periodontics
18. Muscles of facial expression 47. Orthodontics periodontal relationship
19. Temporomandibular joint 48. restorative periodontal relationship
20. Cryosurgery and Electro surgery 49. Pulpo periodontal problems and managements
21. Philosophy of periodontal pockets formation, 50. Evolution and development of mammalian
pathogenesis, histopathological changes in tissues periodontium
22. Forms of periodontitis - Aggressive Peridontitis 51. Occlusal therapy in periodontics
23. Rapidly progressing periodontitis, chronic 52. iatrogenic causes of periodontal diseases and
periodontitis management
24. Asepsis and sterilization of dental instruments 53. Biomaterials in periodontics, its utility and
25. Mode of administration of drugs and drug importance in periodontics
interactions 54. Laser in Periodontics
26. Chemotherapeutic drugs and local drug delivery in 55. Mucogingival problems and its management
periodontics 56. Periodontal instruments and latest designs in
27. Blood supply of head and neck and periodontal instruments
tissues 57. AIDS and Periodontium. Recent advances in
diagnosis and management
xlviii List of
Seminar Topics

58. Gingival and Periodontal diseases in children 81. Bone Morphogenetic Proteins
59. Biologic aspects of Implant therapy(Osseo- 82. Role of viruses in periodontal diseases
integration) 83. Drug and Periodontium
60. Clinicosurgical aspects of implantology 84. Plaque control measures in periodontal therapy
61. Peri implantitis and its management 85. Gingivectomy and other excisional procedures and
62. Eruption of teeth, theories and concepts its relevance in periodontics
63. Pain, types of pain and pathways of pain 86. Medical emergencies and life support measures in
64. Physiology of mastication and deglutition periodontics
65. Repair and regeneration 87. Smoking and tobacco in etiology of periodontal
66. Local anesthetics - merits and demerits diseases
67. Analgesics and anti - inflammatory drugs 88. Route of administration of drugs, bio transformation
68. Antibiotics in the management of periodontal of drugs
diseases-concepts and long term evaluation 89. Oral microbial flora and its significance Bacterial
69. Epidemiology flora of plaque
70. Research methodology - principles and pit falls of 90. Acute Gingival infections and its management
clinical trials - current concepts 91. Acute gingival and periodontal abscess including
71. Periodontal indices and their reliability - usefulness, differential diagnosis and management
advantages and disadvantages 92. Actinobacillus Actinomycetamcommitans,
72. Risk factors in periodontal diseases P.Gingivalis.
periodontium 93. Advanced diagnostic aids in periodontics - other
73. Periodontal dressings. Controversies in their methods
use 94. Incidence and prevalence of periodontal diseases
74. Cervical dentinal hypersensitivity and management in India as compared to developed countries and
75. Ultrasonic versus hand instrumentation change in trends
76. Tissue engineering 95. Diabetes mellitus and its influence on periodontal
77. Supportive periodontal therapy tissues
78. Genetic implications in periodontics 96. Guided tissue regeneration
79. Periodontal medicine 97. Ultrasonic versus hand instrumentation
80. Calculus and its role in its role in its etiology of 98. Stress and periodontium
periodontal diseases
 xlix

Introduction

History Of
Periodontology
l
 Introduction

History of
Periodontology

T. R. Gururaja Rao

S ince early times, homo sapiens are afflicted with

dental problems. Gingival and periodontal diseases
are also shown to be affecting since the dawn of
instructions for oral hygiene. These developments
were beautifully documented by the great pioneer
in American periodontology Dr Isadore Hirschfeld
history. Studies in paleopathology have indicated that in his classic work, The tooth brush its use and
destructive periodontal diseases as evidenced by bone abuse. Hirschfeld noted that it was common for our
loss affected humans in such diverse cultures as ancient Simian ancestors to use bits of straw as tooth picks.
Egypt and early pre-Columbian America. He also indicated that the Buddhists, Hebrews and
Mohmmadans incorporated a ritual tooth cleaning into
The earliest assumptions about disease were related religious practice, several thousand years ago. In his
to religious practices and frequently blamed on divine text he has noted that angled tooth brush heads as well
caprice or retribution for sin, illness or misfortune. This as inter-dental proximal brush were advanced for more
view held that disease or injury was a deserved evil than 140 years.
visited upon an individual by deity for infractions in
thought or deed. The earliest historical records dealing with medical
topics reveal an awareness of periodontal disease and
All well-defined cultures which left record of their need for treating them. Almost all of the early writings
history have mentioned gingival diseases. These that have been preserved have sections or chapters
included Sumerians, Egyptians, Hindus, Chinese, dealing with oral diseases, and periodontal problems
Hebrews, and Etruscans. take up a significant amount of space in their writings.
The relationship of calculus to periodontal disease was
Many early clinicians connected pathological often considered and underlying systemic disease was
conditions of the gingival with oral debris and often postulated as a cause of periodontal disorders.
uncleanliness and several religious treatises contained However, methodical carefully reasoned, therapeutic
lii History
of Periodontology

discussions did not exist until Arabs surgical treatises labours of the past ages, the world must remain in
of Middle Ages and modern treatment, with illustrated infancy of knowledge.
texts and sophisticated instrumentation did not develop
until the time of Pierre Fauchard. How much more important it is today to be aware of
our historical antecedents, when changes are occurring
so rapidly that only by keeping our eyes steadily on
what went before can we progress with intelligence and
confidence.

Pierre Fauchard Thus, the study of dental history is in every way

worthwhile, illuminating, fascinating and entertaining.

The first dental healers were physicians, but by the Ancient Civilization
middle ages the barbers surgeons of Europe had
specialized in the care of tooth. The practitioners not Greece
only learned by the trial and error method but also
made more progress in their new-fledged field than the The practice of oral hygiene was slow in coming to
doctors in the long-established practise of medicine. Greece. A disciple of Aristotle, Theophasus wrote that
The pace of achievement redoubled in the eighteenth it was considered a virtue to shave frequently and to
century, when the immortal Pierre Fauchard, through have white teeth; yet, regular dental care was not known
his great treatise, Le Chirurgien Dentiste solidly until Greece became a Roman province. Under the
established dentistry as a true profession. No longer Roman influence, the Greeks learned to use a multitude
mired in superstition and ignorance, at last, the field of materials as tooth cleaners, such as pumice, talc,
was based on sound rational and scientific principles. emery, ground alabaster, coral powder, and iron rust.

