M1 Lesson 1 Definition and Scope of

Periodontology
II. Classical World
PERIODONTICS/PERIODONTOLOGY is a
branch of Dentistry that deals with diagnosis Greeks
and treatment of diseases and supporting  Hippocrates
structures of the teeth which includes the
gingiva cementum, periodontal ligament and Romans
alveolar bone (periodontium)
 Aulus Cornelius Celsus
 Study of normal and diseased  Paul of Aegina
periodontium includes structural,
III. Middle Ages
functional and environmental factors.
 Include topics on assessment, etiology, Ottoman Empire
pathology, histopathology, and role of
inflammation in periodontal disease, as  Albucasis
well as classification of periodontal  Avicenna
diseases
IV. Renaissance
 application of treatment modalities,
therapeutic and preventive periodontics  Serefeddin Sabuncuoglu
to the clinical setting.  Ambroise Paré
 Girolamo Cardano
Diagnostics Aids:
V. 18th Century
 Probes
 Radiographs  Pierre Fauchard
 Imaging techniques  John Hunter
 Microbial analysis
VI. 19th Century
Periodontal Therapy:
 Leonard Koecker
 Non-surgical  Levi Spear Parmly
 Surgical  John Riggs
 Salomon Robicsek
Scope:
VII. 20th Century
 Periodontics - Orthodontics
 Periodontics - Prosthodontics  Bernhard Gottlieb
 Periodontics - Oral Surgery  Oskar Weski
 Periodontics - Restorative Dentistry  Robert Neumann
 Periodontics - Endodontics  Per-Ingvar Bränemark
 Periodontics - Forensics  Jens Waerhaug
 Periodontology - Geriatrics
 Periodontology - Internal Medicine HISTORY LECTURE CLASS
 Pulmonology EARLY CIVILIZATION (SUMMERIAN)
 Cardiology
 OB - Gyn - THERE IS SUCH AT THING
CALCULAR DEPOSIT
History of Periodontics/Periodontology - AWARE OF PERIODONTAL
I. Early Civilizations DISEASE

 India
 China
 Hebrews
 - GIVES EMPHASIS ON THE
PRESENCE OF
CLASSICAL WORLD MICROORGANISM WHICH
- HEPPOCRATES – FATHER OF CONSIDER TO BE THE
MODERN MEDICINE AND GIVE ETIOLOGICAL FACTOR IN
EMPHASIS OF THE TERM PERIODONTAL DISEASE
“CALCULUS” OR THE CALPITA. - BALINT ORBAN HELP GOTTLIEB
AND GIVE THE FACT THAT IN THE DEVELOPMENT OF
CALCULUS GIVES PROBLEM IN PERIODONTAL TREATMENT and
THE PERIODONTIUM until now there were instruments
before that periodontists are still
MIDDLE AGES using.
- ABULCASIS LESSON 1 THE PERIODONTIUM
- MEDICAL ENCYLOPEDIA – AL
TANSRIF (30 VOLUMES) PERIODONTIUM
- DEVELOPED SET OF PERT – AROUND
PERIODONTAL INSTRUMENT ODONTOS – TOOTH
(SCALERS)
Function and characteristics of
RENAISSANCE Periodontium
- SEREFEDDIN SABUNCUOGLE  Attached tooth to the bone tissue
- ILLUSTRATED SURGIVAL (because of the presence of
REMOVAL OF HYPERTROPIC periodontal ligament that unites
AND SWOLLEN GINGIVA cementum and alveolar bones)
- HYPERTROPIC MEANS  Subjected to morphologic changes
INCREASE IN SIZE BECAUSE OF (physiologic changes)
INCREASING THE NUMBER OF  Undergoes changes with age
FIBER OR INCREASE IN THE  Attachment apparatus/supporting
SIZE OF FIBERS. tissue of teeth
EIGTHEENTH CENTURY  Maintain the integrity of the surface of
the mucosa (presence of keratinized
- PIERRE FAUCHARD epithelium in the gingiva)
- FATHER OF DENTAL
PROFESSION WHO INTRODUCE STRUCTURE OF ORAL MUCOSA
THE HIS BOOK OF DENTISTRY Soft tissue that we see Inside the oral
AND GIVE EMPHASIS OF cavity
PERIODONTAL DISEASE
- FATHER OF DENTISTY 1. MASTICATORY MUCOSA must
be KERATINIZED
19TH CENTURY A. GINGIVA
- JOHN W. RIGS B. HARD PALATE
- THERE IS MICROORGANISM VASCULATORY MUCOSA
CAUSE THE “TARTAR” IN THE
TEETH Tissue that is exposed as we do
- PERIODONTAL DISEASE ALSO vascutation or chewing process
TERM “RIGS DISEASE”
2. SPECIALIZED MUCOSA
20TH CENTURY  Dorsum of the tongue is
specialized mucosa because
- BERNHARD GOTTLIEB it has Taste Buds.
 3. LINING MUCOSA not keratinized Constant renewal
as thick as masticatory mucosa
Structure/parts  Replacement of damage cells
 Floor of the mouth Cell to cell attachment
 Vestibules
 Cheeks/buccal mucosa  Desmosomes
 Lips  Adherents junctions
 Tight junctions
 Gap junctions
Cell basal lamina
Synthesis of basal lamina components

