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Periodontal Diseases
Dr. Mustafa Alkhader
OMFR
Chapter 18
Reference
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What is meant by the
Periodontium ?
4 components
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The periodontium
Gingivitis: Inflammation of the gingiva.

Periodontitis: loss of connective tissue attachment and
subsequent bone loss.
Definitions
Gingivitis commonly starts with local
irritating factors Or poor oral hygiene
Chronic inflammation response
Loss of marginal bone
Apical migration of epithelial attachment
Pocket formation ( soft tissue lesion)
Looseness then loss of teeth
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Contribution of Radiographs in Assessment
of the Periodontal Condition
1. The amount of bone
present

Condition of the alveolar crest
Bone loss in furcaition areas
Width of the periodontal ligament
space
Contribution of radiographs in assessment of the
periodontal condition ( cont )
2. Local irritating factors
that either cause or
increase severity of
periodontal disease :
Calculus
Calculus
Overhangs
overhanging or poorly
contoured or restorations
Calculus
Contribution of radiographs in assessment of the
periodontal condition ( cont )
3. Root length and
morphology and the crown
- root ratio

4. Anatomical considerations
Position of the maxillary sinus
in relation to a periodontal
deformity.
Missing , supernumerary or
impacted teeth.

Contribution of radiographs in assessment of the
periodontal condition ( cont )
5. Pathologic considerations

Caries
Periapical lesions
Root resorption

Limitations of radiographs
1. Bony defects are commonly
overlapped by existing bony
walls.

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Limitations of radiographs

2. Failure to image buccal and
lingual bone as they are
superimposed by the roots of
teeth.


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Limitations of radiographs
1. Bony defects are commonly
overlapped by existing bony
walls.

2. Failure to image buccal and
lingual bone as they are
superimposed by the roots of
teeth.

3. Early (mild) destructive
lesions are not detected
radiographically.

Limitations of radiographs (cont)
4. Radiographs tend to show less
severe destruction than is actually
present.


6. Radiographs will not identify a successfully managed
case as opposed to an untreated one.

5. Radiographs do not demonstrate soft
tissue defects (as pockets) .


Limitations of radiographs (cont)
7. Minute variations in the
projection technique
considerably affect the
radiographic appearance
of periodontal tissues.
8. Exposure factors can have a marked effect on
the apparent crestal bone height (overexposure
causes burn - out).








N.B. In treatment planning , radiographs should be
supplemented by careful clinical examination.
Limitations of radiographs (cont)
Technical Procedures
Films Used:

Bitewing
Periapical
Panoramic
Technical procedures
I. Film placement and types of films used:
Interproximal (bitewing) and periapical films are useful for
evaluating the periodontium.

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Technical procedures

Periapical Films

Periapical films should
be performed using the
paralleling technique.

The film should be
parallel with the tooth as
possible to avoid
distortion.

Technical procedures
Bitewing Films
Bitewing films are more
accurate to record the
distance between the
CEJ and the crest of the
bone.

Because:
film parallel to teeth
Contacting teeth

Bitewing Films

Vertical interproximal
radiographs : 7 no. 2
films to cover all
regions of the mouth.
Technical procedures
Panoramic films
Panoramic radiographs are used only for gross evaluation of the
condition.
If more details are required , a full mouth survey is performed (or
selective areas radiographed).
Technical procedures
II. Angles of projection
Criteria assuring the correct
relative position of the teeth in the
alveolar process:

Technical procedures
The interproximal spaces between
tooth roots not overlapped.

The proximal contacts between
crowns not overlapped.

Overlap of the buccal and lingual
cusps of molars.

Angles of projection (cont)
The optimum vertical and horizontal angles of
projections will show properly proportioned
anatomic features such as :

CEJ
Crest of the interdental bone.
Correct crown - to - root ratio.

Technical procedures
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Special considertions and techniques
The frequency of radiographic examination is determined
by the activity of the disease.
A full mouth intraoral examination is used for:
1. Treatment planning
2. As a baseline for later comparisons.