The medical works of ancient India devote a significant Among the ancient Greeks, Hippocrates of Cos (460-
amount of space to oral and periodontal problems. In 377B.C.) was the father of modern medicine. It is to
the Susruta Samahita there are numerous descriptions him that the honor of developing empirico-rational
of severe periodontal diseases with purulent discharge medicine belongs. He was the first man to separate
from the gingival. In a later treatise, Charaka Samahita, medicine from religion. He discussed the functions and
tooth brushing and oral hygiene have been stressed. eruption of teeth and also the etiology of periodontal
disease. He believed that the inflammation of gingival
It must be noted that although little has been written tissue could be caused by accumulation of pituita or
about the history of periodontology in recent times, calculus, with gingival haemorrhage occurring in cases
we must be greatly indebted to people like Sachs, of persistent diseases.
Hirschfeld, Frolich, Proskauer, Meritt and numerous
others who compiled detailed works from which we Ancient Greeks were ministered medically by
can draw both inspiration and substance. Aesclepiadae, priest physician, who traced his lineage
to Aesculapius, God of Medicine (Geist-Jacobi1899).
Dentists and dental researchers employed by The sons of Aesculapius, Podalinus, and Machaon
government agencies and individual practitioners recorded in the Homeric legend as warriors with unusual
struggling to meet professional demands would do surgical strength and skill. Among the daughters of
well to examine the history of dentistry and use that Aesculapius were Panacea and Hygiene, both of whom
knowledge as a directional. The only guide to what lies have remained within periodontal pantheon.
ahead is the study of the past. The great Roman orator
Cicero was well aware of this when he said: Not to Hippocrates dental treatment was most distinguished in
know what has been transacted in former times is to the area of fractures and dislocations. These instructions
continue always as a child. If no use is made of the in larger part remain accurate even today. One of the
 History liii
of Periodontology

better known dicta, Nature is the physician of disease, Galen of Pergamum gave more accurate anatomical
to do thy good, or at least to do no harm remains a descriptions of the teeth than were available until then.
good piece of advice to this day. It was however, with He was also the first to describe the innervations of
the recognition of Hippocrates that disease arose from the teeth as well as development of primary dentition.
natural causes and responded to specific remedy that Galen was the physician to Marcus Aurelius and other
laid the foundation for all development in medical Roman Emperors. He advocated conservative surgical
science resections, instead of amputations and his writings
indicate that he had considerable anatomical and
Romans surgical knowledge as well.

The Romans had high regards for oral hygiene. The Paul of Aegina differentiated between epulis, a fleshy
use of tooth cleansing procedure was apparently excrescence of gums in the area of a tooth and parulis,
widespread. The more involved their preparation and which he described as an abscess of the gums. He
the more numerous their ingredients, the more highly wrote that incrustations must be removed with either
were they regarded. A variety of substances were a scraper or a small file and that the teeth should be
used for this purpose: dentifricium bones, egg shells carefully cleaned after the last meal of the day.
and oyster shells. Having been burnt and sometimes
mixed with honey, they were reduced to a fine powder. He also considered the need for oral hygiene. He wrote
Although fancy and superstition dictated the choice of that black stains on the teeth were to be scrapped off
ingredients, the addition of such astringents as myrrh, and the teeth rubbed with a mixture of pounded rose
or nitre suggests a desire not only to clean the teeth leaves, wall nuts and myrrh after which the mouth was
but also to strengthen them when loose. References to be rinsed in pure wine.
have been found that a substance that Romans called
Nitrum, probably either potassium carbonate or sodium Egyptian
carbonate, was burnt and rubbed on the teeth to restore
their color. The earliest culture to record the daily activities
in detail were the Egyptians. Periodontal diseases
Among the Romans, Aulus Cornelius Celsius (25 B.C were the commonest of all diseases of which there is
to 50A.D.) referred to diseases that affect the soft parts evidence in the embalmed bodies of ancient Egyptians.
of mouth and their treatment as follows: If the gums The earliest evidence that has been well-documented
separate from the teeth, it is beneficial to chew unripe is George Ebers Papyri who had numerous references
pears and apples and keep their juices in the mouth. to both dental and gingival maladies. Numerous
He also described looseness of teeth to be caused by remedies were offered for strengthening the teeth and
weakness of their roots or by flaccidity of the gingival gingival tissues. This book is preserved in the library
tissue and noted that in these cases it is necessary to of Leipzig University and is the most voluminous and
touch the tissue lightly with a red hot iron and then best preserved work. Dating from about 1550BC, it is
smear it with honey. Celsius believed that stains on the not an original work for merely a compilation of many
teeth should be removed and the teeth then rubbed with medical texts of still earlier times some written as early
dentifrice. The use of tooth brush is mentioned in the as 1500 BC. It contains numerous references of dental
writings of many Roman poets. illnesses, including gingivitis, erosion, pulpitis, and
toothache. Among the treatment cited is one to cure
Celsius mentioned in his book (on medicine) about throbbing of bennet blisters of the teeth, probably
the ligation of loose teeth to stabilize them. It was some type of swelling of the gums in order to case
Celsius who first used the term tartar to describe the tooth that gnaws into the upper part of the flesh,
the concretions found on the teeth. He recognized the one was advised to use this formula: Reduce to a paste
periodontal abscess and described surgery of the gums and apply on the tooth one part of cumin, one part of
which included the use of cautery and lancet. He also incense, and one part of onion.
described gingival massage using a tooth brush.
Another remedy to cure blisters of the tooth and to
liv History
of Periodontology

strengthen the flesh (gingival) has also been described. have been stressed: The stick for brushing the teeth
It was composed of seps-grains, dough, honey and oil should be either astringent or pungent or bitter. One
to be applied locally as a plaster. Many such poultices of the ends should be chewed in the form of brush. It
or rinses for oral swelling and pain were also described. should be used twice a day taking care that the gums
not be injured. Following tooth cleansing the tongue
Since the red hot iron was used as cautery for the scraped with a portion of stick.
treatment of certain swellings or tumors, it is reasonable
to suppose that some surgical application was made of
this instrument in the mouth.

Herodotus (500 - 424 BC) described Egyptian

specialists in the 5th century BC, thus: Egypt is full of
doctors, those for the eyes, those for the head, some for Sushrutha
the teeth, others for the belly, or for occult maladies.

Archaeologists have noted that skull materials from The acacia and latifolia trees were also recommended
ancient Egypt seldom exhibited caries, but during the to be among the best sources for chewsticks. The twig
time of Ptolemy, caries were far more common. During was about 20cm long and 7mm in diameter. In use, the
the Byzantine Era, caries levels were more similar to end was chewed until it became tooth brush like and
prefluoride modern times and heavy accumulation of soft, thereby preventing gingival injury. Tooth powders
calculus could be seen. The peasants subsisted on a of charcoal and rock salt were also advocated.
largely vegetarian diet which kept them caries-free;
while the more luxurious life of the aristocrats made Traditional anatomical knowledge gained from the
them more susceptible to the usual dental maladies of dissections was available to Indian doctors. The maxilla
the modern man. One of the oldest medical papyri of was divided into the palate, the alveolar process and
the Middle Dynasty mentions tooth pain associated facial bone. While the mandible was divided into
with gynaecological disease. Burial crypts of royal alveolar process, the base-chin and the rami, strict
princesses of the 12th dynasty contained oral hygiene codes of hygiene based on religious sanction were
devices among the toilet articles. traditionally practiced by the Hindus.