GINGIVA
Made up of collagen TYPE 1 Characteristics of attached gingiva
CHARACTERISTICS  Firm consistency
 CORAL PINK  Coral pink
 DULL SURFACE – THE SURFACE  Free gingival groove
IS NOT SHINY  Stippled
 FIRM CONSITENCY – NOT  Mucogingival junction
BOUNCING BACK Gingival fluid/sulcular fluid
 ROUNDED
 FOLLOWS THE CONTURE OF  Known as GCF represented as
THE CEJ WITH MEASUREMENT either a transudate or exudate
OF 1-5.2MM Transudate vs exudate
FUNCTION AND FEATURE OF GCF is transudate when gingiva is
GINGIVAL EPITHELIUM healthy
Function GCF is exudate when gingiva is
 Mechanical, chemical, water and unhealthy
microbial barrier signaling  Contains a vast array of
function. biochemical factor’s
Architectural integrity  Components of connective tissue,
epithelium, inflammatory cells
 Cell-cell attachment serum, microflora
 Basal lamina dura
 Keratin cytoskeleton Functions of GCF

Major cell type 1. Cleanse material from the sulcus

2. Contains plasma proteins that
 Keratinocytes may improve adhesion of
Other cell types epithelium to the tooth
3. Possess anti-microbial property
 Langerhans cells 4. Exert antibody activity to defend
 Melanocytes the gingiva.
 Merkel cells
Gingival Fibers function
  To brace the marginal gingival  Joints root cementum with socket
firmly against the tooth wall
 To provide the rigidity to withstand  The width is approximately
the forces of mastication without 0.25mm (range 0.2-0.4mm)
being deflected away from the
tooth surface Any changes in the width of the PDL
 To unite the free marginal gingiva measurement means there is a
with the cementum of the root movement happens in the tooth.
and the adjacent. Where there is an area of pressure and
Gingivodental group tension.
Radiograph PDL:
 Radiolucent – appears black
 PDL space becomes widen
 Permits forces to be distributed to
and resorbed by the alveolar
process via the alveolar bone
proper
 Essential for mobility of teeth
 Cells includes: fibroblast,
osteoblast, cementoblast,
epithelial cells and nerve fibers
Transseptal Fiber
Bundles of collagen fibers
Fibers that is seen between of the two
teeth

