Desquamative Gingivitis

• Characteristics: Desquamative gingivitis is characterized by intense erythema, desquamation, and ulceration of both free and attached gingiva.
• Associated Diseases:
  • Lichen Planus
  • Pemphigus
  • Pemphigoid
  • Linear IgA Disease
  • Chronic Ulcerative Stomatitis
  • Epidermolysis Bullosa
  • Systemic Lupus Erythematosus (SLE)
  • Dermatitis Herpetiformis

Gingival crevicular fluid is an inflammatory exudate found in the gingival sulcus. It plays a significant role in periodontal health and disease.

A. Characteristics of GCF

• Glucose Concentration: The glucose concentration in GCF is 3-4 times greater than that in serum, indicating increased metabolic activity in inflamed tissues.
• Protein Content: The total protein content of GCF is much less than that of serum, reflecting its role as an inflammatory exudate.
• Inflammatory Nature: GCF is present in clinically normal sulci due to the constant low-grade inflammation of the gingiva.

B. Drugs Excreted Through GCF

• Tetracyclines and Metronidazole: These antibiotics are known to be excreted through GCF, making them effective for localized periodontal therapy.

C. Collection Methods for GCF

GCF can be collected using various techniques, including:

1. Absorbing Paper Strips/Blotter/Periopaper: These strips absorb fluid from the sulcus and are commonly used for GCF collection.
2. Twisted Threads: Placing twisted threads around and into the sulcus can help collect GCF.
3. Micropipettes: These can be used for precise collection of GCF in research settings.
4. Intra-Crevicular Washings: Flushing the sulcus with a saline solution can help collect GCF for analysis.

Significant Immune Findings in Periodontal Diseases

Periodontal diseases are associated with various immune responses that can influence disease progression and severity. Understanding these immune findings is crucial for diagnosing and managing different forms of periodontal disease.

Immune Findings in Specific Periodontal Diseases

1. Acute Necrotizing Ulcerative Gingivitis (ANUG):

   • Findings:
     • PMN (Polymorphonuclear neutrophil) chemotactic defect: This defect impairs the ability of neutrophils to migrate to the site of infection, compromising the immune response.
     • Elevated antibody titres to Prevotella intermedia and intermediate-sized spirochetes: Indicates an immune response to specific pathogens associated with the disease.

2. Pregnancy Gingivitis:

   • Findings:
     • No significant immune findings reported: While pregnancy gingivitis is common, it does not show distinct immune abnormalities compared to other forms of periodontal disease.

3. Adult Periodontitis:

   • Findings:
     • Elevated antibody titres to Porphyromonas gingivalis and other periodontopathogens: Suggests a heightened immune response to these specific bacteria.
     • Occurrence of immune complexes in tissues: Indicates an immune reaction that may contribute to tissue damage.
     • Immediate hypersensitivity to gingival bacteria: Reflects an exaggerated immune response to bacterial antigens.
     • Cell-mediated immunity to gingival bacteria: Suggests involvement of T-cells in the immune response against periodontal pathogens.

4. Juvenile Periodontitis:

   • Localized Juvenile Periodontitis (LJP):
     • Findings:
       • PMN chemotactic defect and depressed phagocytosis: Impairs the ability of neutrophils to respond effectively to bacterial invasion.
       • Elevated antibody titres to Actinobacillus actinomycetemcomitans: Indicates an immune response to this specific pathogen.
   • Generalized Juvenile Periodontitis (GJP):
     • Findings:
       • PMN chemotactic defect and depressed phagocytosis: Similar to LJP, indicating a compromised immune response.
       • Elevated antibody titres to Porphyromonas gingivalis: Suggests an immune response to this pathogen.

5. Prepubertal Periodontitis:

   • Findings:
     • PMN chemotactic defect and depressed phagocytosis: Indicates impaired neutrophil function.
     • Elevated antibody titres to Actinobacillus actinomycetemcomitans: Suggests an immune response to this pathogen.

6. Rapid Periodontitis:

   • Findings:
     • Suppressed or enhanced PMN or monocyte chemotaxis: Indicates variability in immune response among individuals.
     • Elevated antibody titres to several gram-negative bacteria: Reflects an immune response to multiple pathogens.

7. Refractory Periodontitis:

   • Findings:
     • Reduced PMN chemotaxis: Indicates impaired neutrophil migration, which may contribute to disease persistence despite treatment.