Ancient India For centuries in India the daily ritual of oral hygiene
has included scraping the tongue as well as brushing
The ancient medical sciences of Hindus Ayurveda the teeth usually with chewed end of twig of the mango
(the science of life) contained descriptions of dental tree and rinsing the mouth with concoction of aromatic
diseases as well as remedies for them. These directions herbs and spices.
were believed to have come from Brahma and were
transmitted through various deities to the Ayurveda Both Charaka and Sushruta discuss the proper
doctors. The first mention of dentistry in ancient Hindu deportment and daily regimen giving special attention
legend has Ashwins, the twin sons of the Sun, giving to oral cleanliness. Charaka and Vagbhatta speak for
teeth to Pushan. removing calculus from the teeth using for the purpose
a special instrument with a flat diamond shaped end.
The ancient medical works of Indians devote a Sushruta begins his chapter on general hygiene with
significant amount of space to oral and periodontal admonition: Early in the morning a man should leave
problems. The information available today is from the his bed and brush his teeth.
sacred Hindu Vedas (4000-3100BC).In the Sushruta
Samahita there are numerous descriptions of severe Ancient China
periodontal disease with loose teeth and purulent
discharge from the gingiva. In a later treatise, The The Chinese assumed the destructive action of tooth
Charaka Samahita, tooth brushing and oral hygiene worms can be prevented by removing food debris
 History lv
of Periodontology

from the mouth after eating or rinsing the mouth after away down the roots. The wound was then cauterized
meals remained a common practise, as does brushing with iron vitriol or another hemostatic. In the event of
the teeth. The tooth brushing as we know it today, with recurrence, the lesion was resected with wider margins
bristles perpendicular to the handle, was invented by and red hot cautery used. He also described calculus
Chinese in 1190s. removed in great detail.

In the oldest Chinese medical works written by Hwang The instruments used were of different shapes;
Ti (255BC) there is a chapter described and devoted scrappers, most of which were double ended. Those
to dental and gingival diseases. were pronged, grooved or curved at the working tips
Oral diseases were divided into three types: with zigzag shanks for a more certain finger grasp with
1. Fong-ya or inflammatory conditions small instruments.
2. Ya kon or diseases of the soft investing tissues of
the body He had clear understanding of the major etiologic
3. Chong ya or dental caries role of calculus deposits and he described in detail
the technique of scaling teeth using sophisticated set
Gingival inflammation, periodontal diseases and of instruments that he had developed. He also wrote
gingival ulcerations are described in accurate detail. in detail on the extraction of teeth, on splinting loose
Herbal remedies Zn-Hinetong are mentioned for a teeth with gold wire and on filing gross occlusal
number of gingival conditions. abnormalities.

The Chinese were among the earliest people to use Albucasis contributions to dentistry are among his
chew stick as tooth pick and tooth brush to clean the greatest achievements. He understood that the calculus
teeth and massage the gingival tissues. on the teeth is a major cause of periodontal disease and
gave explicit instructions for scaling teeth; describing
Arab Medicine instruments of his own devising that were to be used.
The following excerpt from the chapter On Scrapping
Among the more important contributions to dental of Teeth indicates how important he considered this
knowledge during this period were works of Albucasis treatment:
and Mamonides.
Sometimes on the surface of the teeth, both inside and
The earliest Rhazes (841-926) left a number of works outside as well as under the gums are deposited rough
including The Almansor, a text book of medicine, The scales, of ugly appearance and black, green, yellow
Liber which contains an encyclopaedia of medicine. in color thus the teeth do get denuded. It is necessary
Rhazes introduced chemical preparations (as distinct for you to lay the patients head upon your lap and to
from herbal remedies) to medicine. scrape the teeth and molars on which they are observed,
either true incrustations or something similar to sand,
Albucasis Abul Qasim (936-1031) was considered to until nothing more remains of such substances; and
be the greatest surgeon of Arabian school. He had clear also, until the dirty color of the teeth disappears, be it
understanding of the major etiologic role of calculus black, green or yellowish or any other color. If a first
deposits and described in detail the technique of scaling scrapping is sufficient so much the better; if not, you
the teeth, using sophisticated sets of instruments that shall repeat it on the following day or even on the third
he developed. His works included illustrations of and fourth day, until the desired purpose is obtained.
instruments specifically designed for dental procedures,
including illustrations of both scalers and small surgical Albucasis also recommended ligation of loose teeth
knives. even going so far as to suggest replanting loose teeth
that had fallen out and wiring them to their neighbouring
He described two specific periodontal procedures. The tooth to stabilize them. He also advised that when
first was the operation for the removal of epulis. The the teeth were missing, they should be replaced with
lesions were retracted with rakes or forceps and cut artificial ones made of bone and ligated to the sound
lvi History
of Periodontology

teeth The third member among the notable Arabic occasions described by Ibn Abdin a Muslim theologist
physicians was Mahmonides. Perhaps best known as a of the last century.
philosopher and popular theologian, he was, in fact, an 4. When the teeth become yellowish;
accomplished physician. His fame spread far and wide 5. When the taste of the mouth changes;
and he was eventually appointed body physician to 6. After rising from bed at any time;
the Emperor Salladin. Among his treatises were works 7. Before prayer;
on diet and personal hygiene, formulated as letter to 8. After ablutions.
Sultan Salladin.
The Middle Ages added little but myth and superstitions
Ibn-Sina (Avicenna 980-1037) to medical or dental knowledge. The texts of classical
civilizations of Greece, Rome, and Islam golden age
Avicenna used an extensive material medica for oral provided foundations of medical sciences. The veils
and periodontal disease and rarely reported to surgery. of ignorance and superstitions were lifted with the
He wrote a comprehensive treatise on medicine. European Renaissance; significant advances were
once again made in medicine and dentistry. The first
The headings in the canon include: Bleeding gums, renewed interest in anatomical knowledge was lead by
Fissures of the gums, Separation of gums, Recession of the great illustrators, notably Michelangelo, Raphael
gums, Looseness of gums, and Epulis. and Leonardo de Vinci. However, the true founder of
modern anatomical knowledge was Andres Vesalius
He stressed the importance of keeping ones teeth (1514-64) who was born at Brussels and educated at
clean and recommended a number of dentifrices for the Paris. In spite of his great fame, Vesalius knowledge
purpose: such as, meerschaum, burnt hart horn, salt and of dental anatomy was cursory and added little that was
burnt and powdered snail shells. original. One exception was the precise knowledge of
humans tooth formula. Vesalius set the number as 32
The Prophet Muhammad and and was the first to note that this number was equal for
Oral Hygiene men and women. He further differentiated between the
structure of tooth and the bone noting the absence of a
Muhammad who was born in Mecca about 570AD defined periosteum on the teeth. He located the dental
introduced basic oral hygiene into the Arab world by nerve entrance at the apical foramina.
incorporating it into the Muslim religion.
Another great anatomist, Bartolomenus Eustachius
The prophet also recommended cleaning the teeth (1574) taught anatomy in Rome. His contribution
within a siwak (miswak) a twig of salvadora percia to dentistry was the book Libellus de dentibus. He
tree, whose wood contains sodium bicarbonate and compared the gingival attachment to the tooth like
tannic acid as well as other astringents that have a the attachment of the skin to its nail bed. Libellus de
beneficial effect upon gums. A siwak twig about dentibus was published at Venice in 1574. Eustachius
half an inch in diameter is soaked in plain water for described dental anatomy as the best in the 16th century.
24 hours until the fibers have separated. Then a small
portion of it is peeled off, exposing the fibers which are Among the great surgeons of the 16th century was
dense and moderately stiff. When these fibers of this Ambroise Pare (1510-90) who contested many of the
natures tooth brush wears down, a section can be accepted medical ideas of his time. Pare introduced the
prepared by cutting of the worn out portion. It is said ligation of blood vessel into amputation procedure and
that Muhammad was so fond of cleaning his teeth that was regarded as a careful and conservative worker. He
he asked for his siwak on his deathbed and expired a was a surgeon par excellence to four Kings of France
few minutes later. Pare accurately recorded the number of roots of various
teeth and described their attachment to bone via a
Many other hygiene practises of Muhammads time are fibrous ligament. He further noted continuous eruption
still observed and siwak is still commonly used in five of teeth and their continued eruption when not in use.
Pare described the use of a file to plane down a tooth
 History lvii
of Periodontology

