DANIELLE ANN

PERIODONTICS NOTES 3
CEMENTUM  These lines represent rest periods in cementum formation and are more
Normal Microscopic Features: mineralized than the adjacent cementum
- It is the calcified mesenchymal tissue that forms the outer covering of the  Sharpey’s fibers make up most of the structures of acellular cementum,
anatomical root which has a principal role in supporting the tooth

2 main forms of root Cementum: Thickness of Cementum

 Acellular or Primary Cementum  The thickness of cementum on the coronal half of the root varies from
- is the first to be formed and covers approximately the cervical two-thirds of 16 to 60 microns, or the thickness of a hair
the root and doesn’t contain cells  It attains its greatest thickness (up to 150 to 200 microns) in the apical
- formed before the tooth reaches the occlusal plane third and also in furcations areas
- contains other collagen fibers that are calcified and irregularly arranged or
parallel to the surface Development and Acquired Anomalies Associated With Cementogenesis
 Cellular or Secondary Cementum
- formed after the tooth reaches the occlusal plane Enamel Projection
- more irregular and usually contains cells in individual spaces  continuous enamel formation over root surface normally covered by
(lacunae) that cementum from odontogenic epithelium destined to form Hertwig’s root
- communicate with each other through a system of anatomizing sheath and frequent in furcations in mandibular molars
canaliculi
- less calcified and Sharpey’s fibers occupy a smaller portion of cellular Enamel pearls
cementum  Globules of enamel on root surface in cervical region and resemble
small pearls, up to several millimeters in diameter
 Both acellular and cellular cementum are arranged in lamellae separated by  Its clinical relevance is that is promotes periodontal lesions by acting as
incremental lines parallel to the long axis of the root plaque – retentive structures
 It may mimic calculus clinically and
 radiographically and can be scaled off or can be removed by grinding
 Large pearls may contain pulpal extensions ALVEOLAR BONE
 ALVEOLAR PROCESS – It is the part of the maxilla or mandible that
Cementicles forms and supports the teeth
 Globular masses of acellular cementum generally less than 0.5 mm in  ALVEOLAR BONE PROPER – It consists of a thin lamella of bone
diameter, which form within the periodontal ligament (cortical bone) surrounding the root. Fibers of the periodontal ligament
 Cementicles are not of clinical significance unless they become are embedded in this bone
exposed to the oral environment where they may act as sites for plaque  SUPPORTING BONE – It consists of cancellous trabeculae and
retention surrounds the alveolar bone proper and provides additional support
Types:  In radiographs the alveolar bone proper (inner wall of the socket or
 Free cementicles – lie free in periodontal ligament inner cortical plate) appears as an opaque line called the lamina dura
 Attached / Sessile cementicles – fused or attached to radicular  The alveolar bone proper is perforated by many openings through
cemental surface which the blood vessels, lymphatics, and nerves of the periodontal
 Interstitial cementicles – totally incorporated or embedded in cementum ligament pass and also called the cribriform plate because of these
Hypercementosis (Hyperplastic Cementum) perforations
 Formation of abnormally thick radicular cementum  The outer cortical plate is covered by a fibrous and cellular periosteum
 May take the form of multiple, localized, knoblike or spike shaped  The interdental septa (singular, septum) are bony partitions that
projections, which give the root an irregular contour separate adjacent alveoli
 May occur as a thickening of the cementum layer, generally more  Alveolar bone proper is formed for the express purpose of supporting
marked in the apical third of the root and attaching the teeth. The alveolar process depends on the presence
 Generalized hypercementosis may be hereditary or may be associated of teeth for its existence
with Paget’s disease  Alveolar dehiscence is a dipping of the crestal bone margin exposing
 Localized hypercementosis may be observed in impacted teeth and the root surface
teeth without antagonists
 Alveolar fenestration is a circumscribed hole in the cortical plate over
the root and does not communicate with the crestal margin
Cementoma
 Masses of cementum generally located apical to the teeth, to which Periosteum
may or may not be attached  It is a lining at the outer surface of the alveolar process
 Considered either odontogenic neoplasm or developmental  It contains the neural, vascular, as well as the cellular elements
malformation necessary for the maintenance of normal bone function and repair
 Occur more frequently in females and more often found in the mandible  On the alveolar surface, the periodontal ligament serves in the same
than in the maxilla capacity as the periosteum
 Harmless  The endosteum is the corresponding cellular layer found within marrow
spaces
Ankylosis
 It is the fusion of the mineralized root surface with alveolar bone with Physiologic Tooth Migration
obliteration of the periodontal ligament  Under physiologic conditions teeth migrate continuously in a mesial
 Generalized injury or removal of the periodontal ligament may lead to direction towards the midline. This is called physiologic mesial drift
the condition  The migration leads to a resorption of the inner wall of the alveolus on
 Results in resorption of the root and its gradual replacement by bone the mesial side of the tooth and the formation of new bone on the distal
tissue surface
 DANIELLE ANN
PERIODONTICS NOTES 3
 Physiologic tooth migration continues throughout life but slows or halts  Physiologic Pigementation (Melanin)
in old age  Melanin, a non-hemoglobin-derived brown pigment is responsible for
 The alveolar bone adapts and reconstructs itself continuously the normal pigmentation of the skin, gingiva, and remainder or the oral
 Pathologic changes occur when this process of adaptation is disturbed mucous membrane