8. Desquamative Gingivitis:

   • Findings:
     • Diagnostic or characteristic immunopathology in two-thirds of cases: Suggests an underlying immune mechanism.
     • Autoimmune etiology in cases resulting from pemphigus and pemphigoid: Indicates that some cases may be due to autoimmune processes affecting the gingival tissue.

Periodontal Diseases Associated with Neutrophil Disorders

1. Acute Necrotizing Ulcerative Gingivitis (ANUG)

   • Description: A severe form of gingivitis characterized by necrosis of the interdental papillae, pain, and foul odor.
   • Association: Neutrophil dysfunction can exacerbate the severity of ANUG, leading to rapid tissue destruction.

2. Localized Juvenile Periodontitis

   • Description: A form of periodontitis that typically affects adolescents and is characterized by localized bone loss around the permanent teeth.
   • Association: Impaired neutrophil function contributes to the pathogenesis of this condition.

3. Prepubertal Periodontitis

   • Description: A rare form of periodontitis that occurs in children before puberty, leading to rapid attachment loss and bone destruction.
   • Association: Neutrophil disorders can play a significant role in the development and progression of this disease.

4. Rapidly Progressive Periodontitis

   • Description: A form of periodontitis characterized by rapid attachment loss and bone destruction, often occurring in young adults.
   • Association: Neutrophil dysfunction may contribute to the aggressive nature of this disease.

5. Refractory Periodontitis

   • Description: A form of periodontitis that does not respond to conventional treatment and continues to progress despite therapy.
   • Association: Neutrophil disorders may be implicated in the persistent nature of this condition.

Sutures for Periodontal Flaps

Suturing is a critical aspect of periodontal surgery, particularly when managing periodontal flaps. The choice of suture material can significantly influence healing, tissue adaptation, and overall surgical outcomes.

1. Nonabsorbable Sutures

Nonabsorbable sutures are designed to remain in the tissue until they are manually removed. They are often used in situations where long-term support is needed.

A. Types of Nonabsorbable Sutures

1. Silk (Braided)

   • Characteristics:
     • Excellent handling properties and knot security.
     • Provides good tissue approximation.
   • Applications: Commonly used in periodontal surgeries due to its ease of use and reliability.

2. Nylon (Monofilament) (Ethilon)

   • Characteristics:
     • Strong and resistant to stretching.
     • Less tissue reactivity compared to silk.
   • Applications: Ideal for delicate tissues and areas requiring minimal tissue trauma.

3. ePTFE (Monofilament) (Gore-Tex)

   • Characteristics:
     • Biocompatible and non-reactive.
     • Excellent tensile strength and flexibility.
   • Applications: Often used in guided tissue regeneration procedures and in areas where long-term support is needed.

4. Polyester (Braided) (Ethibond)

   • Characteristics:
     • High tensile strength and good knot security.
     • Less pliable than silk.
   • Applications: Used in situations requiring strong sutures, such as in flap stabilization.

2. Absorbable Sutures

Absorbable sutures are designed to be broken down by the body over time, eliminating the need for removal. They are often used in periodontal surgeries where temporary support is sufficient.

A. Types of Absorbable Sutures

1. Surgical Gut

   • Plain Gut (Monofilament)

     • Absorption Time: Approximately 30 days.
     • Characteristics: Made from sheep or cow intestines; provides good tensile strength initially but loses strength quickly.
     • Applications: Suitable for soft tissue approximation where rapid absorption is desired.

   • Chromic Gut (Monofilament)

     • Absorption Time: Approximately 45 to 60 days.
     • Characteristics: Treated with chromium salts to delay absorption; retains strength longer than plain gut.
     • Applications: Used in areas where a longer healing time is expected.

2. Synthetic Absorbable Sutures

   • Polyglycolic Acid (Braided) (Vicryl, Ethicon)

     • Absorption Time: Approximately 16 to 20 days.
     • Characteristics: Provides good tensile strength and is absorbed predictably.
     • Applications: Commonly used in periodontal and oral surgeries due to its handling properties.

   • Dexon (Davis & Geck)

     • Characteristics: Similar to Vicryl; made from polyglycolic acid.
     • Applications: Used in soft tissue approximation and ligation.

   • Polyglycaprone (Monofilament) (Maxon)

     • Absorption Time: Similar to Vicryl.
     • Characteristics: Offers excellent tensile strength and is absorbed more slowly than other synthetic options.
     • Applications: Ideal for areas requiring longer support during healing.

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.