Today we just start talking about something that you already know, we need to focus because it is the foundation

when we learn about periodonticis. We will talk about Normal priodontum (you already study this in oral histology course), we will go through some refreshment of the information and maybe we will find some additional information. Normal periodontum (as we said last week) is composed of 4 main structures: 1-gingiva Periodontal: 2-PDL perio>>around the tooth 3-alveolar bone >>mean something around the 4-cementum tooth it is functional unit that mean when we talk about gingival or cementum or alveolar bone or PDL, we are NOT talking about distinct structure in function, they all work together to help preserving the tooth and monitoring the dentition, so, they are functional system in one term called PERIODONTUM. For today, we will talk about GINGIVA & PDL.

GINGIVA
NOTE>> there is a chapter in the reference book talking about the periodontum and maybe this is the only chapter that will be including in the midterm exam (mid exam >>2 week \4lecs\4topics). -It is the soft tissues that covers every thing underneath &make a seal around the tooth to prevent invading of foreign bodies around the tooth structure. -as introduction, the mucous membrane in the oral cavity divided into 3 main functional and histological groups: 1-masticatory mucosa: which is covering the masticatory system (teeth & alveolar bone). 2-specilized mucosa: this is covering the tongue (the taste buds). 3-lining mucosa: functioning as lining the oral cavity and provide some sort of protection but its consider nothing compared to masticatory mucosa which is the hard part of mucous membrane. -The gingival is part of this masicatory mucosa which is the mucosal membrane that covers the gingival &alveolar bone & hard palate.

-MUCOGINGIVAL JUNCTION it is the junction between the mucous membrane and the gingiva.

This line or junction is very important, because when you come to the clinic, this line has a lot of significance in demarcating disease vs. health &in different parts of oral cavity because it is not the same width wherever you go in the oral cavity. As you can see in the next pic, you can see this line even in the lingual surface of the lower jaw, we have gingival tissue which is attached to the tooth structure (around it) &and mucous membrane & the line between them called mucogingival line or junction.

But in the palate, you can imagine in the palatal surface, do we have a lining mucosa??NOO, it is just masticatory mucosa .thats why, you cant demarcate the MGJ in the palatal surface. **SOO, you can see MGJ in the lower jaw (bucally &lingaully) but in the upper jaw you only can see it bucally, because when you stretch the lip you can see the lining mucosa mobile while the gingiva is attached to the tooth and there is a line demarcating both of them but in the hard palate the nature of tissue is very hard and attached to the periostum of the bone and you cant locate MGJ in the palatal surface. GENERALLY, the gingiva is classified into 3 main anatomical components: 1-free gingiva 2-attached gingiva 3-interdental gingiva (papilla)

FREE GINGIVA
-extend from gingival margin (the tip of the soft tissue) to the marginal groove ( anatomically ,when you come to the clinic insha2allah ,you should be able to see this groove which is like a line going all the way ,and this groove where the beginning of attached gingival start ). -so if you introduce something through this part you should be able to reflect this part of the gingiva. this part of the gingiva is very important; because if you can imagine, around the tooth there is thin rim of gingiva is not attached so there is a space between the gingival and the tooth, why do we need this space?? We will come in the next slide to understand why this is important and what is the significance of increasing the depth of this space.

NOW , this space is called GINGIVAL SULCUS >>normally in healthy person ,it should not be more than 3 mm in depth ,we have a special instrument called PERIODONTAL PROB (it is just a piece of metal that is graduated and you introduce it between the gingival and the tooth to see the depth) if you introduce it and find that the depth is 5mm ,you know that there has been destruction ,so the sulcus has been extend more than 3mm and this is indication of pathology .

So in healthy slucs it should not more than 3 mm, and of course to call it healthy, when u introduce this instrument there should be no bleeding when you do the instrumentation because sometimes even with 3mm depth so its within normal but when you introduce the prob there is bleeding thats mean that the gingiva is very fragile and you can easily induce bleeding this also indicate pathology. So this free gingeva form like a sac around the tooth (or just 63dgree around the tooth like a sac) and there is a fluid fill this space and we call it gingival crevicular fluid.

ATTACHED GINGIVA
NOW , come to the other part of the gingiva which is the attached gingiva , in this part the gingival tissue is attached very well to the preiosteum of the bone , when you go the clinic and try to reflect this tissue (the gingiva) (some surgeons need to remove this tissue to see what is underneath ) if you do it in a classic way you will see that the preiosteum attached to the gingiva and will be reflected from the tooth with the gingival because it is very will attached to it and if you need to separate it you have to used special technique . SO THE ATTACHMENT BTW the gingival tissue (epithelial & connective tissue) & the preiosteum.