Blood Supply  Size

 Branches of the alveolar artery  Alteration in size is a common feature of gingival disease

Periodontal Structure in Aging Humans  Contour

Age changes affect the following periodontal tissues:  The marginal gingiva envelops the teeth in collar-like fashion and
1. Vasculature follows a scalloped outline on the facial and lingual surfaces
2. Periodontal ligament  It forms a straight line along teeth with relatively flat surfaces
3. Cementum  On teeth with pronounced mesiodistal convexity of teeth in
4. Alveolar bone labioversion, the normal arcuate contour is accentuated and the gingiva
5. Gingiva and alveolar mucosa is located further apically
 On teeth in linguoversion, the gingiva is horizontal and thickened
Vasculature  Shape
 In advancing age, there is a reduction in blood flow  The shape of the interdental gingiva is governed by the contour of the
proximal tooth surfaces and the location and shape of gingival
 a decrease in connective tissue cellularity and an increase in the
embrasures
number of coarseness of collagenous fibers
 principal fibers of the periodontal ligament are thicker in ageing humans
 Consistency
than in younger individuals
 The gingiva is firm and resilient and, with exception of the movable free
 fewer fibroblasts, osteoblasts, and cementoblasts
margin, tightly bound to the underlying bone
 degenerative hyaline changes
 calcified bodies are common in the periodontal ligament of elderly  Surface Texture
humans  The gingiva presents a textured surface like that of an orange peel and
is referred to as being stippled
 The attached gingiva is stippled; the marginal gingiva is not
Cementum  The central portion of the interdental papillae is usually stippled, but the
 Cemental deposition slows in old age marginal borders are smooth
 The attachment of cementum to dentin may be weakened  Stippling varies with age. It is absent in infancy, increases until
 Spurring of cementum is sometimes the result of the fusion of adulthood , and frequently begins to disappear in old age
calcospheroid bodies near cementum or of the calcification of epithelial  Microscopically, stippling is produced by alternate rounded
rest aggregates protuberances and depressions in the gingival surface
 The papillary layer of the connective tissue projects into the elevations,
Alveolar Bone and both the elevated and the depressed areas are covered by
 Physiologic tooth migration may be slow or halt in old age stratified squamous epithelium
 The vascularity of bone appears to be diminished  Stippling is a form of adaptive specialization or reinforcement for
 Osteoporosis may be observed in aging, particularly in the alveolar function
bone of postmenopausal women  It is a feature of healthy gingiva, and reduced or loss of stippling is a
 There is slowing and even a halt in bone remodeling common sign of gingival disease
 When the gingiva is restored to health following treatment, the stippled
 Thus the replacement of extracted teeth with prostheses in order to
appearance returns
prevent overeruption, malpositioning, and tilting of neighboring teeth
 The surface texture of the gingiva is also related to the presence and
may not be necessary
degree of epithelial keratinization
 Function and esthetics will be the principal reasons for tooth
 Keratinization is considered to be a protective adaptation to function
replacement  It increases when the gingiva is stimulated by toothbrushing

Gingiva and Alveolar Mucosa PERIODONTAL LIGAMENT

 The gingiva becomes fibrotic in old age  The periodontal ligament is the connective tissue structure that
surrounds the root and connects it with bone
 It is continuous with connective tissue of the gingiva and communicates
with the marrow spaces through vascular channels in the bone
 Dense fibrous connective tissue attaching the tooth to the alveolar bone
 Function—to support the tooth in the alveolus & to maintain the
physiologic relation between the cementum and bone

