2015م - 1444هـ
Clinical Periodontology

and Implant Dentistry

4th edition

Jan Lindhe

Thorkild Karring . Niklaus P. Lang

Editors



Contents

Foreword xv

Giorgio Vogel

Preface xvii

Jan Lindhe

Classification of Periodontal Diseases xix

Denis F. Kinane and Jan Lindhe

Adult periodontitis — chronic periodontitis

Early-onset forms of periodontitis — aggressive

periodontitis

Systemic disease forms of periodontitis

Necrotizing forms of periodontitis — necrotizing

forms of periodontal diseases

Contributors xxi

Basic Concepts

Chapter 1

Anatomy of the Periodontium 3

Jan Lindhe, Thorkild Karring and Mauricio Araujo

Introduction 3

Gingiva 5

Macroscopic anatomy 5

Microscopic anatomy 8

Periodontal ligament 27

Root cementum 31

Alveolar bone 34

Blood supply of the periodontium 43

Lymphatic system of the periodontium 47

Nerves of the periodontium 48

Chapter 2

Epidemiology of Periodontal Diseases 50

Panos N. Papapanou and Jan Lindhe

Methodological issues 50

Examination methods — index systems 50

Critical evaluation 52

Prevalence of periodontal diseases 54

Introduction 54

Periodontitis in adults 54

Periodontitis in children and adolescents 57

Periodontitis and tooth loss 61

Risk factors for periodontitis 61

Introduction and definitions 61

Studies of putative risk factors for periodontitis 63

Longitudinal studies and conclusions 68

Periodontal infections and risk for systemic disease

70

Atherosclerosis — cardiovascular/cerebrovascular

disease 70

Preterm birth 72

Diabetes mellitus 73

Concluding remarks 73

Chapter 3

Dental Plaque and Calculus 81

Niklaus P. Lang, Andrea Mombelli and Rolf Attstrom

Microbial considerations 81

General introduction to plaque formation 83

Dental plaque as a biofilm 85 Structure of

dental plaque 85

Supragingival plaque 85

Subgingival plaque 90

Peri-implant plaque 98

Dental calculus 98

Clinical appearance, distribution and clinical

diagnosis 98

Attachment to tooth surfaces and implants 100

Mineralization, composition and structure 101

Clinical implications 102

Chapter 4

Microbiology of Periodontal Disease 106

Sigmund S. Socransky and Anne D. Haffajee

Introduction 106

Periodontal diseases and other infectious diseases 106

Unique features of periodontal infections 107

Historical perspective 108

The early search 108

The decline of interest in microorganisms 110

Non-specific plaque hypothesis 110

Mixed anaerobic infections 110

VI • CONTENTS

Return to specificity in microbial etiology of

periodontal diseases 110

Changing concepts of the microbial etiology of

periodontal diseases 111

Current suspected pathogens of destructive

periodontal diseases 112

Criteria for defining periodontal pathogens 112

Periodontal pathogens 114 Mixed infections

122

The nature of dental plaque —

the biofilm way of life 122

The nature of biofilms 122

Properties of biofilms 123

The oral biofilms that lead to periodontal diseases 125

Microbial complexes 126

Factors that affect the composition of subgingival

biofilms 127

Microbial composition of supra and subgingival

biofilms 132

Prerequisites for periodontal disease initiation and

progression 132

The virulent periodontal pathogen 133

The local environment 133 Host

susceptibility 134

Mechanisms of pathogenicity 135

Essential factors for colonization of a subgingival

species 135

Final comments 139

Chapter 5

Host-Parasite Interactions in Periodontal Disease

150

Denis F. Kinane, Tord Berglundh and Jan Lindhe

Initiation and progression of periodontal disease

150

Introduction 150

Initiation of periodontal disease 150

Initial, early, established and advanced lesions 155

Host-parasite interactions 163

Introduction 163

Microbial virulence factors 164

Host defense processes 165

Overall summary 175

Chapter 6

Modifying Factors: Diabetes, Puberty, Pregnancy

and the Menopause and Tobacco Smoking 179

Richard Palmer and Mena Soory

Diabetes mellitus 179

Type 1 and Type 2 diabetes mellitus 180

Clinical symptoms 180

Oral and periodontal effects 180

Association of periodontal infection and diabetic

control 181

Modification of the host/bacteria relationship in

diabetes 182

Periodontal treatment 183

Puberty, pregnancy and the menopause 183

Puberty and menstruation 184

Pregnancy 184

Periodontal treatment during pregnancy 186

Menopause and osteoporosis 186

Hormonal contraceptives 187

Tobacco smoking 188

Periodontal disease in smokers 189

Modification of the host/bacteria relationship in

smoking 190

Smoking cessation 192

Chapter 7

Plaque Induced Gingival Disease 198

Noel Claffey

Histopathologic features of gingivitis 200

Gingivitis associated with local contributing factors

200

Tooth abnormalities such as enamel pearls and

cemental tears 200

Dental restorations 200

Root fractures 201

Cervical root resorption 201

Treatment of plaque induced gingivitis 201

Gingival diseases modified by endocrine factors

(see also Chapter 6) 201

Pregnancy associated gingivitis 201

Puberty associated gingivitis 202

Menstrual cycle associated gingivitis 202

Pyogenic granuloma of pregnancy 202

Gingival diseases modified by malnutrition 202

Gingival diseases modified by systemic conditions

203

Diabetes mellitus 203

Leukemias and other blood dysplasias 203

Gingival diseases modified by medications 203

Necrotizing ulcerative gingivitis (see also

Chapter 10) 205

Microbiology, host response and predisposing factors

