Online learning materials have always been a great tool for helping undergraduate dental students to study, prepare coursework, and revise for exams. Now that much of our theoretical learning has moved online as a consequence of the COVID-19 pandemic, these online resources are more valuable than ever.
In this article, we’re focusing specifically on online materials to support you in learning about periodontitis. We’ll outline the key areas of study in this broad topic, such as etiology, signs and symptoms, diagnosis, and treatment. We’ll point you towards detailed online resources to expand your clinical knowledge, and we’ll ask you a quick question at the end of each section to test your learning.
Let’s get started!
What is periodontitis?
Periodontitis is a chronic multifactorial inflammatory disease of the periodontium - the soft tissues and bone that surround and support the teeth. It is preceded by gingivitis, which is inflammation of the gingiva. If left untreated, gingivitis can progress to periodontitis, which involves destruction of the periodontium including bone loss.
Section 1 – The Epidemiology and Etiology of Periodontitis
Periodontal disease is prevalent globally, more prevalent in older age groups and varies in severity. In the early phase of biofilm formation, the bacteria mainly consist of Streptococcus species, along with Actinomyces, Neisseria and Veillonella. Within 2 days, other bacteria colonize the area including Porphyromonas gingivalis, Bacteroides forsythus and Prevotella intermedia all of which are gram-negative. The biofilm mass is held together by extracellular polysaccharides (EPS) secreted by bacteria.
As the biofilm accumulates, subgingival biofilm develops and more bacterial species arrive and aggregate in the biofilm as well as co-aggregating with other bacteria. Under healthy conditions, a homeostasis (or equilibrium) is present, with a balanced state between the biofilm and the oral cavity. When unfavorable ecological changes occur the equilibrium is lost, dysbiosis occurs and a dysbiotic biofilm develops which can result in the onset of disease.
You can refer to the following resources to learn more about biofilm maturation, dysbiosis and the development of a dysbiotic biofilm with subsequent development of periodontitis.
Question 1: What state occurs when homeostasis is lost due to unfavorable ecological changes?
Section 2 – The Pathophysiology of Periodontitis
The periodontium undergoes significant changes throughout the course of periodontal disease, first in gingivitis and if it progresses then in periodontitis. While pathogens are necessary for periodontal disease, the host response determines the onset and progression of periodontitis.
During the initial phase of gingivitis, an initial inflammatory response involves the release of antimicrobial agents such as immunoglobulins in the gingival crevicular fluids. Neutrophils are then recruited into the area as part of the early host response to protect the area. If this fails, an acute inflammatory reaction occurs. Other protective chemicals are also released, including alarmins. The release of these agents is part of the innate immune response.
Loss of epithelial integrity occurs, with easy separation of the gingiva from the tooth surface. This established lesion takes 2 to 3 weeks to develop. At this point the neutrophils still form a protective barrier (or wall) for the base of the sulcus. When this is breached, and a chronic inflammatory response begins and chemical mediators are released, the transition from gingivitis to periodontitis is initiated. Pro-inflammatory mediators are released that result in the tissue destruction associated with periodontitis. Depending on the host response, periodontitis may or may not be initiated and if it is will vary in its progression and severity.
Question 2: It is the immune response, and not bacteria themselves, that determines whether tissue destruction characteristic of periodontitis occurs – true or false?
You can refer to the following resources to learn more about the pathophysiological changes that occur during periodontitis.
Introduction to Periodontology by the University of North Carolina at Chapel Hill School of Dentistry and Colgate-Palmolive - Inflammation
Section 3: Signs, Symptoms and Diagnosis of Periodontitis
All patients - new and existing - should receive a regular periodontal examination, allowing for early detection and treatment before periodontitis develops as well as diagnosis and treatment of periodontitis. Signs of gingivitis include redness, swelling, bleeding on probing and loss of healthy gingival contouring.
The periodontal examination includes an extra-oral examination, an intra-oral examination of the oral soft tissues and of the periodontium, and full-mouth radiographs. The intra-oral examination of the periodontal tissues include:
Visual examination for redness, swelling, texture and loss of contour
Measurement of the position and extent of gingival recession (or hyperplasia)
Use of a periodontal probe to determine probing depths and bleeding on probing
Use of a periodontal probe or furcation probes to determine whether there is furcation involvement and to measure the level of involvement if present
Examination of the dental arches, teeth and evaluation of tooth mobility
Determine clinical attachment loss
Using this information together with the radiographs, the diagnosis can be made, including a determination of localized or generalized periodontitis and its stage and grade, in accordance with the 2018 Classification. The patients medical and dental history must also be considered in assessing the patient.
Diagnostic criteria for periodontitis vary by region, so you should refer to your local national dental or periodontal association for the most accurate information. As a general guide, you can refer to the following resources:
Introduction to Periodontology by the University of North Carolina at Chapel Hill School of Dentistry and Colgate-Palmolive - Diagnosis
Periodontal Examination (University of Toronto)
2018 Classification for Periodontal and Peri-Implant Diseases and Disorders
Question 3: What does the term “furcation involvement” mean?
Section 4 – Treatment of Periodontitis
The complexity of periodontal therapy depends on the stage and grade of disease and the host response. All patients with periodontitis require ongoing periodontal maintenance visits following diagnosis and treatment of periodontitis.
Initial periodontal therapy consists of debridement, scaling and root planing is first performed. If iatrogenic factors are present, such as restoration overhands or defective margins, these must also be addressed. Patients should also be given oral hygiene instruction, and recommendations on lifestyle changes to change modifiable risk factors such as smoking tobacco, and may benefit from a chemotherapeutic rinse. The patient should then be recalled to evaluate response to therapy. If the response is favorable, the patient should now be placed on their periodontal maintenance schedule. For some patients, adjunctive therapy - such as a locally applied antimicrobial agent - or surgical treatment may also be indicated.
You can refer to the following resources to learn more about the treatment of periodontitis.
Question 4: What type of visits are necessary after periodontal therapy for patients with periodontitis?
Further learning
For dental students in the U.S. and Europe, the following websites provide information on the periodontics curriculum. You can use this information to understand what clinical knowledge is expected of you and guide your independent studies.
For students outside of the U.S., periodontal education will vary from region to region. Check your regional dental and periodontal associations’ websites for information about your local curriculum.
Answers
Throughout this article, we’ve given you the opportunity to test your learning with a question about periodontitis at the end of each section. You can find the answers below.
Question 1: What state occurs when homeostasis is lost due to unfavorable ecological changes?
Dysbiosis
Question 2: It is the immune response, and not bacteria themselves, that determines whether tissue destruction characteristic of periodontitis occurs – true or false?
True.
Question 3: What does the term “furcation involvement” mean?
“Furcation involvement” refers to alveolar bone loss at and beyond the branching point of the roots in multi-rooted teeth.
Question 4: What type of visits are necessary after periodontal therapy for patients with periodontitis?
Periodontal maintenance visits
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