Pathology of periodontal disease

2021-02-02 12:00 AM

The periodontal ligament occupies most of the distance between the teeth and the alveolar bone, creating the periodontal membrane, there are many blood vessels and nerves that create a sense of touch and positioning.

Structure of periodontal tissue

Periodontal tissue or supporting tissue is composed of four components:


Consists of two parts: removable and sticky gums.

Gums left

1 - 2mm in height can move a little bit.

The place where the gums come into contact with the visible tooth surface is the gum line.

Between the loose gum and the tooth, there is a V-shaped space called the gum gap.

The base of the gum gap is where the gums attach to the teeth called the adhesion epithelium.

Between the teeth, the loose gums protrude into a three-sided pyramid called the gum spine.

Sticky gums

Beneath the loose gums are gums that are firmly attached to the teeth and the alveolar bone, and cannot be moved.

Stretches to the gingival-synaptic line - mobile mucosa.

The surface of the gums is a waving stratified epithelium (keratinized or non-horned - 4 layers: horn, seed, spiny, base) inside is connective tissue.

Alveolar bone

The jaw bone is wrapped around the base of the tooth.

Is a type of spongy bone located between two thick bone walls.

The thick bone adjacent to the base of the tooth is called the lamina dura with many small holes for the blood vessels, lymph and nerves to pass through.

Alveolar bones are susceptible to change: destruction or regeneration depending on the case (periodontal disease, trauma, not chewing, orthodontic ...).


A thin layer that looks like a bone that covers the root of the tooth, except for a hole called the apical foramen that allows blood vessels and nerves to enter the pulp.

Mineralizes more than bone (61% inorganic - 27% muscle damage - 12% water).

Periodontal ligaments adhere to this cement layer.

More than 90% of petrol stations are exposed to tooth enamel.

Periodontal ligament

It is a fibrous system, mainly collagen fibres, connecting teeth to the alveolar bone.

It is divided into many groups: vertex group, horizontal group, tilt group, root group with the function of conduction and dispersion of mastication.

The periodontal ligament occupies most of the distance between the teeth and the alveolar bone, creating the periodontal membrane, there are many blood vessels and nerves that create a sense of touch and positioning.

Normal periodontal tissue characteristics

Pale pink gums, orange-dotted surface.

The rim of the gums is sharp, hugging the neck of the teeth.

Dai, toned.

No bleeding on examination.

X-ray: the tip of the alveolar bone, no bone resorption phenomenon, normal periodontal membrane, lamina dura clearly visible.

 Periodontal disease concept

Periodontal disease is a medical condition of the periodontal tissue consisting of gingivitis and destructive peritonitis, an infection that begins in the gum gradually spreads down the underlying periodontal tissue structures, causing the gums to lose adhesion. Into the tooth, the alveolar bone is destroyed and the periodontal pocket is formed.


Cause in place

Deviated teeth, occlusion disorder, occlusal injury ...

Excess fillings, false teeth.

The bacteria in plaque and tartar are the most common and important local factor that covers all other causes.

General cause

Atopic: the state of the body's immune response.

Hormonal changes during puberty, pregnancy and lactation ...

Systemic diseases such as blood diseases, diabetes ... and other diseases lead to a decrease in the body's resistance.

The body's immune response is the most important general cause.

The local cause is primary and decisive, the general cause only has a supporting role and is only effective when the local cause is available.

Classification of periodontal disease


As a gum disease with only local inflammation in the gums, other components are not or less affected.

Chronic gingivitis


Usually, there is no subjective evidence.

The gums change from pink to red, then crimson or bluish-grey (starting with the gum line and gingival spines, then also sticky gums)

The gums are soft, the gum surface becomes smooth, loses the orange patch, the gum line is round, the gums are swollen.

Swollen and swollen gums that form a pseudo-sac (gum pocket)

Bleeding easily when examining and brushing teeth; More severe bleeding may spontaneously.


Mainly due to poor oral hygiene, which creates a buildup of bacterial plaque around the teeth, especially in the gum slot.

Tartar: due to the deposition of saliva calcium creates plaque calcification.

Fillings or false prostheses.

Cramming food.


Eliminate the cause.

Get tartar.

Dental hygiene.

Acute gingivitis (Vincent gingivitis-acute ulcerative necrotic gingivitis)


Necrosis and sores begin on the gum spine, reaching the rim of the gum, forming concave lesions like a cup or crater.

The surface of the lesion has a white or pale yellow imitation film that is difficult to peel, causing bleeding if peeling.

Gingivitis on examination or spontaneous is caused by the gum epithelium necrosis exposing the connective tissue rich in capillaries.

The mouth stinks fiercely, the breath and taste smell of metal.

The erythematous contour: is created separating the necrotic area from the surrounding healthy area, it is raised by congestion of blood vessels and oedema of connective tissue in the necrotic area.

Patients with burning pain that cannot eat or drink especially eat hot, spicy foods. Often there is swollen glands and high fever.

If worse, it can cause necrosis of both the sticky gum area and the deep periodontal tissue below, exposing the root, destruction and deformation of the alveolar bone. There may be sepsis.


Multi-bacteria: mainly spirochetes (represented by Borrelia Vincent) and spindle-shaped bacillus Bacillus Fusiform.

Factors favourable for pathogenesis and alteration of resistance:

Gingivitis, periodontitis already has a background.

Immunodeficiency, stress, fatigue or some systemic diseases such as viral infection, malnutrition ...

Addiction to tobacco and alcohol.


Gargle with Chlorhexidine gluconate 0.12%.

Systemic antibiotic (Penicillin or Tétracilline).

Teeth scraping and oral hygiene.