that stands out above the levels of others, and also for from between teeth. Using this small and primitive
other similar purposes instrument, Leeuwenhoek made observations recorded
by means of detailed drawings which were transmitted
The ligation of avulsed tooth or partially avulsed tooth to the British Royal Society. The illustrations showed
to the adjacent firm tooth with subsequent healing is not only various classes of bacteria but also cross-
presented along with description of appropriate soft sectional view of dental histological structure which
diet. Pare and Albucasis both described replantation. demonstrated enamel rods, dentinal tubules, and pulp
structures.
The necessity of scraping the material collected on the
tooth was stressed and a small instrument was designed In 1673, correspondence was initiated with Royal
for the purpose. The scrapping was followed by tooth Society in London. This correspondence eventually
cleaning with aqua fortis and aqua vitae mixed included 1200 letters. These letters described
together to remove any residual material not removed microscopic observations on protozoa, bacteria,
by scrapping procedures. He indicated that the teeth crystalline structure of minerals as well as microscopic
should be rubbed frequently with appropriate dentifrice anatomy of insects and plants. Letter number 39,
to preserve them. Pare described charcoal made from which was sent to Francis Acton Secretary to the
pulverised burnt bread crusts Royal Society, described microorganisms found on
the human tooth. This letter, dated 17th September
Giullo Cesare Aranzio (1530-1580) a celebrated 1639, reads as follows: but what there sticketh or
surgeon and anatomist of Bologna was of the opinion growth between some of my from ones(incisors) and
that parulides i.e., inflammation or abscess of the my grinders (molars) whenever I inspected them
gums and epulides i.e., fleshy excrescence of the with magnifying mirrors a little white matter which
same are usually caused by caries or putrescence of is as thick as it was butter. On examining this, I judged
teeth, but that in certain individuals, from a peculiar (albeit I could discern nought moving in it) that there
weakness of the gums, these are easily attacked by were living animalcules there in. I have therefore mixed
inflammation. it, at adverse times, with clean rain water (in which
there was no animalcules) and also with spittle, that I
Girolaimo Fabrizio (1537-1619) an Aquapendente took out of my mouth after ridding it of air bubbles
anatomist wrote several works. He also described (lest the bubbles should make any motion in the spittle)
a set of scrapers of silver for removal of tartar and then I most saw with great wonder, that in the said
which showed unfamiliarity with dental procedures. matter there were many little animalcules very prettily
He repeated the same methods of treatment as Pul of a moving. The biggest sort had a very strong and swift
Aegina for epulides and parulides. motion, and shot through the water (or spittle) like a
pike does through water. These were always a few in
Although the majority of the 16th Century work number
was published in Italy and to a lesser extent France,
one notable exception was Collaquio Brevery Leeuwenhoek further described squamous cells and
Compendioso written by Francisco Martinez in Spain. white blood cells in this white matter. Earlier in the
This work described a number of operative procedures letter, he described his own oral hygiene practices:
including scaling of teeth. Several illustrations pictured Every morning I rub my teeth with salt and then swill
instruments used by Martinez were also shown. my mouth with water and often, after eating, to clean
my back teeth with a tooth pick, as well as rubbing
In the 17th Century, the Dutch scientist, Anton Van them with a cloth, wherefore my teeth back and front
Leeuwenhoek described the oral microflora using a remain as clean and white as falleth to the lot of few
primitive microscope. Van Leeuwenhoek enjoys a niche men of year and my gums (no matter how hard the salt
in the history of science that remains unchallenged be that I rub them with) never start bleeding
after four centuries. He built a prototype microscope
and in 1683 described animalcules found in scraping
lviii History
of Periodontology

Scientific Developments in In his descriptions of what is now recognized as

Modern Periodontics chronic periodontitis, Fauchard distinguishes himself
as an observer and recorder of dental diseases. In a
Modern dentistry owes its greatest debt to remarkable short passage he certified periodontitis as a purely local
Frenchman who synthesized what was known in the problem, described the obvious clinical course signs
west about dentistry and presented it in an organized and symptoms of redness, swelling, bleeding as well
form so that all practitioners could benefit. Pierre as some of the more subtle characteristics (expression
Fauchard was able to develop a systematic approach of pus on gentle manipulation). He also described
to dental practice based on knowledge of his age. a local treatment for periodontitis. These principles
Fauchard significantly improved the instruments and have continued to be the subject of debate within the
technical skills required for dental treatment profession for at least two centuries. Fauchards book
not only transformed dental practice but also served to
In 1723, he completed his epic work Le Chirurgien educate the succeeding generation of dentists; some
Dentist ou Traite des Dente (The surgeon dentist or of whom emigrated to the United States of America to
treatise on the teeth). This was published in 1728 which practise in the early years of the republic.
enhanced the respect of the profession and developed
a wide appreciation for the technical and surgical skill The 18th Century ushered in profound changes in the
of dental practitioners. Dentistry began to assume its practice of dentistry, the impetus for which came from
identity as a distinct clinical discipline. the scientific discoveries of the preceding century.
Dentistry ultimately became an independent scientific
Fauchard recognized the relationship between oral discipline not overnight however; but after much
hygiene and the etiology of periodontal disease and painstaking experimentation and dedicated efforts on
wrote: Little or no care as to the cleanliness of the the part of several generations of practitioners.
teeth is ordinarily the cause of the maladies that destroy
them. John Hunter (1728-1793) was the most distinguished
anatomist surgeon and pathologist of the 18th Century
As regards therapy, Fauchard in 1746 advocated England. He wrote an excellent treatise on dentistry
treatment and extolled its benefits, thus: Although it entitled The Natural History of Human Teeth. He
is necessary to prevent these disorders to combat the offered remarkably clear illustrations of the anatomy
general cause contained to the mass of blood to have of the teeth and their supporting structures. He also
consequently recourse to experienced physicians, described the features of periodontal disease and
operations and the applications of remedies suitable enunciated the concept of active and passive eruptions
for the occasion of great effect to ward off and preserve of teeth.
the teeth, the alveoli, and the gums from the bad results
which scurvy has already produced or may produce Born at Edinburgh in 1728, Hunter was a distinguished
subsequently. scholar. After completing his medical education at
St Bartholomews Hospital, he was appointed house
Gums are so inflamed or tumified as to exceed their surgeon at St George Hospital in 1756. With his
natural levels, as nearly as possible all that which is recognition as an outstanding surgeon and anatomist,
detached from the teeth or alveoli is removed with he was made Fellow of Royal Society in 1767 and
scissors, straight or curved but very sharpWhere the appointed as Surgeon Extraordinary to the King in
gums have been cut away the same dressings, pledges 1776. Hunter amassed more than 13,000 anatomical
or bits of linen in suitable dressing must be applied specimens in his extraordinary collections, many of
frequently the mouth must be rinsed often between which are on display at the Hunterian Museum of the
dressings to counteract by these means the action of Royal Society of Surgeons even now.
acrid and corrosive salts which is much more to be
feared in these case than the others. Hunters two volumes on dentistry contain gems of
what evolved as the disciplines of dental anatomy,
physiology, embryology, pathology, oral surgery,
 History lix
of Periodontology

