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Periodontal diseases are characterized by localized infections and inflammatory conditions where anaerobic Gram-negative bacteria are mainly involved and directly affect teeth-supporting structures. Periodontal disease affects one or more of the periodontal tissues, alveolar bone, periodontal ligament, cementum and gingiva. The pathogenesis of this disease involves immunological responses leading to tissue destruction and bone loss. Periodontitis is a chronic inflammatory disease characterized by destruction of gingival connective tissue, periodontal ligaments, and alveolar bone8.Periodontitis produces irreversible destruction of periodontal tissue and tooth loss. This condition is diagnosed clinically by loss of attachment between the tooth and the supporting tissues, thus creating a pocket between the root of the tooth and the supporting tissues, and/or by radiography showing bone loss9. The main causative factor is the formation of a microbial biofilm at the gingivocervical margin, which evokes anti-inflammatory response in the gingival tissue, which progresses deeper into the periodontal tissue.10

Periodontal diseases are mainly categorized into gingivitis and periodontitis and always the former precedes the latter. But in some cases gingivitis never progresses to periodontitis. Initial lesion, early lesion, established lesion and advanced lesion are the four stages of plague induced periodontal lesion. During the initial lesion the high activity of immune response generally occurs in gingival tissues. Early lesion generally will take four to twelve days and comprises of inflammatory responses. Established lesion is marked by significant occurrence of plasma cells. Formation of periodontal pocket, ulceration and suppuration of gingiva, alveolar bone and periodontal ligament destruction, tooth mobility and tooth loss are the major features of advanced lesion.

Oral  bacteria  gather  and  coaggregate in colonies on the tooth surface, first supragingivally and thereafter subgingivally. With time, Gram-negative anaerobic microorganisms e.g.,Treponema denticola, Porphyromonas gingivalis, Fusobacterium nucleatum, and Tannerella forsythensis (former Bacteroides forsythus.) become more prevalent in the subgingival plaque, thereby enhancing its pathogenicity. 11,12

The “red complex” that appears later in connection with the development of the biofilm consists of species that are considered to be periodontal pathogens, namely, Porphyromonas gingivalis, Treponema denticola and Tannerella forsythensis, which occur more commonly in deeper pockets13. The ecological plaque theory proposes that the increasing quantity of plaque provides an appropriate environment for colonization and growth of more pathogenic bacteria19.  Thus dynamic relationship is established whereby the inflammatory response results in environmental changes subgingivally, produce a shift in the balance of the resident microflora which changes the gingivally healthy situation to gingivitis. Bacteria then move further through the junctional epithelium and into underlying tissues, thereby predisposing to periodontal disease.14

Diagnosis of periodontitis usually relies mainly on clinical data but microbiological studies are also useful both in establishing the etiology of the disease and in controlling the treatment of the patient . Other periodontal disease markers (e.g. proteins, enzymes, immunoglobulins) are also potentially useful but have to date been rarely applied in differential diagnosis15.

Fig.1.1: Flow chart representing pathogenesis of periodontal diseases16.

Fig.1.2: Diagrammatic representation of changes involved in the transition from healthy gingivae to the pathological periodontitis. Stage 1: healthy gum tissue (gingiva); Stage 2: plaque formation due to bacterial invasion; Stage 3: bacterial toxins irritate gums and trigger host-mediated responses that lead to gingivitis; Stage 4: destruction of gingiva and bone that support the tooth leading to periodontitis17.

Fig.1.3:Comparison of healthy periodontum and periodontal disease18

1. Mild Periodontitis (Gingivitis)

Gingiva is red, shiny, swollen and soft, or spongy in texture.  The gums begin to separate from the teeth, forming pockets, which fill with plaque.  Toxins produced by the bacteria in plaque irritate the gums.  Patients suffering from gingivitis will have a pocket depth of 3mm.

2 .Moderate Periodontitis
Deeper pockets form as more bone and tissue are lost.  The toxins stimulate a chronic inflammatory response in which the body in essence turns on itself and the tissues and bone that support the teeth are broken down and destroyed. It is characterized by puffy, bleeding gums with a pocket depth of up to 5mm and early stages of bone loss.

3. Advanced Periodontitis
This is a major state of periodontitis.  It is characterized by swollen, bleeding gums, more bone loss, gum recession and a pocket depth up to 6mm or more which is harder to treat.  Teeth may become loose because a large amount of bone and tissue have been lost. Further destruction could lead to the loss of teeth due to poor support.

4. Refractory Periodontitis
This stage can usually result in tooth loss because the major amount of bone is lost due to the excessive destruction of the bone and tissue, which are supporting to the teeth.

Various types of  Periodontitis are being seen in above pictures


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