Characteristics
 Its fibers are inserted into the alveolar bone and into the cementum
Normal Clinical Features of Gingiva  Its quite cellular, well innervated, vascular and contains epithelial
aggregates
 Color
 It occupies the narrow space between the calcified surfaces of the
 The color of the attached and marginal gingivae is generally described
cementum and alveolus
as coral pink and is produced by the vascular supply, the thickness and
 Is detectable in radiographs—a radioluscent line parallel to the root
degree of keratinization of the epithelium, and the presence of pigment-
surface (lamina dura in radiographs—radiodense line that represents
containing cells
the alveolar bone proper
 DANIELLE ANN
PERIODONTICS NOTES 3
 Varies in thickness—0.1 - 0.25 mm depending on age, stage of  OSTEOCLASTS and ODONTOCLASTS –Osteoclasts work with
eruption of the tooth and functional characteristics osteoblasts to remodel existing alveolar bone. Odontoclasts can resorb
 Thicker in adolescents than in older individuals mineralized dental tissue, including cementum
 Teeth without antagonists would have thinner ligaments; with impacted  EPITHELIAL CELLS – They are commonly found in the ligament close
teeth they’re even thinner to cementum. They originate from Hertwig’s epithelial root sheath
 Under normal function tends to be narrowest near the middle of the root  Undifferentiated mesenchymal cells OR PROGENITOR CELLS --
and wider near the apex These cells have a perivascular location within 5 micrometers of blood
vessels and a source of new cells for the periodontal ligament
Normal Microscopic Features  MACROPHAGES –In the ligament are important defense cells because
 The most important elements of the periodontal ligament are the of their phagocytic activity and mobility (take up bacteria, dead cells
principal fibers, which are collagenous, arranged in bundles, and follow and foreign bodies)
a wavy course when viewed in longitudinal section  LEUCOCYTES – Individual leukocytes, specially small lymphocytes
 Terminal portions of the principal fibers that insert into cementum and and plasma cells may appear in periodontium when it is stressed by
bone are termed Sharpey’s fibers disease
 Transseptal Group – extend interproximally over the alveolar crest and
are embedded in the cementum of adjacent teeth Vascular Supply
 Alveolar Crest Group – extend obliquely from the cementum just  Compared with other connective tissues, the periodontal ligament is
beneath the Junctional epithelium to the alveolar crest and their exceptionally well vascularized, which reflects the high rate of turnover
function is to counterbalance the coronal thrust of the more apical of its cellular constituents
fibers, thus helping to retain the tooth within the socket and resists  Its main blood supply is from the SUPERIOR AND INFERIOR
 Horizontal Group – their fibers extend at right angles to the long axis of ALVEOLAR ARTERIES
the teeth from the cementum to the alveolar bone and function is
similar to alveolar crest group. They function to resist horizontal or Nerves
lateral pressures applied to the tooth crown  The periodontal ligament contains both sensory and autonomic nerve
 Oblique Group – largest group in the periodontal ligament, extends endings
from the cementum in a coronal direction obliquely to the bone and  The sensory nerve endings are able to identify pain and pressure
bears the brunt of vertical masticatory stresses and transform them into  The mechanoreceptors for pressure are extremely sensitive and are
tension on the alveolar bone able to detect minute particles between occluding tooth surfaces
 Apical Group – they radiate from the cementum to the bone at the  The autonomic innervation that originates from the superior cervical
fundus of the socket and not present in incompletely formed roots. It ganglion is primarily responsible for the control of smooth muscles
prevents vestibulo-oral tipping associated with the periodontal vasculature
 Interradicular Fiber Group - Found only between roots of multirooted
tooth and running from the cementum into the bone forming the crest of Functions of Periodontal Ligament
the interradicular septum. It resists tipping and torque  PHYSICAL
 FORMATIVE
Other Fibers:  NUTRITIVE AND SENSORY
 Elastic fibers - this group of fibers are scarce and are confined to the loose
connective tissue surrounding neurovascular channels Physical
 Oxytalan - is found interspersed among the collagen fibers, and is  Transmission occlusal forces to the bone
morphologically similar to those in gingiva and run in an occluso-apical  attachment of teeth to bone
direction associated with blood vessels and nerve fibers. They are found  maintenance of the gingival tissues in their proper relationship to the