prosthetic dentistry, and periodontology. Hunters One of the German texts on dentistry was authored by
experiments with red dyes (madder) were the first to Philip Pfaff (1756), dentist to King Fredrick of Prussia,
demonstrate sites of bone growth, and his demonstration and probably the most important and influential German
that constant pressure upon a tooth could alter its text of 18th Century.
position, were landmarks in the development of oral
physiology. He observed and recorded the continuous In the mid 19th Century, John W. Riggs (1811-1885)
eruption of teeth, formation and types of tartar, recession was the leading authority on periodontal disease and
of gingival tissue and alveolar process and development its treatment in the United States, to the point that
of scurvy. Well in advance of long-standing and current periodontitis or alveolar pyorrhoea was known as
controversy on repair and regeneration Hunter said: Riggs Disease.
If alveoli have really been destroyed in those cases
of loose teeth which have become firm again, it would
be difficult to ascertain whether they have a power of
renewing themselves analogous to that power by which
they first grow, or whether the fastening be affected by
a closing of the gums and the process to the tooth.
John Riggs
Following Hunters treatise, several comprehensive text
books of dentistry appeared including Serre (1791) and
Fox (1806) which had the merit of greatly contributing John. W. Riggs was synonymous with periodontal
to the raise the level of dental literature. Joseph Foxs disease was a pre authority in the field during his
book, Natural History and Diseases of Human Teeth, lifetime. He first participated with Horace Wells in the
was published in England in 1806 and was reprinted first demonstration of nitrous oxide anaesthesia. He
till 1833. proposed a classification depending on the extent of
periodontal destruction and was not markedly different
Thomas Berdmore (1740-1785) was considered to be from the stages currently being used.
another outstanding dentist in England and was known
as Dentist to His Majesty. In 1770 he published his Riggs seems to have been the first individual to limit his
work, Treatise in Disorders and Deformities of Teeth practice to periodontics and therefore can be considered
and Gums, with several chapters devoted to periodontal the first periodontist. He advocated cleanliness of the
problems. In Chapter 7 on tartar of teeth and recess mouth, as he believed that the teeth themselves with
of the gums and toothache, occasioned by tartarous their accumulated accretions and roughened surfaces
concretions long neglected, he offered detailed are the exciting cause of the disease.
descriptions of instrumentation for tartar removal but
stressed on its prevention. He also used surgery to The first to identify bacteria as cause of periodontal
remove hyperplastic gingival tissue. disease appears to have been the German dentist
Adolph Wizel (1847-1906) who taught at the University
John Baker (1732-1796) was one of the George at Jena. But the first true oral microbiologist was
Washingtons dentists and had a very successful career. Willoughby. D. Miller (1853-1907). He described the
He imparted his dental knowledge to Paul Revere, Isaac features of periodontal disease and considered the role
Greenwood and Josiah Flagg. In an advertisement in of predisposing factors, irritating factors and bacteria
the New York Weekly Journal of 1768, Baker tells in the etiology of pyorrhoea alveolaris.
the public that he cures the scurvy in the gums, be it
ever so bad, first cleans and scales the teeth from that Leonard Koecker (1785-1850), a German born dentist
corrosive tartarous gritty substance, which hinders the practised at Baltimore. In his paper in the Philadelphia
gums growing, infects bad breath and is one of the Journal of Physical Sciences in 1821, Koeker described
principle causes of scurvy and if not timely prevented, inflammatory changes in gingiva and the presence of
eats away the gums so that many peoples teeth fall out calculus on the teeth leading to their looseness and
fresh.
lx History
of Periodontology

exfoliation. He also mentioned the careful removal of Etiology

tartar and the need for oral hygiene in people.
Bernard Gottleib and Baliant Orban were two
William Younger was born in Santiago, Chile in 1839. distinguished and notable pioneers in periodontology.
He was raised and educated in California and practised These talented teachers and researchers produced more
in San Francisco. His best known work, Pyorrhoea than four decades of active work that began in Austria
Alveolaris, was published in a Swiss Dental Quarterly and continued in United States. Several of the more
1905. He recognized periodontal disease as a bacterial significant publications include: The Etiology and
infection and was unsure whether a specific Bacillus Therapy of Alveolar Pyorrohea, Studies on Epithelial
could be isolated but stated that disease is without Attachment, Diffuse Atrophy of Alveolar Bone, Studies
question of bacterial etiology. He is known for many on Sulcus Normal Pocket, Histological Observation of
instruments under his name. Youngers method of Periodontally involved Tissues, Gingival Inflammation
treatment consisted of meticulous scaling to remove and Tooth Mobility, Etiology and Pathology of the
calculus, followed by the use of lactic acid to clean Tooth and its Supporting Mechanisms, Biology of
the root surface. Younger underscored the need for the Cementum, and finally, in 1958, he wrote Orbans
lactic acid treatment based on his belief that metabolic Periodontics which is a standard textbook for all
products sealed the cemental channels and served to practicing dentists.
secure periodontal fibers to the root. After seventy five
years, once again, the concept of bio-modification of Orban also collaborated with Weinnman to popularize
root emerged in the 1980s. Modification of Youngers one of the early concepts of non inflammatory
instrument was made by Good in United States and by periodontal diseases and published the classic
Sachs in Germany and serve as pattern for the most description of root resorption and epithelial attachment
modern instrument designs today. in which he described active and passive eruptions of
the human teeth. Although both of them are no more,
Leon Williams (1852-1932), an American dentist who these teachers and researchers live still with their works
practised at London recognized plaque as a gelatinous to occupy forefront positions in periodontal research
accumulation of bacteria adherent on the enamel and education, so said Grant in 1963.
surface in relation to caries. Sir G. V. Black (1836-
1915) coined the term gelatinous microbic plaque in
1899.

J. H. Vincent (1862-1950) described the spirillum

and fusiform bacilli associated with what later known
as Vincents angina and in 1904 he described these Gottleib
organisms in acute ulcerative gingivitis.

Soloman Robicsck (1845-1928) was born in Hungary. In their paper describing Berlin as the Germ cell of
He obtained his medical degree and practised dentistry German Periodontology Fugen Frolich documented
at Vienna where he developed a surgical technique the activities of Neumann and his associates who
consisting of a scalloped continuous gingivectomy included Hans Sacha, Oscar Weski, and Mamlok.
excision, exposing the marginal bone for subsequent Sachs promoted local clinical treatment of Good. The
curettage and remodelling. evolution of tooth pick from the ancient to the present
was done by Sachs. His contribution, Handbook of
Moritz Karoyi (1865-1945) described the possible role Dentistry, Vol. 2, questions pyorrhoea as a diagnostic
of trauma from occlusion and bruxism in periodontal term.
disease, who also recommended its correction by
grinding occlusal surfaces and preparation of bite
plates.
 History lxi
of Periodontology

Oskar Weski Irving Glickman

Oscar Weski from Berlin showed with a lengthy paper In the development of current therapy, much has
on the radiographic anatomic studies in the field of been written about occlusion and the use of occlusal
periodontal pathology who documented the destruction adjustment, splints and therapeutic appliances. The
of supporting bone in periodontitis. James and consel use of bite plates and occlusal splints was introduced
1927 discussed the pathway of inflammation from in early 1950s and 1960s. It is less well-known that
gingiva to bone and periodontal attachment. They Gottleib and Orban in 1936 described the use of bite
documented cases with photomicrographs. Similarly, plate many, many, years ago. The explanation included
Weinnman documented the spread of gingival a description of the eruption of posterior teeth.
inflammation in 1941.

