Localized Aggressive Periodontitis and Necrotizing Ulcerative Gingivitis

Localized Aggressive Periodontitis (LAP)

Localized aggressive periodontitis, previously known as localized juvenile periodontitis, is characterized by specific microbial profiles and clinical features.

• Microbiota Composition:
  • The microbiota associated with LAP is predominantly composed of:
    • Gram-Negative, Capnophilic, and Anaerobic Rods.
  • Key Organisms:
    • Actinobacillus actinomycetemcomitans: The main organism involved in LAP.
    • Other significant organisms include:
      • Porphyromonas gingivalis
      • Eikenella corrodens
      • Campylobacter rectus
      • Bacteroides capillus
      • Spirochetes (various species).
  • Viral Associations:
    • Herpes viruses, including Epstein-Barr Virus-1 (EBV-1) and Human Cytomegalovirus (HCMV), have also been associated with LAP.

Necrotizing Ulcerative Gingivitis (NUG)

• Microbial Profile:
  • NUG is characterized by high levels of:
    • Prevotella intermedia
    • Spirochetes (various species).
• Clinical Features:
  • NUG presents with necrosis of the gingival tissue, pain, and ulceration, often accompanied by systemic symptoms.

Microbial Shifts in Periodontal Disease

When comparing the microbiota across different states of periodontal health, a distinct microbial shift can be identified as the disease progresses from health to gingivitis to periodontitis:

1. From Gram-Positive to Gram-Negative:

   • Healthy gingival sites are predominantly colonized by gram-positive bacteria, while diseased sites show an increase in gram-negative bacteria.

2. From Cocci to Rods (and Later to Spirochetes):

   • In health, cocci (spherical bacteria) are prevalent. As the disease progresses, there is a shift towards rod-shaped bacteria, and in advanced stages, spirochetes become more prominent.

3. From Non-Motile to Motile Organisms:

   • Healthy sites are often dominated by non-motile bacteria, while motile organisms increase in number as periodontal disease develops.

4. From Facultative Anaerobes to Obligate Anaerobes:

   • In health, facultative anaerobes (which can survive with or without oxygen) are common. In contrast, obligate anaerobes (which thrive in the absence of oxygen) become more prevalent in periodontal disease.

5. From Fermenting to Proteolytic Species:

   • The microbial community shifts from fermentative bacteria, which primarily metabolize carbohydrates, to proteolytic species that break down proteins, contributing to tissue destruction and inflammation.

Periodontal Medicaments

Periodontal diseases often require adjunctive therapies to traditional mechanical treatments such as scaling and root planing. Various medicaments have been developed to enhance the healing process and control infection in periodontal tissues. This lecture will discuss several periodontal medicaments, their compositions, and their clinical applications.

1. Elyzol

• Composition:
  • Elyzol is an oil-based gel containing 25% metronidazole. It is formulated with glyceryl mono-oleate and sesame oil.
• Clinical Use:
  • Elyzol has been found to be equivalent to scaling and root planing in terms of effectiveness for treating periodontal disease.
  • However, no adjunctive effects beyond those achieved with mechanical debridement have been demonstrated.

2. Actisite

• Composition:

  • Actisite consists of tetracycline-containing fibers.
  • Each fiber has a diameter of 0.5 mm and contains 12.7 mg of tetracycline per 9 inches of fiber.

• Clinical Use:

  • The fibers are placed directly into periodontal pockets, where they release tetracycline over time, helping to reduce bacterial load and promote healing.

3. Arestin

• Composition:

  • Arestin contains minocycline, which is delivered as a biodegradable powder in a syringe.

• Clinical Use:

  • Arestin is indicated for the treatment of periodontal disease and is applied directly into periodontal pockets, where it provides localized antibiotic therapy.

4. Atridox

• Composition:

  • Atridox contains 10% doxycycline in a syringeable gel system that is biodegradable.

• Clinical Use:

  • The gel is injected into periodontal pockets, where it solidifies and releases doxycycline over time, aiding in the management of periodontal disease.

5. Dentamycin and Periocline

• Composition:

  • Both Dentamycin and Periocline contain 2% minocycline hydrochloride.

• Clinical Use:

  • These products are used similarly to other local delivery systems, providing localized antibiotic therapy to reduce bacterial infection in periodontal pockets.

6. Periochip

• Composition:

  • Periochip is a biodegradable chip that contains chlorhexidine.

• Clinical Use:

  • The chip is placed in the gingival crevice, where it releases chlorhexidine over time, providing antimicrobial action and helping to control periodontal disease.

Platelet-Derived Growth Factor (PDGF)

Platelet-Derived Growth Factor (PDGF) is a crucial glycoprotein involved in various biological processes, particularly in wound healing and tissue repair. Understanding its role and mechanisms can provide insights into its applications in regenerative medicine and periodontal therapy.

Overview of PDGF

1. Definition:

   • PDGF is a glycoprotein that plays a significant role in cell growth, proliferation, and differentiation.

2. Source:

   • PDGF is carried in the alpha granules of platelets and is released during the process of blood clotting.

3. Discovery:

   • It was one of the first growth factors to be described in scientific literature.
   • Originally isolated from platelets, PDGF was found to exhibit mitogenic activity specifically in smooth muscle cells.

Functions of PDGF

1. Mitogenic Activity:

   • PDGF stimulates the proliferation of various cell types, including:
     • Smooth muscle cells
     • Fibroblasts
     • Endothelial cells
   • This mitogenic activity is essential for tissue repair and regeneration.

2. Role in Wound Healing:

   • PDGF is released at the site of injury and plays a critical role in:
     • Promoting cell migration to the wound site.
     • Stimulating the formation of new blood vessels (angiogenesis).
     • Enhancing the synthesis of extracellular matrix components, which are vital for tissue structure and integrity.