more often on the cemental than on the bony side of the ligament teeth
 Indifferent fiber plexus - appears to course parallel to the root surface,  resistance to the impact of occlusal forces (shock absorption)
forming a loose intersecting network and may also be incorporated into the  provision of “soft tissue casing” to protect the vessels and nerves from
mineralized matrices injury by mechanical forces
Formative
Cells  Periodontal ligament serves as the periosteum for cementum and bone
 The main function of periodontal ligament cells is to maintain the normal  Cells of the periodontal ligament participate in the formation and
organization of the fiber system by synthesizing new fibers and remove old resorption of cementum and bone which occur in physiologic tooth
ones movement
 Generally the cellular density in periodontal ligament is greatest in young  In the accommodation of the periodontium to occlusal forces and in the
individuals and decrease with age repair of injuries
 Cellular density also increases with heavy function and decreases with lack Nutritive
of function  The periodontal ligament supplies nutrients to the cementum, bone,
and gingiva by way of the blood vessels and provides lymphatic
Fibroblast drainage
 They make up the major cellular population of the ligament Sensory
 principal cells of the periodontal ligament  The innervation of the periodontal ligament provides proprioceptive and
 Their function is to synthesize collagen, which aggregates into fibrils tactile sensitivity which detects and localizes external forces acting
and fibers extracellularly upon the individual teeth and serves an important role in the
neuromuscular mechanism controlling the masticatory musculature
Cementoprogenitor And Osteoprogenitor Cells
 CEMENTOBLASTS – Are observed during active deposition of cellular ANATOMY OF THE PERIODONTIUM
cementum
 OSTEOBLASTS – Found in the peripheral part of the periodontal Periodontium
ligament adjacent to bone and seen where alveolar bone is deposited  Attachment to bone tissue
 hard tissue: Cementum; Alveolar Bone
 Soft tissue: Gingival tissue ; Periodontal ligament
 DANIELLE ANN
PERIODONTICS NOTES 3
 Maintains the integrity of the surface mucosa • Represented as either transudate (normal state) or exudate (pathologic
 attachment apparatus/ supporting tissue of teeth state)
 Undergoes change with age • Contains a vast array of biochemical factors
 morphologic change • Components of connective tissue, epithelium, inflammatory cells,
serum and microbial flora
 3 Zones of Oral Mucosa • Marker by checking the microbial flora
 Masticatory – Gingiva| Covering of hard palate
 Specialized – Dorsum of the tongue (Taste buds) Functions:
 Lining mucosa - Ventral part of tongue  Cleanse material from sulcus
 Vestibule  Contains plasma proteins that may improve adhesion of
 Buccal periosteum epithelium to tooth
 Gingiva  Possess antimicrobial property
 Frenum  Exert antibody activity to defend the gingiva
 Floor of the mouth
 Soft Palate Clinical Features of Gingiva
• Color – coral pink produced by the vascular supply, thickness and
Gingiva degree of keratinization of the epithelium
• Marginal gingiva • Size – correspond s with the sum total of the bulk of cellular and
– Not attached ; where calcular deposit is lovated intracellular elements and their vascular supply
• Attached gingiva • Contour – depends on the size of the tooth tooth and their alignment in
– Attached on alveolar bone the arch.
• Alveolar mucosa • Shape – interdental gingiva – triangular
– Darker in color than the attached gingiva • Consistency – firm and resilient
• Mucogingival junction • Surface texture - stippled
– Changes in color is observed
Characteristics Periodontal Ligament
 Highly vascular •  is composed of a complex vascular and highly cellular connective
 Color: coral pink tissue that surrounds the tooth root and connects it to the inner wall of
 Appearance: stippled the alveolar bone.
 Texture: firm
 Surface: dull Periodontal Fibers
 Rounded: Specially on the marginal • The terminal portions of the principal fibers that are inserted into
 1.5 -2mm from coronal to CEJ cementum and bone are termed Sharpey’s fibers
• The most important elements of the periodontal ligament are the
Function and features of gingival epithelium principal fibers, which are collagenous and arranged in bundles and
 Function follow a wavy course when viewed in longitudinal section
 Mechanical, chemical, water and microbial barrier, signaling
functions Collagen
 Architechural Integrity • is a protein composed of different amino acids, the most important of
 Cell-cell attachments which are glycine, proline, hydroxylysine, and hydroxyproline.