ROOT CEMENTUM
 3RD HARDEST TISSUE OF THE
BODY
PERIODONTAL LIGAMENT  MINERALIZED TISSUE
 DEMINIRALIZED –
Characteristics of Periodontal ligament PRESENCE OF
 Soft STREPTOCOCCUS MUTANTS
 Richly vascular (healing is fast) AND LACTOBACILLLUS
 Cellular connective tissue ACIDOPHILUS
(odontocytes, fibroblast, ENAMEL SURFACE IS SOFT.
cementoblast) CHARACTERISTICS OF ROOT
 Surrounds roots of the teeth CEMENTUM
  SPECIALIZED MINERALIZED  Product of fibroblasts and
TISSUE COVERING THE ROOT cementoblasts and is found in
SURFACES the cervical third of the root in
 CONTAINS NO BLOOD OR LYMPH humans but may extent farther
VESSELS (avascular it cannot apically.
heal itself)
 NO INNERVATION (no Cellular mixed stratified cementum (CM)
hypersensitivity, dentinal tubules  Composed of extrinsic (sharpey’s)
is exposed that why it is sensitive and intrinsic fibers and may
at root portion) contain cells.
 DOES NOT UNDERGGO  CMSC is a co-product of
PHYSIOLOGIC RESORPTION OR fibroblasts and cementoblasts.
REMODELING  In humans it appears primarily in
 CHARACTERIZED BY the apical third of the roots and
CONTINUING DEPOSITON apices and in furcation areas of
THROUGHOUT LIFE the molars.
(this is the reason why
cementum is not as smooth as Cellular intrinsic fibers cementum (CIFC)
the enamel, no exact shape, from  Contains cells, but no extrinsic
the cells of PDL) collagen fibers
Function of root cementum  CIFC is formed by cementoblasts
 In humans it fill resorption lacunae
1. Attaches the periodontal
ligament fibers to the root Intermediate cementum
2. Contributes to the process of  A poorly defined zone near the
repair after damage to the root cementodentinal junction of
surface certain teeth that appears to
Forms of cementum contain cellular remnants of
HERTWIG’S sheath embedded in
Acellular afibrillar cementum (AAC) calcified ground substance.
(contains no cells, no collagen fibers
found in the coronal area of the
cementum)
 Contains neither cells nor extrinsic ALVEOLAR BONE
or intrinsic collagen fibers,
except for a mineralized ground Alveolar Process
substance
 Parts of the maxilla and mandible
 Product of cementoblasts and is
that form and support the
found as coronal cementum in
sockets of teeth
humans
 Consist of bone (spongy, cortical
Acellular extrinsic fiber cementum bone and compact bone)
(AEFC)  Made up of calcium and
(have cells known as SHARPEY’s phosphate
FIBERS)  Any breakage of the white line or
the lamina dura means there is
 Is composed almost entirely of an infection
densely packed bundles of
SHARPEY’S fibers and lacks
cells.
MODULE 2: CANVAS
M2 Lesson 1: Normal Anatomy of
Periodontium

The gingiva can be anatomically divided

into the following parts:

The periodontium is a complex structure

that consists of the gingiva, periodontal
ligament, cementum, and alveolar bone.
They allow the teeth to be attached to the
bone and protect the underlying structures.
The free gingiva (or marginal gingiva,
THE GINGIVA: not to be confused with gingival margin) is
 Consists of three zones unattached at the terminal edge, usually
- MASTICATORY MUCOSA - which 1mm wide, that surrounds the teeth like a
covers the gingiva and hard palate collar. The margin of the free gingiva is
rounded in such a way that a small
- SPECIALIZED MUCOSA - covers the invagination or gingival sulcus is formed
dorsum of tongue between the tooth and the gingiva.

- ORAL MUSOUS MEMBRANE - lining of

the remainder of oral cavity

M2 Lesson 1: GINGIVA
The gingiva is the soft tissue structure
that surrounds the teeth and alveolar bone.
In a healthy state, the gingiva is coral pink,
which may sometimes be pigmented
depending on the person's ethnicity. It is
firm in consistency, and is attached to
the underlying alveolar bone. The
surface of gingiva is keratinized and
may exhibit an orange peel appearance,
called stipplings.
 epithelium) and the underlying central core
of connective tissue (lamina propria).
Although the epithelium is predominantly
cellular in nature, the connective tissue is
less cellular and composed primarily of
collagen fibers and ground substance.
These two tissues are considered
separately. The stratum corneum is found
on only keratinized tissues like the
attached gingiva.

The attached gingiva is the keratinized

tissue that is firmly attached to the
underlying periosteum of the alveolar bone.
It extends from the free gingiva (delineated
by the free gingival groove) to the loose,
unkeratinized alveolar mucosa facially M2L2: PERIODONTAL LIGAMENT
(delineated by the mucogingival junction).
It is generally wider in the anterior region
and gets narrower towards the posterior
region.

The interdental gingiva is formed by the The periodontal ligament is a specialized