Normal Anatomy
of the alveolar bone

Radiographic appearance
of normal alveolar bone :
Corticated

0-2 mm apical to the level of
the CEJ of adjacent teeth.

Continuous with the lamina
dura of adjacent teeth.
2 mm
2 mm
Radiographic appearance of
alveolar bone (cont) :

Between the anterior teeth
the alveolar crest is
pointed and dense.

Between the posterior
teeth :
1. The alveolar crest and the
lamina dura form a
sharp well defined angle.

2. The alveolar crest is parallel
to a line connecting the
CEJ of posterior teeth.

Alveolar Bone Loss
Physiologic level of bone
Height of remaining bone
Alveolar Bone Loss
Types
Horizontal bone loss

Vertical bone loss
( oblique- angular )
There is loss of height of the
alveolar bone but the crest
is still horizontal.

Bone loss occurs in an oblique
or vertical plane to the CEJ of
adjacent teeth.
Alveolar Bone Loss
Types
Horizontal bone loss

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Alveolar Bone Loss
Types
Vertical bone loss

Horizontal Bone Loss

According to the region involved
Localized generalized

Horizontal Bone Loss
Severity
Mild bone loss : 20 - 30 %
Moderate bone loss : 30 - 50 %
Severe bone loss : more than
50 %
Mild bone loss
Severe bone loss
moderate bone loss
According to the extent of bone loss
Mild - moderate - severe
e.g. Generalized moderate .
Horizontal Bone Loss
Mild bone loss
Severe bone loss
moderate bone loss
Supra-eruption and passive eruption increased
distance between CEJ and bone level
Alveolar Bone Resorption
Alveolar Bone Resorption
Which is horizontal and which is vertical ABR ?
A B
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Alveolar Bone Resorption
Which is mild , which is moderate
and which is severe?
Interdental Craters
Buccal or Lingual
Cortical Plate Loss
Furcation Involvement
Osseous defects in the furcation of
multirooted teeth

Widening of the periodontal ligament space at the
apex of the inter radicular bone crest.

Furcation Involvement
If involves only buccal or lingual cortical plate + extends under
the roof of the furcation

appears irregular and more RL compared to adjacent normal
bone.
Furcation Involvement
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Furcation Involvement
If sufficient bone loss
occurs buccally and
lingually


the lesion will be sharply
outlined between the
roots

Furcation Involvement
Inverted J shadow


Hook of J extending
into trifurcation

Septal bone lost from buccal or lingual cortical
plate ???
Convergent roots obscure furcation defects
Limitations of Radiographs
in Viewing
Furcation Area

In maxillary molars:
palatal root superimposed
on the defect

In lower third molar region:
External oblique ridge may
mask furcation.
Limitations Of Radiographs In
Viewing The Furcation Area :

Changes in Bone density
Like all inflammatory conditions, may
stimulate reaction in bone (RO or RL)
Dental Conditions Associated
With Periodontal Disease
Occlusal trauma
Open contact (food impaction)
Local irritating factors
* Calculus
* Defective restorations
* Tilted teeth
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Calculus Occlusal trauma
Widening of the
PDLS
Thickening of L.D.
Normal PDLS
and L.D.
Occlusal trauma
Normal PDLS
and L.D.
Occlusal trauma
Widening of the periodontal ligament space.
Decreased definition of the lamina dura.
Bone loss (commonly angular)
Altered trabeculation.
Less commonly hypercementosis and root fracture.
Evaluation of Periodontal Therapy
Follow - up serial radiographs

Radiographs should be standardized:
film placement
angulation
exposure factors
processing techniques.
Special considertions and techniques
Occlusal template may be used especially when
follow up of the case is indicated.


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Evaluation of periodontal therapy
Successful periodontal therapy means :
No evidence of new bone loss.
The cortical bone in the inter-septal area may
become more dense.
The affected margins of bone may become
more sclerotic (radiopaque).
Other Patterns of Periodontal Bone Loss
Abscess
Aggressive Periodontitis
Differential Diagnosis
Effect of Systemic Diseases on periodontal Disease
AIDS
D.M.
Radiation Therapy
Not Included
Questions ?