Occlusion

In 1928, it was Box who with animal model studies

using sheep demonstrated the effects of occlusal
traumatism. The overstress in horizontal loading with
consequent increase of liability to infection or actual Jens Waerhaug
cellular alterations in this region prepares the tissue
for involvement from superimposed gingival infection In 1962, Glickman and Smulow came out with the
and there is rapid formation as a rule pockets which concept of change in the pathway of the inflammation
is narrow, deep and with its base varying greatly as to attributed to the trauma from occlusion. Convincing
position all being recognized characteristic of complex evidence has been presented to demonstrate that
periodontitis. occlusal injuries do not initiate periodontitis, according
to Waerhaug in 1955 as originally proposed by Karolyi
and supported by Box. However, the use of extensive
splints on the teeth with reduced periodontal support
and extensive mobility remains a justified therapeutic
approach as described by Nyman and Lindhe in 1977.

Orban Periodontal Surgery

It was the turn of the century that the first recognition of

In 1931, Gottleib and Orban documented tissue changes periodontics as a separate discipline can be noted. The
produced by occlusal trauma but remained firm in the pioneers that followed came at a time that was unique
belief that the primary lesion causing tooth migration and was not repeated again until the 1950s in the north
was diffuse atrophy. Box, in 1939, disagreed with this eastern United States.
concept and debated for many years. Unfortunately this
has been one of the most controversial topics till date. If ever the science of periodontics has progressed, there
were contributions from Athens, Rome in 19th Century,
and Berlin during 1920s. The Berlin group was led by
lxii History
of Periodontology

men like Partsch 1900, Sachs 1913; but was ultimately on periodontology had a chapter on surgical treatment
dominated by Robert Neumann who championed details in which flap surgery was used. Flap surgery
Radical surgical treatment for Pyorrhoea. In 1920s, was used for debridement as well as apicectomy. The
the controversy centring on the priority of periodontal partsch semilunar incision was used and instruction for
flap surgery involved Cieszynski 1926,Widman 1923 suturing and post operative oral hygiene was described.
and Neumann 1923 each claiming to have been the The need for thorough removal of calculus and careful
first to publish this material . As in many other areas apposition of wound margins was stressed. The revised
of science and medicine, it is seldom the work of one editions of this textbook were published in 1920 and
person produced in isolation from his colleagues that in 1927.
is responsible for a departure from the current thought,
but rather a moulding of ideas arising from a synthesis
of thoughts of those that preceded them. This is clearly
the case in the aforementioned dispute. Advances in
surgical therapy were surely the result of the combined
creative spirits in the 19th Century scientific temper.
Robert Neumann

Neumann published articles on root resection, tooth re-

plantation and treatment of trauma to the jaws, as well
as papers and monographs on surgical management
Henry M Goldman of periodontal disease. In 1912, he discussed the
first mention of flap surgery. In earlier procedures
he incorporated a semilunar (Partsch) incision,
Among the events that should be recognized is the the principles of his refined surgical approach was
development of a reliable local anaesthetic culminating done between 1914 and 1916. However, the English
in 1905 with the works of Einhorn and Uhfelder , on Language translation work was available in 1926 in his
the synthesis of procaine, the discovery of X-Rays by monograph published in 1927.
Roentgen in 1895, and the studies on dental radiography
by Cieszynski 1914 and by Weski in 1921. The first incision are vertical and are made long axis
of the tooth generally encompassing a five to six tooth
It was Robiscek who popularized gingivectomy area (sextants) papilla should not be bisected by the
procedure which combined curettage of bony lesions. vertical incision through periosteum to bone. The
This operation was first demonstrated at Vienna in the mucoperiosteal flap, thus outlined, is then reflected
late 19th Century. This evolution was to be repeated sufficiently to gain a clear view of the entire field being
in the development of American Periodontology by the operated. If granulation or scarification interferes with
works of Orban, Glickman, Goldman, Prichard, and the reflection, sharp dissection utilizing tissue forceps
even Schlugar, three decades later. and scalpel were carried out. The flap is drawn aside
with a sharp hook (retractor). Sickle and spoon shaped
Robert Neumann was born at Patschkau in 1882, a curettes are used to remove all the granulation tissue.
town earlier in the eastern part of Germany and now in The bone is smoothed with chisels and a rotating bur
Poland. He studied medicine and dentistry at the Dental in a dental hand piece. The pockets in the bone are
Institute at Royal University of Berlin. He lectured on removed and the bone itself is given, as far as possible,
Pyorrhoea as early as in 1912 in Posco and Oslo. He the normal shape nature intended for it.
practised at Berlin and outlined a treatment method
which included full radiographic survey, clinical When the bone is completely smoothed, the mucosal
examination, instructions on oral hygiene, meticulous flap is trimmed so that after suturing, it just covers
scaling and root planing as well as flap surgery, in cases the bone exactly above the boundary of the bone.
of abscess or deep granulation tissue. The three books Before suturing, the field of the operation is sprayed
 History lxiii
of Periodontology

with carbonic acid atomizer and carefully inspected 3. Use of scaling instrument pre-surgically,
for concretion or granulation tissue. The mucous particularly the back action hoes for stubborn
membrane must be scalloped with a very fine pair of deposits.
gingival scissors. The operator must be careful to leave 4. Follow up treatment for long-term success.
mucous membrane to cover the inter-dental space. 5. The use of adrenaline in anaesthetic solution for
haemostatic and clear surgical field, and lastly,
6. Treatment of sensitive dentin for postoperative
patient comfort.

In a lecture at Stockholm in 1923, Neumann stated his

differences with Widmans procedure in presence of
Saul Schluger Widman, who was also there. Widman advocated the
radical surgical treatment with both buccal and lingual
flaps in all cases of periodontitis; his own extensive
Neumann went on to describe the management of clinical experience enabled him to select cases for local
frenula in surgical procedures. He further elaborated (scaling and oral hygiene) or partial surgical treatment
on postoperative care, prosthetic fixation of mobile depending on the merits of the case. He said that where
teeth, follow-up prophylaxis and treatment of acute no lingual or palatal pockets existed only a buccal or
periodontal diseases (endo-perio, periodontal abscess). labial flap should be used.