 Basal cell lamina • responsible for maintenance of the framework and tone of tissue, and it
 Keratin cytoskeleton exhibits a wide range of diversity
 Major Cell Type • is synthesized by fibroblasts, chondroblasts, osteoblasts, odontoblasts,
 Keratinocyte and other cells. 
 Other Cell Types
 Langerhans cells Principal Fibers of PDL
 Melanocytes, Merkel cells • Transseptal Group
 Constant Renewal • Alveolar Crest Group
 Replacement of damaged cells • Horizontal Group
 Cell-cell attachments • Oblique Group
 Desmosomes, adherens junctions, tight junctions, gap junctions • Apical Group
 Cell-Basal Lamina • Interradicular Group
 Synthesis of basal lamina components
 Hemidesmosome  Transseptal Group
 Transseptal fibers extend interproximally over the alveolar bone
Gingival Epithelium crest and are embedded in the cementum of adjacent teeth
Junctional Epithelium  Alveolar Crest Fibers
• Close attachment to enamel  Alveolar crest fibers extend obliquely from the cementum just
Sulcular epithelium beneath the junctional epithelium to the alveolar crest
• Found on sulcus  Horizontal Group
**Sulcus – triangular shaped  Horizontal fibers extend at right angles to the long axis of the
Interdental Gingiva tooth from the cementum to the alveolar bone
• Triangular  Oblique Group
• Usually violated during dental treatment  Oblique fibers, the largest group in the periodontal ligament,
extend from the cementum in a coronal direction obliquely to the
Gingival Fluid or Sulcular Fluid bone
 Apical Group
 DANIELLE ANN
PERIODONTICS NOTES 3
 The apical fibers radiate in a rather irregular manner from the • Attaches the periodontal ligament fibers to the root
cementum to the bone at the apical region of the socket. They do • Contributes to the process of repair after damage to the root surface
not occur on incompletely formed roots
 Interradicular Group Alveolar Process
 The interradicular fibers fan out from the cementum to the tooth in • Parts of the maxilla and the mandible that form and support tahe
the furcation areas of multirooted teeth. Other well-formed fiber sockets of the teeth
bundles interdigitate at right angles or splay around and between • Consists of bone
regularly arranged fiber bundles • Bone Dehiscence- complete removal of bony part
• Fenestration- Marginal bone is still intact
Cellular Elements
• Four types: AGING AND PERIODONTIUM
 Connective tissue cells Effects of aging on the periodontium
 Epithelial rest cells • Gingival epithelium
 Immune system cells • Gingival connective tissue
 Cells associated with neurovascular elements • Periodontal ligament
• Cementum
 Connective Tissue Cells • Alveolar bone
 include fibroblasts, cementoblasts, and osteoblasts.Fibroblasts • Bacterial plaque
are the most common cells in the periodontal ligament and • Gingival epithelium – thinning and decreased keratinization of gingival
appear as ovoid or elongated cells oriented along the principal epithelium
fibers, exhibiting pseudopodia-like processes. • Gingival connective tissue - coarser and denser gingival connective
 Epithelial Rest of Malassez tissue
 form a latticework in the peri- odontal ligament and appear as • Periodontal ligament – decreased numbers of fibroblasts and more
either isolated clusters of cells or interlacing strands, depending irregular structure
on the plane in which the microscopic section is cut. Continuity o Decreased organic matrix production and epithelial cell rests
with the junctional epithelium has been suggested in experimental o Increased amount of elastic fiber
animals.  Cementum – increased in cememtal width
 Alveolar bone - more irregular periodontal surface of bone
Epithelial Rest  Less regular insertion of collagen fibers
are distributed close to the cementum throughout the periodontal  Bacterial plaque – dentogingival plaque accumulation
ligament of most teeth and are most numerous in the apical area  Subgingival plaque – increased number of enetric rods and
and cervical area pseudomonads
 diminish in number with age by degenerating and disappearing or
by undergoing calcification to become cementicles. The cells are Response to treatment of the periodontium
surrounded by a distinct basal lamina, are interconnected by • Both meticulous homecare plaque control by the patient and meticulous
hemidesmosomes, and contain tonofilaments. supragingival and subgingival debridement of the therapist
 Ground Substance
 also has a high water content (70%). The cell surface CLASSIFICATION OF DISEASES AND CONDITIONS AFFECTING
proteoglycans participate in several biologic functions, including PERIODONTIUM
cell adhesion, cell-cell and cell-matrix interac- tions, binding to Classification of Diseases and Conditions affecting periodontium