gingival tissues in the interproximal spaces tissue that connects the cementum to the
beneath the tooth contact. It can have a gingiva and alveolar socket. It is
pyramidal shape where the tip of the composed mostly of collagen bands and
papilla is immediately below the contact fibroblasts. Interstitial spaces contain the
point, or a col shape where it has a valley- blood vessels and nerve trunks, which
like depression that connects the facial communicate freely with vessels and
and lingual papilla. nerves at the apex of the roots and the
alveolar bone. This tissue is highly cellular,
containing fibroblasts and vascular, neural,
bone, and cemental cells. The primary
function of the periodontal ligament is
support for the teeth. The ligament also
transmits neural input to the masticatory
apparatus and has a nutritive function
Microscopic examination reveals that essential to maintaining the ligament’s
gingiva is composed of the overlying health, which has important clinical
stratified squamous epithelium (oral implications.
 collagen fiber bundles (collagen types I
The collagen fibers are strategically and III) and cells found between the roots
arranged as variously orientated dense of teeth and the inner walls of the alveolar
fiber bundles that connect alveolar bone socket. The cells of the PDL are
and cementum, which may help to resist heterogeneous including fibroblasts,
movement in specific directions. Two osteoblasts, cementoblasts, and stem
groups of principal fibers are named cells. The PDL firmly anchors the tooth to
according to their location with respect to the bone via Sharpey’s fibres and
the teeth. The gingival group is located distributes applied force to contiguous
around the necks of the teeth, and the alveolar bone. The PDL thus represents an
dentoalveolar group surrounds the roots of essential tissue that maintains the
the teeth. periodontal environment and function and
is therefore important in dentistry including
in both periodontics and orthodontics.

M2L1: CEMENTUM
The cementum is the mineralized tissue
covering the dentin surfaces of the tooth
root and is known to be the attachment
site for the periodontal ligaments. It is light
yellow in appearance, and is thinner at
the cervical area and thickens towards
the root apex.

GINGIVAL FIBER GROUP

Cementum is slightly softer than dentin

and consists of about 45–50% inorganic
DENTOALVEOLAR FIBER GROUP mineral (mainly the apatite crystals) and
50–55% organic matter (mainly collagen
and glycoproteins) and water. Sharpey’s
fibers (perforating fibers) are portions of
the principal collagenous fibers of the
periodontal ligament embedded in the
cementum and alveolar bone. Cementum
is formed continuously throughout life
because a new layer of cementum is
deposited to keep the attachment intact as
the superficial layer of cementum ages,
The periodontal ligament (PDL) is a
but unlike bone tissue that can be
connective tissue consisting primarily of
constantly rebuilt and remodeled,
cementum has a stronger anti-absorption fundamentally in mammalian teeth, which
capacity compared to the alveolar bone fit into alveolar sockets of alveolar bone,
and is only capable of repairing itself to a and functions as a tooth-supporting device
limited degree. in concert with the periodontal principal
fibers and alveolar bone. Cementum is
The structure of cementum is similar to the often referred to as a bone-like tissue.
compact bone. Both are composed of Cementum, however, is avascular, does
cells and mineralized extracellular matrix. not undergo dynamic remodeling, and
But unlike bone, it is avascular. Two kinds increases in thickness throughout life. On
of cementum are formed, acellular and these points, cementum is markedly
cellular, and fibers can be intrinsic or different from bone.
extrinsic, which results in four possible
permutations. The cementum attached to Cementum has been classified into cellular
the root dentin and covering the upper and acellular cementum by inclusion or
(cervical) portion of the root is acellular non-inclusion of cementocytes. Generally,
and thus is called acellular, or primary, acellular cementum is thin and covers the
cementum. The lower (apical) portion of cervical root, whereas thick cellular
the root is covered by cellular, or cementum covers the apical root.
secondary, cementum. In this case, Cementum contains two types of fibers, i.e.
cementoblasts become trapped in lacunae extrinsic (Sharpey's) fibers which are
within their own matrix, very much like embedded ends of the principal fibers and
osteocytes occupy lacunae in bone; these intrinsic fibers which are fibers of
entrapped cells are now called cementum proper. It is believed that the
cementocytes. Acellular cementum extrinsic fibers are secreted by fibroblasts
anchors PDL fiber bundles to the tooth; and partly cementoblasts and that the
cellular cementum has an adaptive role. intrinsic fibers are secreted by only
Bone, the PDL, and cementum together cementoblasts. Acellular extrinsic fiber
form a functional unit of special cementum (AEFC) contains densely
importance when orthodontic tooth packed extrinsic fibers and no
movement is undertaken. cementocytes. AEFC corresponds to
classical acellular cementum. Cellular
intrinsic fiber cementum (CIFC) contains
intrinsic fibers and cementocytes. Cellular
mixed stratified cementum (CMSC)
corresponds to classical cellular
cementum. Typical CMSC is partitioned by
intensely hematoxylin-stainable lines or
incremental lines. The individual
partitioned cementum is CIFC, and
occasionally AEFC. Namely, CMSC
represents the whole of cellular cementum
composed of stratified CIFC and AEFC.
Cellular cementum with both intrinsic and
extrinsic fibers is often found within CMSC.
This type of cementum is not distinctively
classified and is regarded as a sub-variety
of CIFC in the current classification.