3. Involvement in Periodontal Healing:

   • In periodontal therapy, PDGF can be utilized to enhance healing in periodontal defects and promote regeneration of periodontal tissues.
   • It has been studied for its potential in guided tissue regeneration (GTR) and in the treatment of periodontal disease.

Clinical Applications

1. Regenerative Medicine:

   • PDGF is being explored in various regenerative medicine applications, including:
     • Bone regeneration
     • Soft tissue healing
     • Treatment of chronic wounds

2. Periodontal Therapy:

   • PDGF has been incorporated into certain periodontal treatment modalities to enhance healing and regeneration of periodontal tissues.
   • It can be used in conjunction with graft materials to improve outcomes in periodontal surgery.

PERIOTEST Device in Periodontal Assessment

The PERIOTEST device is a valuable tool used in dentistry to assess the mobility of teeth and the reaction of the periodontium to applied forces. This lecture covers the principles of the PERIOTEST device, its measurement scale, and its clinical significance in evaluating periodontal health.

Function: The PERIOTEST device measures the reaction of the periodontium to a defined percussion force applied to the tooth. This is done using a tapping instrument that delivers a controlled force to the tooth.

Contact Time: The contact time between the tapping head and the tooth varies between 0.3 and 2 milliseconds. This duration is typically shorter for stable teeth compared to mobile teeth, allowing for a quick assessment of tooth stability.

PERIOTEST Scale

The PERIOTEST scale ranges from -8 to +50, with specific ranges indicating different levels of tooth mobility:

Clinical Significance

Assessment of Tooth Mobility:
The PERIOTEST device provides a quantitative measure of tooth mobility, which is essential for diagnosing periodontal disease and assessing the stability of teeth.

Correlation with Other Measurements:
The PERIOTEST values correlate well with:

• Tooth Mobility Assessed with a Metric System: This allows for a standardized approach to measuring mobility, enhancing the reliability of assessments.

• Degree of Periodontal Disease and Alveolar Bone Loss: Higher mobility readings often indicate more severe periodontal disease and greater loss of supporting bone, making the PERIOTEST a useful tool in monitoring disease progression.

Treatment Planning:
Understanding the mobility of teeth can aid in treatment planning, including decisions regarding periodontal therapy, splinting of mobile teeth, or extraction in cases of severe mobility.

Finger Rests in Dental Instrumentation

Use of finger rests is essential for providing stability and control during procedures. A proper finger rest allows for more precise movements and reduces the risk of hand fatigue.

Importance of Finger Rests

• Stabilization: Finger rests serve to stabilize the hand and the instrument, providing a firm fulcrum that enhances control during procedures.
• Precision: A stable finger rest allows for more accurate instrumentation, which is crucial for effective treatment and patient safety.
• Reduced Fatigue: By providing support, finger rests help reduce hand and wrist fatigue, allowing the clinician to work more comfortably for extended periods.

Types of Finger Rests

1. Conventional Finger Rest:

   • Description: The finger rest is established on the tooth surfaces immediately adjacent to the working area.
   • Application: This is the most common type of finger rest, providing direct support for the hand while working on a specific tooth. It allows for precise movements and control during instrumentation.

2. Cross Arch Finger Rest:

   • Description: The finger rest is established on the tooth surfaces on the other side of the same arch.
   • Application: This technique is useful when working on teeth that are not directly adjacent to the finger rest. It provides stability while allowing access to the working area from a different angle.

3. Opposite Arch Finger Rest:

   • Description: The finger rest is established on the tooth surfaces of the opposite arch (e.g., using a mandibular arch finger rest for instrumentation on the maxillary arch).
   • Application: This type of finger rest is particularly beneficial when accessing the maxillary teeth from the mandibular arch, providing a stable fulcrum while maintaining visibility and access.

4. Finger on Finger Rest:

   • Description: The finger rest is established on the index finger or thumb of the non-operating hand.
   • Application: This technique is often used in areas where traditional finger rests are difficult to establish, such as in the posterior regions of the mouth. It allows for flexibility and adaptability in positioning.

Periodontics: Dental specialty deals with the supporting and surrounding tissues of the teeth. 

1. Periodontium: tissues that invest and support teeth Includes Gingiva, Alveolar mucosa  Cementum, Periodontal ligament, Alveolar bone, Support bone

2. Periodontal disease: changes to periodontium beyond normal range of variation

a. Specific plaque hypothesis: specific microorganisms cause periodontal disease; mostly anaerobes. Three implicated: Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Bacteriodes forsythus

b. Contributing factors: often a combination of factors

i. Local: calculus (tarter, home for bacteria, ­ with age), traumatic occlusal forces, caries (root caries), overhangs and over-contoured restorations, open contacts with food impaction, missing/malaligned teeth

Invasion of biological width: from free gingival margin -> attached gingiva need ~ 3 mm.  If enter this area -> problems (e.g., resorption)

ii. Host factors: exacerbate periodontal problems; e.g., smoking/tobacco use, pregnancy and puberty (hormonal changes, ­ blood vessel permeability), stress, poor diet

iii.Medications: often -> tissue overgrowth; e.g., oral contraceptives, antidepressants, heart medicines, transplant anti-rejection drugs

iv.Systemic diseases: e.g., diabetes, immunosuppression

B. Gingivitis: inflammation of gingiva; ­ with age; generally reversible

C. Periodontitis: inflammation of supporting tissues of teeth, characterized by loss of attachment (PDL) and bone; generally irreversible

D.       Periodontal disease as risk factor for systemic diseases:

1.        Causes difficulty for diabetics to control blood sugar

2.        Pregnant women with periodontal disease ~ 7 times more likely to have premature and/or underweight baby

3.        Periodontal diseased patients may be at risk for heart disease