The principles of successful operative procedures

according to Neumann are:
1. Immediate, distinct survey over the entire field of
operation
2. Complete removal of concretions on the root.
3. Complete removal of granulation tissue, especially Leonard Widman
in the bone arches
4. Transformation of vertical bony defects into
horizontal atrophy. In another point of contention, Neumann always
5. Removal of inlets and niches of bone going recommended provisional splinting prior to surgery;
underneath one another (pyorrhoea intra alveolaris but Widman felt that it interfered with surgical
and cavernosa ) approach and only stabilized the teeth post-surgically.
6. Removal of gum pockets by carrying of pitutious Neumanns approach to flap surgery was to divide the
tunicle mucoperiosteal flap up to healthy bone mouth into sextant rather than the three tooth areas,
structure (apical positioning of flap) commonly used by Widman. Neumann felt that his
7. Transformation of vertical atrophy into horizontal approach was less tiring for the patient and that a
atrophy(after Weski). larger surgical area gave a better result in terms of
8. Covering of healthy bone with healthy pitutious tissue contour. This was particularly true with regard to
tunicle in order to obtain ideal condition of total gingival architecture (festoons). He stipulated that the
atrophy. objective of bone contouring (removal of unsupported
bone) should be to once more resemble the natural
Neumann also narrated the importance of: form as far as possible.
1. Diagnostic X-Rays including use of diagnostic
gutta percha points to outline pockets
2. Oral hygiene, particularly using the tooth brush
in the horizontal rather than a vertical direction to
approach the gingival crevice.
lxiv History
of Periodontology

Force for two years, he specialized in periodontics at the

University of Alabama. A formidable periodontologist,
he introduced the concept of Periodontal Plastic
Surgery in periodontics. His novel classification of
gingival recession to the literature is a milestone in
Kronfeld periodontics. He went on to refine periodontal plastic
surgery which was earlier conducted by Grupe and
Warren, described earlier by Harlan. He showed that
In 1949, it was Schluger who thought of radical surgical free gingival graft to have success in covering roots
treatment although Neumann had provided the surgical with soft tissue autografts by getting a piece of tissue
approach defined almost 30 years a generation earlier. with no blood supply to attach to the root, which was
His premier paper showed histological and radiographic not supposed to happen. He documented over a 100
illustrations as well as clinical photographs documented cases. Although he had no academic reputation, he was
his hypothesis. In 1914, the First World War, he served unknown from a small southern city, his research was
in the Army as a dental surgeon in a surgical hospital; being done in a private practice environment rather than
and later, he further practised and published detailing a university setting, he felt he had to report on at least
his approach to flap surgery. In 1927, his monograph 100 cases so that the results would be taken seriously.
The Radical Surgical Treatment of Periodontitis was Not only was he successful, but also discovered that
used for over half a century. He has done the use of smoking had a negative effect on healing process.
curettes, burs, chisels and different tools for the flap Presently, he is doing a full-time practice at Memphis
surgery. Tennessee, and is on staff at several schools in
academics.
Gingival Grafts
Present Periodontology in India
The use pedicle or free tissue grafts to cover denuded roots
is considered to be a hallmark of modern periodontics India has been fascinated and charmed by several
It was on the 8th of June 1906, at a joint meeting of scientists in the international community who have
Maryland State Dental Association and District of contributed to the cause of Periodontology and we
Columbia Dental Society held at Washington, a paper have to know the lives of great men for the younger
was presented by Harlan on Restoration of Gum Tissue generation to follow their footprints on the sands of
on the Labial Aspect of Teeth. He described the surgical time.
technique and added the precaution that in order for this
procedure to be successful, the tooth should not have
a filling on the neck and that the neck should be free
from caries. Another description and illustration of a
surgical procedure used for covering a denuded labial
surface of a tooth appeared in an article published in
Per Ingver Branemark
1911 by Rosenthal titled, Le Rechaussement des Dente
par Lautoplastic [Autoplasty in the Treatment of
Denuded Teeth]. An English translation of this article
was published on 13 Jan 1912 in The Dental Surgeon Prof. Per Ingver Branemark, born on May 3, 1929 is a
and in Dental Cosmos. Swedish orthopaedic surgeon and Research Professor
and often known as the Father of Dental Implantology.
Preston Dallas Miller, the father of periodontal plastic He studied at the University of Lund in Sweden and
surgery, was born on 6th September 1938, at Norton became Professor of Anatomy at the University of
Virginia. He did his graduation from Davidson College Gotheburg. He evolved a concept of osseointegration
and was a merit graduate of Medical College of Virginia in 1969. In 1978, he did report with retrospective data
School of Dentistry. After serving the United States Air on dental implants were collected, analyzed, criteria
 History lxv
of Periodontology

and standards were set for implant dentistry. In 1982 in

Toronto, Branemark presented his fifteen years of work
conducted at Gotheburg on implants. His discovery and
application of osseointegration a biologic fusion of
bone to a foreign material was unparalleled which was
a major breakthrough in dentistry. Branemarks system Ray Williams
of dental implants was bought at and is available at
Noble Biocare. He was a recipient of the Swedish
Society of Medicines Soederberg Prize in 2002.He Ray Williams did his DMD from Alabama School
was honored at the Harvard School of Dental Medicine Dentistry. His advanced training was certificate in
with a medal for his work on implants. He holds 30 Periodontology and Oral Medicine from Harvard
honorary positions throughout Europe and North School of Dental Medicine. Presently, he is the Dean
America, including an Honorary Fellowship of the for Stony Brook University School of Dental Medicine
Royal Society of Medicine at U.K. In 2003 he received and the chairman of Periodontology at University of
the honorary doctorate from Universidad Europea de North Carolina School at Chapel Hill. His interests
Madrid. are in clinical research and transitional research in
pharmacological modification to treat periodontal
diseases, the risk factor for periodontitis. Periodontitis
as one of the risk factor for systemic diseases, wound
healing around teeth and dental implants.

Max A. Listgarten

Prof Max A. Listgarten is a world renowned researcher

and preceptor. He did his DDS from the University of Thomas Van Dyke
Toronto in 1959 and certification in periodontics from
Harvard University in 1963. During his illustrious
career he has held major positions in several institutions Thomas Van Dyke DDS., Ph.D. is associated with
at the universities of Harvard and Pennsylvania. His the Department of Oral Biology and Periodontology
contributions are in the understanding the structural at the Dental School Harvard University, Boston. He
biology of periodontal tissues in health and disease, has been in the field of basic research to gain further
periodontal microbiology periodontal diagnosis and knowledge of the structural and functional relationship
implant dentistry. He was first to use the electron of inflammatory process by defining the complex
microscopy in order to detail the structure of periodontal interactions between phagocytes and their environment
tissues. He has authored 250 articles and published in particularly micro organisms. These interactions are
many international journals. He is Professor Emeritus. important in the pathogenesis of many disease processes.
Department of Periodontics, School of Dental Medicine His collaboration with Robert Genco and Gibbon has
Pennsylvania, Philadelphia Clinical Professor of examined the role of specific micro organisms in the
Periodontics, Department of Stomatology, University inflammatory periodontal diseases and atherosclerosis
of California, San Francisco. He has been associated as using animal models. His clinical research is focused
an editor to several journals and is with AAP, AADR, in elucidation of factors inherent in the pathogenesis
and ADA. of periodontal diseases, with emphasis on disease
prevention. His applied clinical research programs
are focused upon clinical elucidation of products,
procedures, and diagnostic approach for management
of periodontal diseases including anti inflammatory
agents.
lxvi History
of Periodontology