Cementum is a mineralized tissue covering

the entire root surface. Cementum exists
M2L2: ALVEOLAR BONE

The alveolar process is the part of the

maxilla and mandible that supports the
roots of teeth and is composed of alveolar
bone proper and supporting bone. Alveolar
bone proper is the bone lining the tooth
socket. In clinical radiographic terms, it is
defined as the lamina dura. Dense bone
serves as the attachment bone that
surrounds the roots of the teeth.
Supporting bone is the bone that serves as
a dense cortical plate to sustain the
alveolar bone proper. This cortical plate
covers the surface of the maxilla and
mandible and supports the alveolar bone
proper. The supporting cancellous bone
underlies and supports the dense cortical
bone. The existence of alveolar bone is
entirely dependent on the presence of Characteristic of all bones are a dense
teeth. Alveolar bone develops initially as a outer sheet of compact bone and a central,
protection for the soft developing primary medullary cavity. This cavity is filled with
teeth and later, as the roots develop, as a red or yellow bone marrow that is
support for the teeth. Finally, as the teeth interrupted, particularly at the extremities
are lost, the alveolar bone resorbs. Teeth of long bones, by a network of bone
are responsible not only for the trabeculae (trabecular, cancellous, or
development but also for the maintenance spongy bone are the terms used to
of the alveolar process of the mandible. describe this network
The coronal border of the alveolar process
is known as the alveolar crest. This crest is
normally located approximately 1-2 mm
below the cementoenamel junction. It is
pointed on the anterior region (1) and
nearly flat in the molar area (2). When teeth
are viewed from the buccolingual aspect,
the alveolar crest may be thin or missing.

.
The alveolar bone is the thickened ridge of surface cementum. Perforating fibers are
bone that contains the tooth sockets not limited to periodontal bone. They also
(dental alveoli) on the maxilla and mandible appear anywhere in the body where
that hold teeth. The alveolar process ligaments or tendons attach to cartilage or
contains a region of compact bone bone. Because bone of the alveolar
adjacent to the periodontal ligament (PDL), process is regularly penetrated by collagen
called the lamina dura when viewed on fiber bundles, it can be appropriately
radiographs. It is this part which is termed bundle bone. Bundle bone, being
attached to the cementum of the roots by synonymous with alveolar bone proper or
the periodontal ligament. It is uniformly lamina dura, appears more dense
radiopaque (or lighter). radiographically than the adjacent
supportive bone. This density is probably
the result of the mineral content or
orientation of the mineral crystals
surrounding the fiber bundles. Blood
vessels and nerves penetrate the lamina
dura through small foramina. Because the
mineral density is sufficient, this bone
appears opaque in radiographs. Tension
on the perforating fibers during
mastication is believed to stimulate this
bone and is considered important in its
maintenance.

The compact or dense bone that lines the

tooth socket is of two types when viewed
microscopically. This bone either contains
perforating fibers from the periodontal The morphological and functional unit of
ligament or is similar to compact bone the bone is the Haversian system, the
found elsewhere in the body. Perforating Haversian or central (longitudinal) canals
fibers or Sharpey fibers are bundles of connected by Volkmann's or perforating
collagen fibers embedded in the alveolar (transverse) canals. Officially, Haversian
bone proper. These fibers are at right and Volkmann's canals are "nutrient and
angles or oblique to the surface of the perforating canal" in Terminologia
alveolar bone proper and along the root of Histologica. The canals have a concentric
the tooth. The fiber bundles inserting in the lamellar organization and are of equal size.
bone are regularly spaced and appear The bone is vascularized by vessels that
similar to those that insert into the root penetrate the matrix from the periosteum.
 is a loss of gingival stippling. In elderly
individuals, all mucosal surfaces are more
susceptible to mechanical irritation in
comparison to younger persons.
Histologically, there is a reduction of
keratinization of the gingiva, as well as
atrophy in the region of the Stratum
spinosum. All of these alterations are more
common in females during menopause
than in males of equal age, and may be
explained by the reduction in ovarian
function.