205

Host response in acute necrotizing ulcerative

gingivitis 206

Treatment of NUG 207

Chapter 8

Chronic Periodontitis 209

Denis F. Kinane and Jan Lindhe

Risk factors or susceptibility to chronic periodontitis

211

Bacterial risk factors 211

Age 211

Smoking 211

Host response related 212

Scientific basis for periodontal therapy 213

Tooth loss 213

Subgingival instrumentation and maintenance 213

Effect of surgical treatment 214

Comparisons of surgical and non-surgical therapy

214

CONTENTS • VII

Chapter 9

Aggressive Periodontitis 216

Maurizio S. Tonetti and Andrea

Mombelli

Classification and clinical syndromes 217

Epidemiology 218

Primary dentition 219

Permanent dentition 220

Screening 221

Etiology and pathogenesis 225

Bacterial etiology 225

Bacterial damage to the periodontium 228 Host

response to bacterial pathogens 228 Genetic

aspects of host susceptibility 231 Environmental

aspects of host susceptibility 232 Current

concepts 232

Diagnosis 233

Clinical diagnosis 233

Microbiologic diagnosis 235

Genetic diagnosis 237

Principles of therapeutic intervention 237

Elimination or suppression of the pathogenic flora 238

Chapter 10

Necrotizing Periodontal Disease 243

Palle Holmstrup and Jytte Westergaard

Nomenclature 243

Prevalence 243

Clinical characteristics 244

Development of lesions 244

Interproximal craters 244

Sequestrum formation 246

Involvement of alveolar mucosa 246

Swelling of lymph nodes 246

Fever and malaise 248

Oral hygiene 248

Acute and recurrent/chronic forms of necrotizing

gingivitis and periodontitis 249

Diagnosis 249

Differential diagnosis 249

Histopathology 250

Microbiology 251

Microorganisms isolated from necrotizing lesions 251

Pathogenic potential of microorganisms 252

Host response and predisposing factors 253

Systemic diseases 253

Poor oral hygiene, preexisting gingivitis and history of

previous NPD 254

Psychologic stress and inadequate sleep 254

Smoking and alcohol use 254

Caucasian background 255

Young age 255

Treatment 255

Acute phase treatment 255

Maintenance phase treatment 257

Chapter 11

The Periodontal Abscess 260

Mariano Sanz, David Herrera and Arie J. van

Winkelhoff

Classification 260

Periodontitis-related abscess 260

Non-periodontitis-related abscess 261

Prevalence 261

Pathogenesis and histopathology 261

Microbiology 262

Diagnosis 262

Differential diagnosis 264

Treatment 264

Complications 266

Tooth loss 266

Dissemination of the infection 266

Chapter 12

Non-Plaque Induced Inflammatory Gingival

Lesions 269

Palle Holmstrup and Daniel van Steenberghe

Gingival diseases of specific bacterial origin 269

Gingival diseases of viral origin 269

Herpes virus infections 269

Gingival diseases of fungal origin 272

Candidosis 272

Linear gingival erythema 274

Histoplasmosis 275

Gingival lesions of genetic origin 275

Hereditary gingival fibromatosis 275

Gingival diseases of systemic origin 277

Mucocutaneous disorders 277

Allergic reactions 286

Other gingival manifestations of systemic conditions

287

Traumatic lesions 289

Chemical injury 289

Physical injury 289 Thermal

injury 291 Foreign body

reactions 291

Chapter 13

Differential Diagnoses: Periodontal Tumors and

Cysts 298

Palle Holmstrup and Jesper Reibel

Reactive processes of periodontal soft tissues 298

Fibroma/focal fibrous hyperplasia 298

Calcifying fibroblastic granuloma 300

Pyogenic granuloma 301

Peripheral giant cell granuloma 301

Reactive processes of periodontal hard tissues 302

Periapical cemental dysplasia 302

Benign neoplasms of periodontal soft tissues 303

Hemangioma 303

Nevus 304

Papilloma 304

Verruca vulgaris 305

Peripheral odontogenic tumors 305

Benign neoplasms of periodontal hard tissues 306

Ameloblastoma 306

Squamous odontogenic tumor 307

Benign cementoblastoma 308

Malignant neoplasms of periodontal soft tissues 308

Squamous cell carcinoma 308

Metastasis to the gingiva 309

Kaposi's sarcoma 310

VIII • CONTENTS

Malignant lymphoma 310

Malignant neoplasms of periodontal hard tissues

311

Osteosarcoma 311

Langerhans cell disease 311

Cysts of the periodontium 312

Gingival cyst 313

Lateral periodontal cyst 313

Inflammatory pm-Mental cyst 314

Odontogenic keratocyst 314

Radicular cyst 315

Chapter 14

Endodontics and Periodontics 318

Gunnar Bergenholtz and Gunnar Hasselgren

Influence of pathologic conditions in the pulp on

the periodontium 319

Impact of disease conditions in the vital pulp 319

Impact of pulpal necrosis 319

Manifestations of endodontic lesions in the marginal

periodontium from lateral canals 323

Manifestations of acute endodontic lesions in the

marginal periodontium 324

Impact of endodontic treatment measures on the

periodontium 326

Root perforations 328

Vertical root fracture 330

Influence of external root resorptions 333

Mechanisms of hard tissue resorption 333

Clinical manifestations of external root resorptions

334

Different forms of external root resorption 335

Influence of periodontal disease on the condition of

the pulp 339

Influence of periodontal treatment measures on the

pulp 340

Scaling and root planing 340 Root

dentin hypersensitivity 341

Endodontic considerations in root resection of

multirooted teeth in periodontal therapy 344

Differential diagnostic considerations 344

Treatment strategies for combined endodontic and

periodontal lesions 346

e developments 397