Classification by Extent

• Generalized: >30% sites affected

Classification by Severity

• Moderate: 3 – 4 mm bone loss
• Severe: >5 mm bone loss

Aggressive Periodontitis

• Rate: 3 – 4 times faster bone loss than chronic
• Classic sign: Arc – shaped bone loss (distal 2nd premolar to mesial 2nd molar)
• Associated: HLA A9 and B15 antigens
• Receptor defect: Poorly functional monocyte FcγR2

Pain Characteristics

• Periodontal pocket pain: "Deep in bone" feeling

Bone Loss Patterns

• Radius of action: 1.5 – 2.5 mm (Page & Schroeder)
• Reverse architecture: Facial/lingual plates lost, radicular bone preserved
• TFO signs: Increased mobility (first clinical sign)

Blade Angulation Protocols

Scaling & Root Planing

• Angulation: 45-90 degrees to tooth surface
• Purpose: Effective calculus removal and root surface debridement

Gingival Curettage

• Angulation: >90 degrees
• Technique: Removal of infected soft tissue from pocket wall

Curette Sharpening

• Optimal Angle: 100-110 degrees
• Maintenance: Critical for effective instrumentation

Curette Design

Gracey Curettes

• Offset Angle: 60 degrees
• Specificity: Area-specific design for different tooth surfaces

Universal Curettes

• Angle: 90 degrees
• Application: Suitable for all tooth surfaces

After-Five Curettes

• Modification: Terminal shank extended by 3mm
• Purpose: Access to deep pockets (>5mm)

Probing Systems

CPITN Probe

• Tip Diameter: 0.5mm
• Markings: 3.5, 5.5, 8.5, 11.5mm
• Use: Community periodontal index assessment

Florida Probe

• Tip Diameter: 0.4mm (more precise)
• Technology: Computerized probing system

Implant Probing

• Maximum Force: 25N
• Probe Type: Plastic probes recommended to prevent implant surface damage

🟡 Jaundice & Liver Disorders

🦠 Viral Hepatitis

• Hepatitis E: Feco-oral; dangerous in pregnancy
• Councilman bodies: Acute viral hepatitis
• Most chronic virus: Hepatitis C
• HBV infectivity: HBsAg + HBeAg
• Window period: ↓ HBsAg, ↑ anti-HBs
• Perinatal HBV transmission: 90% risk
• First marker in acute HBV: HBsAg
• HBV P gene: Codes reverse transcriptase
• Hepatitis A prophylaxis: Human Ig
• Most epidemic-prone hepatitis in India: Hepatitis E

Components of Gingival Crevicular Fluid (GCF) and Matrix Metalloproteinases (MMPs)

Gingival crevicular fluid (GCF) is a serum-like fluid found in the gingival sulcus that plays a significant role in periodontal health and disease. Understanding its composition, particularly glucose and protein content, as well as the role of matrix metalloproteinases (MMPs) in tissue remodeling, is essential for dental professionals.

Composition of Gingival Crevicular Fluid (GCF)

1. Glucose and Hexosamines:

   • GCF contains compounds such as glucose, hexosamines, and hexuronic acid.
   • Glucose Levels:
     • Blood glucose levels do not correlate with GCF glucose levels; in fact, glucose concentration in GCF is three to four times greater than that in serum.
     • This elevated glucose level is interpreted as a result of the metabolic activity of adjacent tissues and the influence of local microbial flora.

2. Protein Content:

   • The total protein content of GCF is significantly less than that of serum.
   • This difference in protein concentration reflects the unique environment of the gingival sulcus and the specific functions of GCF in periodontal health.

Matrix Metalloproteinases (MMPs)

1. Definition and Function:

   • MMPs are a family of proteolytic enzymes that degrade extracellular matrix molecules, including collagen, gelatin, and elastin.
   • They are produced by various cell types, including:
     • Neutrophils
     • Macrophages
     • Fibroblasts
     • Epithelial cells
     • Osteoblasts and osteoclasts

2. Classification:

   • MMPs are classified based on their substrate specificity, although it is now recognized that many MMPs can degrade multiple substrates. The classification includes:
     • Collagenases: e.g., MMP-1 and MMP-8 (break down collagen)
     • Gelatinases: Type IV collagenases
     • Stromelysins
     • Matrilysins
     • Membrane-type metalloproteinases
     • Others