various growth factors as co-receptors, and cell repair.  Gingival Disease
 Chronic Periodontitis
Types of components of Ground Substance  Aggressive Periodontitis
• Glycosaminoglycans  Periodontitis as a Manifestation of Systemic Diseases
• Hyaluronic Acid  Abscesses of the Periodontium
• Proteoglycans  Periodontitis Associated with Endodontic Lesions
• Glycoproteins  Developmental or Acquired Deformities and Conditions
• Fibronectin
• Laminin  Gingival Disease
I. Plaque-induced gingival diseases
The periodontal ligament may also contain calcified masses called II. Non-plaque-induced gingival lesions
cementicles, which are adherent to or detached from the root surfaces  Chronic Periodontitis
I. Localized
Functions of Periodontal Ligament II. Generalized
• The functions of the periodontal ligament are categorized into physical,  Aggressive Periodontitis
formative and remodeling, nutritional, and sensory. I. Localized
Physical Functions Of The Periodontal Ligament Entail The Following: II. Generalized
 1. Provision of a soft tissue “casing” to protect the vessels and nerves  Periodontitis as a Manifestation of Systemic Diseases
from injury by mechanical forces. I. Necrotizing Periodontal Diseases
2. Transmission of occlusal forces to the bone. I. Necrotizing Ulcerative Gingivitis (NUG)
3. Attachment of the teeth to the bone. Cementicles in the periodontal II. Necrotizing Ulcerative Periodontitis (NUP)
ligament, one lying free and the other adherent to the tooth surface.  Abscesses of the Periodontium
4. Maintenance of the gingival tissues in their proper relation- ship to o Gingival abscess
the teeth. o Periodontal abscess
5. Resistance to the impact of occlusal forces (shock absorption) o Pericoronal abscess 
 Periodontitis Associated with Endodontic Lesions
Cementum o Endodontic- Periodontal Lesion
 DANIELLE ANN
PERIODONTICS NOTES 3
o Periodontal- Endodontic Lesion 1. Usually affects persons under 30 years of age
o Combines Lesion 2. Generalized interproximal attachment loss affecting at least 3
 Developmental or Acquired Deformities and Conditions permanent teeth other than first molars and incisors
o Localized tooth-related factors that predispose to plaque-induced 3. Pronounced episodic nature of destruction of attachment and alveolar
gingival diseases or periodontitis bone
o Mucogingival deformities and conditions around teeth 4. Poor serum antibody response to infecting agents
o Mucogingival deformities and conditions on edentulous ridges
o Occlusal trauma PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASE
• Formed by occlusion or trauma to the orifice of the periodontal pocket,
resulting in extension of the infection from the pocket into the soft tissue
GINGIVAL DISEASES
of the pocket wall.
A. Plaque Induced Gingival Disease
- The result of interaction between the microorganism found in the
dental plaque biofilm and the tissues and inflammatory cells of the host
A.1. Gingival Dieseases modified by systemic factors
1.1 Associated with the endocrine system
- Puberty, menstruation, pregnancy, diabetes mellitus
1.2 Associated with blood dyscrasias
- Leukemia, others
A.2. Modified by Medications
2.1 Gingival enlargements
2.2 Gingivitis
A.3. Modified by Malnutrition
B. Non-Plaque induced Gingival Lesion
B.1 Specific Bacterial Origin
- neisseria gonorrhea, pallidum, streptococcus
B.2. Viral Origin
- PHG, recurrent oral herpes, varicella zoster
B.3. Fungal Origin
- Candida, Histoplasmosis
B.4. Lesions of Genetic Origin
- Hereditary gingival fibromatosis
B.5. Manifestations of systemic conditions
5.1 Mucocutaneous lesions
- Lichen planus, pemphigoid, erythema,
lupus, drug induced
5.2 Allergic Reactions
- Dental restorative materials
-Toothpastes, mouthrinses, additives,
food
B.6. Traumatic Lesions
B.7. Foreign Body Reactions

CHRONIC PERIODONTITIS
Clinical Features
1. More prevalent in adults
2. Amount of periodontal destruction is commensurate with oral hygiene,
local predisposing factors, systemic risk factors
3. Microbial plaque is complex
4. Localized- 30% of sites are affected
5. Host factors influence the pathogenesis and progression of disease
6. Progression can only be confirmed by repeated clinical exam and likely
to occur in diseased sites left untreated
Extent of Disease
• Low category- involve 1-10 sites
• Medium category- 11-20 sites
• High category- more than 20 sites
Severity of the Disease
• Mild- 1-2mm CAL
• Moderate- 2-3mm CAL
• Severe- ≥5mm CAL

AGGRESSIVE PERIODONTITIS
Localized Aggressive Periodontitis
1. Circumpubertal onset
2. Localized first molar/ incisor presentation
3. Robust serum antibody response to infecting agents
Generalized Aggressive Periodontitis