As I told you, in the palate we cant see the lining mucosa; its not mobile so we cant locate the mucogingival line. NOW why we need this attachment in the attached gingiva ???? because it gives strength to the gingival tissue to 1- withstand the masticatory forces 2-withstand tooth brushing 3- prevent the movement of marginal gingival or free gingival (coz imagine that we have small thin rim of free gingival and the other part is not attached every things will be deflected away and remove which make it easy for microorganisms and foreign bodies to get into this space and cause disease) VERY IMPORTANT STATEMENT AND CLINICAL FACT SPICIALLY WHEN YOU COME TO DO SURGERY LATER ON but for that time we need to know that the width of attached gingival is not the same, vary in different parts of the mouth The attached gingival (we call it the keratinized gingiva) is basically very important to defense pathology ,so if for any reason (like gingival and periodontal disease) and there is recession your patient lose 3 mm of attached ginfiva and sometimes all attached gingival is lost what you have ??? Only lining mucosa covering the root which is very thin and weak when we see this we need to do some intervention and most of the cases we do what we call gingival grafting (where we take some gingival tissue from the palate and place it here in a grafting procedure).

In general , in the upper jaw you can see this attached gingival is wide on the anterior teeth bucally and gets narrower posteriorly but the narrowest part around premolar at the lower jaw ,there is deference , it is narrowest on the anterior teeth and widest on the posterior . LOOK TO THE PIC ABOVE NOTE >> the width considerably varies.

INTERDENTAL GINGIVA
NOW, the third part is the interdental papilla which is the part of the gingival that fills the space btw the 2 teeth and in normal healthy situation this papilla should fill all the space up to the contact point. one of the indication of pathology and disease that when see loose of this interdental papilla and see space btw these to teeth this is a sign that periodontal destruction has been occurred and alveolar bone resorption has taken place and the covering gingiva just went down or up apically depending in the upper or lower jaw and this is a sign of periodontitis (because you have lost tissues ) how to deal with this ?? Next year you will know the answer: P NOW regarding the shape the gingival tissue will covering the space btw 2 teeth from the buccal side but under the contact point there is a depression and again it will go and covers another side. you need a little pit of imagination, if we talk about the buccule side the shape of the gingival will be pyramid and there is another one from the other side (the lingual side) so 2 pyramids but in between not every place is fill with the tissue, there is concavity we call it the COL which

is below the contact point.

NOW if the contact point be high (goes more apically ) the shape of interdental papilla will differ ,the pyramids will become shorter and more blunt >>> so the location of the contact point determines the shape of the interdental papilla this is factor one , and the width of the proximal surface ,this width btw the anterior teeth or the thickness of the tooth is much less than the molars so that the papilla in the molars teeth is thicker and wider because the proximal surface of the teeth are wider ,this factor two , and of course the shape of cementoenamel junction TO SUM UP >> the shape of interdental papilla determined by: 1-the location of the contact point 2-the width of proximal surfaces 3-shapes of CEJ.

NOW how to differentiate between healthy and diseased gingiva ?? 1-color , the normal color of the gingival is pink( the degree of the color is defer from one area and another within the oral cavity, in keratinized area is pale in color but in non keratinized part of oral mucous is more pinkish ) ,but sometimes there is variation called racial pigmentation . 2-the contour (which means how follows the curvature or anatomy of the tooth): is scalloped outline not straight, this in healthy person in diseased person, its just flat. 3- the margin of the gingiva : when you see the margin of the gingiva is swollen ,thick, this means disease ,this means inflammation of the tissue ,while in healthy person it should be thin knife- edge 4- the texture : stippled appearance ,this stippling duo to the nature of attachment of the connective tissue to the epithelium ,now in disease because of inflammation and blood flow to the area this stippling disappear . But not in all cases you have to see stippling, some healthy gingival the stippling will not be very evident but if you see it >>sign of health.

5-consistency: resilient 6-pointed interdental papllia 7- and as we said the probing depth should not be more than 3mm 8-with no bleeding on probing when we talking about the free gingiva .

NOW this is a slide(#18) to show you 2 normal patients but this is what we call racial

pigmentation ,you know that the color of the gingival is determined by melanocytes (which
gives the color of the skin) so in dark skin people you will see pigmentation like this (this slide is a sort of extreme slid coz most of the time you will see some patches of these pigmentation here and there ) also this pigmentation can be seen in smokers

this is the stippling ,it caused by attachment btw the connective tissue fibers to the underlying cementum and periosteum .

HISTOLOGY

NOW , epithelial tissue of the gengiva is stratified squamous epithelium *stratified >>more than one layer *squamouse cells >> cell type like squamous not cuboidal not columnar which is the cell type that covering the skin and most of the structures in the oral cavity **you know that the skin and the oral tissue is covered by keratin so it is keratinized type of tissue ,we have 2 types of keratin layer>> orthokearten which mean straight while parakeratin its fifty fifty if you like ,so there is no remnant of cell nuclei in ortho but there are remnants of nuclei in Para keratin . the gingiva is mostly parakeratinized and its attached to the connective tissue by abasement membrane

The gingiva consist of 2 main types of tissues: 1-epithelium 2-connective tissue

**the main cell layers of the tissue :

1- the basal cell layer >>which is close to the basement membrane ( stratum basali)

2- spinus cell layer 3-granular cell layer 4-corneal cell layer >> at the top which is the keratin

**the main cell type is the kertinocyte, but there are some few other cell types Although most of the collagen found in the connective tissue gives the resiliency to the gingival tissue, there are some specific protein in the epithelial cells as well like cytokeratin (related to the keratino cyte in the keratin cell layer) &keratolinin &involucrin &filaggrin Some other cells types we need structure .