Sigmund Socransky 1934-2011 was a pioneer in the Dental School, four years later. He has to his credit four
field of periodontal microbiology. He has been aptly decades of hard work with 308 publications and book
called as the Father of Periodontal Microbiology. He chapters, and monographs; 99 % of journal publications
has made remarkable scientific advances during his are authored by an average of four other investigators.
career that have changed oral infectious diseases in A review of co-authors of his publications and abstracts
general and periodontal diseases in particular. His study identifies more than 88 collaborators with diverse
focused on cluster of pathogenecity in the sub gingival disciplines and institutional affiliations and majority of
flora. He evolved the concept of red complexes in which he is the first author of the publications. The NIH
the sub gingival flors. He was the pioneer to describe record places him above 95 percentiles of extramural
Kochs modification for periodontal microbiology grants obtained and funded during 25 years. Roy C
His 49 years of dedicated service, particularly at the Page has influenced many leading scientists because of
Forsyth Center, will be etched in golden letters. He was his insight, support; and high standard of excellence.
the doyen of Brooklyn. He is Professor Emeritus of Periodontics and Pathology
at the University of Washington and Chief Officer of
Orbatec. During his tenure, after getting a Certificate
of Periodontology in 1963 and PhD in Experimental
Pathology in 1967, he served at the University as
Professor of Pathology and Periodontics in School of
Medicine and Dentistry, Director and Associate Dean
Sigmund Socransky for Research Center in Oral Biology. The School of
Dentistry recognized him as aluminous in 2000. He
maintained his part-time practice. His interest was in
Robert Genco DDS, PhD was a graduate at State connective tissue biochemistry, chronic inflammation,
University of New York at Buffalo School of and immune systems response to diseases. He worked
Dentistry. He did his residency in periodontics and on the development of a vaccine for human periodontitis
later his PhD in microbiology and immunology from and technology to assess risk of periodontal diseases.
the University of Pennsylvania He is the Director of He was the president of the AADR, IADR, and AAP.
Buffalo Periodontal Research Center and the Vice He manufactured two protein drugs which enhanced
Provost at the University at Buffalo. His research healing of bone fractures and complex wounds.
interest includes studying the causes, risk factors and
systemic effects of periodontal disease as well as its
management. He established P Gingivalis to be a major
pathogen and identified the role of neutrophils to be the
key protective role against periodontal pathogens. He
identified risk factors like diabetes mellitus, smoking,
stress, low dietary calcium and obesity with periodontal Mark Bartold
diseases. He has contributed over 350 peer reviewed
articles and has contributions for ten books. He was
an editor for the Journal of Periodontology and Annals Mark Bartold received his BDS from the University of
of Periodontology from 1989 to 2006.He is a member Adelaide in 1979. In 1980, he received his Bachelor of
of the Institute of Medicine of National Academy of Science in Dentistry with first class honors. In 1983,
Sciences and the chairman for Oral Health Group he graduated Doctor of Philosophy. He qualified for
the fellowship of Royal Australian College of Dental
Roy C. Page has transformed contributions to Surgeons in Periodontics in 1991; and in 1996, qualified
understanding of pathogenesis and clinical management for DDS. He is a Fellow of Academy of Dentistry, ICD
of periodontal diseases He began his career by earning Pierre Fauchard Academy. He was honored as the
a Bachelor of Arts degree from Berea College in 1953 member of Order of Australia a prestigious award for
and got his DDS summa cum laude from Maryland dental surgeons.
 History lxvii
of Periodontology

Presently, he supervises the clinical programs for post

graduate in periodontics. His interest is in connective
tissue in health and disease. He has co-authored
a book on periodontal connective tissue in health
and diseases. His interest is also in the relationship
between periodontal diseases and its effect on systemic G. B. Shankhwalkar
health. He has over 56 publications to his credit. He
is an editor for the Australian Dental Journal. He is
also presently the Director Colgate Australian Clinical Periodontology in India has come during the last fifty
Dental Research Center, School of Dentistry University years on account of a few geniuses who have dedicated
of Adelaide. to the field of Periodontology. It is apt to remember
Prof G. B. Shankhwalkar BDS, LDSCPS, and MS
Jan Lindhe, born in 1935, completed his graduation (USA). He did his BDS from the University of Bombay
from the Royal School of Dentistry at Malmo, Sweden. in 1954 and got his Licentiate in Dental Surgery from
He completed specialty training in Oral Surgery and the College of Physicians and Surgeons, Bombay and
Periodontology at University of Lund. He began eventually went on to do his MS at the University of
his career as Professor of Roentgenology (Oral and Indiana in 1958.
Maxillofacial Radiology) in 1957 at Lund. His PhD
thesis at Lund was Orthogonal Cutting of Dentine He was a teacher par excellence and served for twenty
A Methodological Study. He became an Assistant five years; over fifteen years at the Government Dental
Professor in Periodontology in 1964 till 1967. After College and Hospital Bombay; and as a Dean for
spending six years studying Radiology, Oral Surgery, another six years. He has produced 36 post graduate
and Periodontology he moved to the University of students from Bombay University. He had authored 39
Umea to become the Associate Professor and Chair of scientific papers at national and international levels. He
Periodontology. In 1969, he became Professor and Chair is aptly called the Father of Periodontology in India. A
of Periodontology at the University of Gothenburg until President of Dental Council of India, Dean Faculty of
2001. He was elected Dean of the School of Dentistry Dentistry of Bombay University, he was a member of
by the faculty in 1977. He was Dean of the School of the IDA; a founder member of the Indian Society of
Dental Medicine at the University of Pennsylvania in Periodontology, and several other institutions.
1983; but returned to Gotheburg in 1988.

Prof Jan Lindhe has over 400 publications in diagnosis,

pathogenesis, and clinical understanding of periodontal
diseases. He has written Text book of Clinical
Periodontology and Oral Implantology. Currently, he is
Tehmi M.S. Ginwalla
researching new bone substitutes and examining how
they respond during periodontal treatment. Though
retired, he considers himself to be a full-time researcher
and continues to give lectures. In 2009, he was awarded Prof Tehmi. M.S. Ginwalla is an eminent personality
the coveted Norton M. Ross Award for Excellence in the field of periodontology. She did her DDS
in Clinical Research for Tissue Regeneration and from Toronto, Canada in 1942 and her LDSRCDS
Implants. (England). She was the first Professor and Head
Department of Periodontology and also the first lady
lxviii History
of Periodontology

to become the Dean Nair Hospital Dental College, University. He returned to India to establish a full-
Bombay. She started the department in 1947 and took fledged Dental Department at King George Medical
over as the Dean in 1973-74.She had been a teacher College, Lucknow, as early as in 1952. He was the man
with significant contributions in periodontology in who showed changes taking place due to malnutrition
India. She had published and presented several papers and protein deficiency. He was a genius who also
and has mentored innumerable post graduate students. participated with Jens Pindborg to study sub mucous
fibrosis. He also contributed to the eruption pattern
Prof. T. N. Chawla, BDS, LDS, RDS, MS, FACD, is the of teeth in Indian children along with Prof Nanda. He
third among the trinity of Periodontology in India. He succeeded the Dental Department from Dr Sampath
was a man who was an oral surgeon, oral pathologist to launch an illustrious career from 1952 to 1980,
and a periodontologist, all rolled in one. during which time in 1965 he got the P L 480 grant
which enabled him to establish the Department of
Periodontology. He focused his research on Fluorides
and also studied the impact of oral prophylaxis on
periodontal tissues.

He was destined to become the first principal of the

T. N. Chawla prestigious Dental College with a separate dental
faculty. Today, the Dental College at KGMC has
been recognised as a separate university the first
A man with diverse vision, Prof Chawla, while doing of its kind in India. He had been a post graduate
his BDS, went on to do his MS under the stewardship teacher and groomed several learned academicians in
of none other than Prof. Irving Glickman at Indiana periodontology.