GINGIVAL EPITHELIUM:

M2L1: AGING AND THE Thinning and decreased keratinization of

the gingival epithelium have been reported
PERIODONTIUM
with age. The significance of these
findings could mean an increase in
Aging alone does not lead to critical loss
epithelial permeability to bacterial antigens,
of periodontal attachment in healthy
a decreased resistance to functional
elderly persons. The effects of aging on
trauma, or both. If so, such changes may
periodontal tissues are based on
influence long-term periodontal outcomes.
molecular changes in the periodontal cells,
However, other studies have found no
which intensify bone loss in elderly
age-related differences in the gingival
patients with periodontitis. These effects
epithelium of humans or dogs. Other
may be associated with (1) alteration in
reported changes with aging include the
differentiation and proliferation of
flattening of rete pegs and altered cell
osteoblasts and osteoclasts; (2) an
density. Conflicting data regarding the
increase in periodontal cell response to the
surgical regeneration times for gingival
oral microbiota and mechanical stress
epithelium have been ascribed to
leading to the secretion of cytokines
problems with research methodology.
involved in osseous restoration; and (3)
systemic endocrine alterations in the
elderly people. JUNCTIONAL EPITHELIUM:
Research studies have not demonstrated
any deviation from normal structural
EPITHELIUM:
relationships in the junctional epithelium
with age.
Changes in the gingival epithelium are
directed for the most part by the
subepithelial connective tissue. For the CONNECTIVE TISSUES:
proliferation, and therewith the turnover of
the epithelium, there are varying Age-related connective tissue changes
explanations: While some authors have can be observed in the gingiva as well as
described an increase in proliferative in the periodontal ligament. The number of
activity with age, others report stationary fibroblasts (and their mitotic activity) is
proliferation or even a decrease. reduced, as is collagen synthesis. The
Regardless of these reports, there is collagen within the periodontal ligament
consensus that the oral mucosa and also exhibits normal distribution, but the fiber
the gingiva becomes thinner, “softer,” and bundles are thicker and more dense.
drier (reduced saliva production) and there (Simultaneously, the organic matrix is
reduced. Hyaline zones may form, and
these (seldom) lead to cartilage-like or
calcified regeneration. The number of CEMENTUM:
Malassez epithelial rest cells becomes Some consensus regarding the effect of
diminished.) aging on cementum exists. An increase in
cemental width is a common finding; this
GINGIVAL CONNECTIVE TISSUES: increase may be 5 to 10 times with
increasing age. This finding is not
Increasing age results in coarser and surprising, because deposition continues
denser gingival connective tissues. after tooth eruption. The increase in width
Qualitative and quantitative changes to is greater apically and lingually. Although
collagen have been reported. These cementum has limited capacity for
include an increased rate of conversion of remodeling, an accumulation of resorption
soluble to insoluble collagen, increased bays explains the finding of increasing
mechanical strength, and increased surface irregularity. The thickness of the
denaturing temperature. These results cellular mixed-fiber cementum increases,
indicate increased collagen stabilization especially in the apical third of the root
caused by changes in the macromolecular surface and in furcation areas.
conformation. Not surprisingly, an
increased collagen content has been BONE:
found in the gingivae of older animals,
despite a lower rate of collagen synthesis In elderly persons, osteoporotic changes
decreasing with age. in bone—resorption of compact bone and
expansion of the marrow spaces— can
PERIODONTAL LIGAMENT: also affect the jaw bones, but in this intra-
oral localization, these lytic processes play
Changes in the periodontal ligament that a less significant role than was previously
have been reported with aging include assumed. Osteoporosis is much more
decreased numbers of fibroblasts and a often observed in the long bones and
more irregular structure, thus paralleling vertebral column. Females, because of the
the changes seen in the gingival reduction in estrogen production, are more
connective tissues. Other findings include often affected than males; women should
decreased organic matrix production, be regularly tested following menopause
epithelial cell rests, and increased (bone thickness/density measurements).
amounts of elastic fiber. Conflicting results
have been reported for changes in the Alveolar Bone
width of the periodontal ligament in human
and animal models. Although true variation Reports of morphologic changes in
may exist, this finding probably reflects the alveolar bone mirror age-related changes
functional status of the teeth in the studies: in other bony sites. Specific to the
the width of the space will decrease if the periodontium are findings of a more
tooth is unopposed (i.e., hypofunction) or irregular periodontal surface of bone and
increase with excessive occlusal loading. the less-regular insertion of collagen fibers.