3. Activation and Inhibition:

   • MMPs are secreted in an inactive form (latent) and require proteolytic cleavage for activation. This activation is facilitated by proteases such as cathepsin G produced by neutrophils.
   • Inhibitors: MMPs are regulated by proteinase inhibitors, which possess anti-inflammatory properties. Key inhibitors include:
     • Serum Inhibitors:
       • α1-antitrypsin
       • α2-macroglobulin (produced by the liver, inactivates various proteinases)
     • Tissue Inhibitors:
       • Tissue inhibitors of metalloproteinases (TIMPs), with TIMP-1 being particularly important in periodontal disease.
   • Antibiotic Inhibition: MMPs can also be inhibited by tetracycline antibiotics, leading to the development of sub-antimicrobial formulations of doxycycline as a systemic adjunctive treatment for periodontitis, exploiting its anti-MMP properties.

Merkel Cells

1. Location and Function:
   • Merkel cells are located in the deeper layers of the epithelium and are associated with nerve endings.
   • They are connected to adjacent cells by desmosomes and are identified as tactile receptors.
   • These cells play a role in the sensation of touch and pressure, contributing to the sensory functions of the oral mucosa.

Clinical Implications

1. GCF Analysis:

   • The composition of GCF, including glucose and protein levels, can provide insights into the inflammatory status of the periodontal tissues and the presence of periodontal disease.

2. Role of MMPs in Periodontal Disease:

   • MMPs are involved in the remodeling of periodontal tissues during inflammation and disease progression. Understanding their regulation and activity is crucial for developing therapeutic strategies.

3. Therapeutic Applications:

   • The use of sub-antimicrobial doxycycline as an adjunctive treatment for periodontitis highlights the importance of MMP inhibition in managing periodontal disease.

4. Sensory Function:

   • The presence of Merkel cells in the gingival epithelium underscores the importance of sensory feedback in maintaining oral health and function.

Iodine Effects

• High dose, short period → Inhibits T4 synthesis (Wolff-Chaikoff effect)
• Low dose, long period → Increases T4 synthesis (Jod-Basedow effect)

Drugs Inhibiting T4→T3 Conversion

Propranolol, Dexamethasone, Propylthiouracil, High-dose iodine, Radiographic contrast

Hypothyroidism

• Best test: Raised TSH (primary hypothyroidism)
• Causes: Amyloidosis, Sarcoidosis, Hemochromatosis, Scleroderma, Cystinosis
• Drugs: Amiodarone, Lithium
• Hashimoto thyroiditis

Pathogens Implicated in Periodontal Diseases

Periodontal diseases are associated with a variety of pathogenic microorganisms. Below is a list of key pathogens implicated in different forms of periodontal disease, along with their associations:

General Pathogens Associated with Periodontal Diseases

• Actinobacillus actinomycetemcomitans:

  • Strongly associated with destructive periodontal disease.

• Porphyromonas gingivalis:

  • A member of the "black pigmented Bacteroides group" and a significant contributor to periodontal disease.

• Bacteroides forsythus:

  • Associated with chronic periodontitis.

• Spirochetes (Treponema denticola):

  • Implicated in various periodontal conditions.

• Prevotella intermedia/nigrescens:

  • Also belongs to the "black pigmented Bacteroides group" and is associated with several forms of periodontal disease.

• Fusobacterium nucleatum:

  • Plays a role in the progression of periodontal disease.

• Campylobacter rectus:

  • These organisms include members of the new genus Wolinella and are associated with periodontal disease.

Principal Bacteria Associated with Specific Periodontal Diseases

1. Adult Periodontitis:

   • Porphyromonas gingivalis
   • Prevotella intermedia
   • Bacteroides forsythus
   • Campylobacter rectus

2. Refractory Periodontitis:

   • Bacteroides forsythus
   • Porphyromonas gingivalis
   • Campylobacter rectus
   • Prevotella intermedia

3. Localized Juvenile Periodontitis (LJP):

   • Actinobacillus actinomycetemcomitans
   • Capnocytophaga

4. Periodontitis in Juvenile Diabetes:

   • Capnocytophaga
   • Actinobacillus actinomycetemcomitans

5. Pregnancy Gingivitis:

   • Prevotella intermedia

6. Acute Necrotizing Ulcerative Gingivitis (ANUG):

   • Prevotella intermedia
   • Intermediate-sized spirochetes