Gingivitis associated with endocrine disorders:


The condition resembles common gingivitis.

In special cases, there is a form of gingivitis resulting from pregnancy (pregnancy gums).


Disorder of stéroit hormones due to taking stéroit drugs or the amount of estrogen, progestérone increased during pregnancy or using birth control pills ... cause an outbreak of gingivitis.


Eliminate the cause, scrape lime, and clean your teeth.

Drug-induced swelling of the gums (non-inflammatory)


Swollen gums due to overproduction, palpable, not bleeding, only increase the volume


Medications: antiepileptic drugs (Phenytoin or Di-hydrants), immunosuppressants (Cyclosporine A)


Eliminate the cause. Oral hygiene to avoid superinfection.


In addition to the features of gingivitis, periodontal pathology also destroys three other components: the alveolar bone, the periodontal ligament and cementum.

Characterized by the disease is the loss of adhesion of the adhesion epithelium, the alveolar bone is destroyed and the formation of a periodontal pocket (real pocket) with pus.

The cause of the switch from gingivitis to periodontitis may be due to some failure in the host's ability to respond to infection and/or a concentration of large numbers of highly pathogenic bacteria.

There are 3 of the most recognized theories:

Bacteria damage tissues directly and indirectly through their metabolites.

Hypersensitivity reactions to certain immune processes.

A decrease in the function of polymorphonuclear leukocytes (chemotaxis, microphages, decrease in neutrophil counts).

Chronic periodontitis in adults


Common in middle age and older (> 35 years).

The convergence of all signs of chronic gingivitis.

The tissue damage lasts for years or even decades, accompanied by loss of adhesion or migration of the adhesion epithelium towards the tip of the tooth root.

The concept of "loss of adhesion" includes always the alveolar resorption phenomenon (X-ray see the horizontal target, the top of the alveolar bone is not pointed), the loss of the periodontal ligament, cement root of the tooth is necrotic and creates the periodontal pocket.

Teeth may waver and move abnormally.


Lime, plaque (from gingivitis is not properly treated).

Injury to the bite joint.

Adolescent periodontitis (-Periodontosis)


Occurs in young people (<25 years).

Localization: disease occurs in one tooth or a group of teeth.

X-ray: there is early resorption of bone in key teeth: the first molar, middle incisors. The alveolar bone is destroyed vertically.

Tartar is usually less.

Inflammation of the gums is little or moderate, but the rate of loss of adhesion is quite rapid


In this disease, the presence of bacteria Actinobacillus actinomycetemcomitans (Aa) was found.

The adhesion loss is directly related to the anti-Aa antibodies.

There is also the role of genetic factors, race and some systemic diseases such as diabetes, blood disease, Down syndrome ...

Periodontitis progresses rapidly


Usually seen in young people younger than 35 years.

The oral hygiene is relatively good, less plaque and tartar.

The first stage is mild with few symptoms, slight loss of adhesion and shallow periodontal pocket lasts several months or years.

After stage, heavy, rattling, serious loss of adhesion, alveolar bone is clearly destroyed horizontally and vertically (angular).

The patient is in pain, gums bleed spontaneously, teeth are loose and may fall out.


May be genetic factors or hormonal disorders, neutrophils decrease the direction of dynamism ...

Treatment of general periodontitis

Handling in place 

Eliminate the cause.

Get tartar.

Handle the root surface.

Guided tissue regeneration, gum grafting ...

Medication use

Antibiotic therapy (however, after the treatment is very difficult and complicated):

In place :

Iodine 5% solution, Chlorhexidine 0.12%, Hexetidine 0.1%.

Gel Metronidazole, Minocycline.

Self-digesting polymer fibres impregnated with Doxycycline, Tetracycline.

To drink :

Tetracycline (250mg x 4 / j) or Amoxicilline plus Metronidazole: especially effective for Aa.

Spiramycin in combination with Metronidazole.

AINS like Flurbiprofen (100mg x 2: 3 / day) ...


Provision level 1

Don't let illness happen.

Proper oral hygiene.

Dental examination every 6 months.

Provision level 2

Early treatment of gingivitis does not progress to an inflammatory periodontal.

Provision level 3

Periodontitis treatment does not turn to tooth loss complications.

Indicators assess the condition of periodontal disease

Simple oral hygiene index (OHI-S: Oral Hygiene Index-Simplified of Green and Vermillon-1964)

Survey of 6 index teeth   

Outer surface teeth 16, 26; inside teeth 36, 46.

The outer surface of two incisors: 11 and 31.

Consists of two components: the plaque index and the tartar index.

0 point: no plaque (or no tartar on the gums).

1 point: plaque (or tartar on the gums) is less than 1/3 of the tooth surface.

2 points: plaque (or tartar on the gums) plaque more than 1/3 but less than 2/3 of the teeth surface.

3 points: plaque more than 2/3 of the teeth surface (or tartar on the gums more than 2/3 of the teeth, or tartar under the gums).

OHI-S Index per person = Total score / Total number of teeth

CPITN = Community Periodontal Index and Treatment Needs - Ainamo-1982

Each arc function is divided into 3 segments called the hexadecimal segment (sextant). Each person has 6 sextants.

Each sextant examines 1 representative tooth (16, 26, 36, 46 and 11, 31) for people under 20 years old if over 20 years old we examine 4 more 7 teeth.

The CPITN of each person is the index of the sextant with the highest number.










Bleeding gums


Shallow bag <5.5mm

Bag depth> 6mm

Treatment needs

No treatment is needed

Guide VSRM

Guide VSRM + Tartar scraping

Guide VSRM + Tartar scraping

+ Intensive treatment