Both scenarios can be anticipated as a Although age is a risk factor for the bone
result of tooth loss in this population. mass reductions in individuals with
These effects may also explain the osteoporosis, it is not causative and
variability in studies that have reported therefore should be distinguished from
qualitative changes within the periodontal physiologic aging processes. Overriding
ligament. the diverse observations of bony changes
with age is the important finding that the
healing rate of bone in extraction sockets
appears to be unaffected by increasing
age. Indeed, the success of
osseointegrated dental implants, which IMMUNE AND INFLAMMATORY
relies on intact bone healing responses, RESPONSES
does not appear to be age related.
However, balancing this view is the recent Recent advances in the study of the
observation that bone graft preparations effects of aging on the immune response
(i.e., decalcified freeze-dried bone) from (i.e., immunosenescence) have altered the
donors who were more than 50 years old understanding of this phenomenon. In
possessed significantly less osteogenic particular, more recent studies have set
potential than graft material from younger tighter controls on excluding individuals
donors. The possible significance of this with systemic conditions known to affect
phenomenon for normal healing responses the immune response. As a result, age has
needs to be investigated. been recognized as having much less
effect on the alteration of the host
BACTERIAL PLAQUE response than previously thought.
Differences between younger and older
Dentogingival plaque accumulation has individuals can be demonstrated for T and
been suggested to increase with age. This B cells, cytokines, and natural killer cells
might be explained by the increase in but not for polymorphonuclear cells and
hard-tissue surface area as a result of macrophage activity. McArthur concluded
gingival recession and the surface the following: “Measurement of indicators
characteristics of the exposed root surface of immune and inflammatory competency
as a substrate for plaque formation as suggested that, within the parameters
compared with enamel. Other studies have tested, there was no evidence for age-
shown no difference in plaque quantity related changes in host defenses
with age. This contradiction might reflect correlating with periodontitis in an elderly
the different age ranges of experimental (65 to 75 years) group of individuals, with
groups as variable degrees of gingival and without disease.” Recent laboratory
recession and root surface exposure. For studies have shown age-related changes
supragingival plaque, no real qualitative in the expression of pro-inflammatory
differences have been shown for plaque mediators and innate immunity with the
composition. With regard to subgingival potential to alter the pathology of
plaque, one study has shown subgingival periodontal diseases or antimicrobial
flora to be similar to normal flora, whereas function. However, the relevance of these
another study reported increased numbers findings to the clinical situation has not
of enteric rods and pseudomonas in older been demonstrated.
adults. Mombelli suggests caution when
interpreting this finding because of the M2L2: PATHOLOGIC FEATURES
increased oral carriage of these species
among older adults. It has been Understanding the structure and histology
speculated that a shift occurs in the of the periodontium is clinically significant
importance of certain periodontal to the discussion of wound healing, drugs
pathogens with age, specifically including and environmental factors affecting it,
an increased role for Porphyromonas periodontal diseases, and overall health
gingivalis and a decreased role for risk factors. Lamina propria of gingiva
Aggregatibacter actinomycetemcomitans. regenerates more readily due to fiber
However, differentiating true age effects differentiation after wounding, compared
from the changes in ecologic determinants to the alveolar bone, which relies on
for periodontal bacteria will be difficult. osteocyte, bone marrow cells, endosteum
This topic was considered in more detail in cells, and osteogenic cells of periosteum,
a recent review. which occupy different compartments.
Histopathology of periodontal diseases is
described in 4 stages:

1. Initially, the gingival crevicular fluid

(GCF) amount is increased due to
vascular changes in response to the
initial insult. At this benign stage,
polymorphonuclear neutrophils are
attracted to the lesion site, and T
lymphocytes are responsible for
fibroblasts in the area.
2. The early lesion is characterized by
redness of the lesion. At this stage,
PMNs clear and breakdown the
collagen fibers, which leads to an
increase in the previously made space
for infiltrates.
3. At this stage, the established lesion
is dominated by B cells and leukocyte
aggregation. This will initiate the lesion
side transformation by changing both
junctional and sulcular epithelium into
an extremely vulnerable epithelium
called the pocket epithelium. This is
apparent as bleeding upon gentle
gingival manipulation.
4. An advanced lesion characterized as
loss of gingival fibers and alveolar
bone is caused by migration of biofilm
into the pocket and creating an
environment for anaerobic bacterial
proliferation.

M2L2: GINGIVITIS