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Gingival and periodontal diseases are infectious diseases by nature. Their effects can be best understood with a basic background in the unique anatomy of the periodontium. Periodontium can be defined simply as tissues that surround, support and are attached to the teeth. These include: Gingiva. Periodontal ligament. Cementum. Alveolar bone. Maintaining the health and function of the periodontium is the most significant factor in the longevity of the dentition

Is the visible component of the periodontium inside the mouth Its one of the soft tissues that lines the oral cavity Described as pink, pale pink, or coral pink In some cases it has a normal variation and melanin pigmentation It includes the: Oral epithelium Sulcular epithelium Junctional epithelium Functions Attaches oral mucous membrane and dental hard tissues Protects perio tissues from invasion by bacteria Macroscopic anatomy Oral mucosa consists of:

Masticatory mucosa Incl gingival and hard palate Attached to underlying bone Covered with keratinised/ parakeratinized epithelium (Contains keratin, a schleroprotein)

Specialized mucosa Covers dorsum of tongue Lining mucosa Loosely attached to underlying structures Non-keratinised epithelium Covers lips, cheeks, fl of mouth, ant/ventral surface of tongue, soft palate, uvula and alveolar mucosa Alveolar mucosa starts at mucogingival junction Brighter red in colour Mucogingival junction variable, grossly indistinct - Histologically distinct line - Marks separation of gingival tissue from oral mucosa
The gingiva can be divided into three parts:

1. Free (marginal) gingiva, Surrounds the tooth Creates a cuff or collar of gingival that extends 1.5 mm coronally Distinguished from attached gingival by free marginal groove FMG is a slight depression on the gingival that corresponds to the depth of sulcus 2. Attached gingiva Apical to free gingival More firmly attached to bone by collagen fibres Bound to bone in form of mucoperiosteum MP is periosteum that has mucous surface Attached gingival extends coronally from mucogingival line Width of attached gingiva varies from individual to individual Commonly stippled
3. Interdental gingiva (located between adjacent teeth) Spaces between teeth in contact Triangular in shape Papillae are gingival that fills embrasures (spaces) When papillae is broad (posterior teeth) youll find a col area COL is a slight depression (concavity) of tissue between buccal and lingual interdental papillae It indicates a fusion of two papillae to cover a wider space

Shape of papillae is determined by: Contact relationships between teeth Width of approximal surfaces Course of CEJ When adjacent teeth do not contact each other, attached gingival forms between teeth, then papillae and col are absent

Microscopic anatomy
Oral epithelium The epithelium covering the free gingiva consists of 1.Oral epithelium. Also called outer gingival epithelium 2.Oral sulcular epithelium. Forms covering of soft tissue wall of gingival tissues/extension of oral epit. Into gingival sulcus 3.Junctional epithelium. Place of coming together of different types of tissues

OE is composed of attached gingival, papillae and outer surface of free gingival Function is protective

Keratinisation when surface cells form scales of keratin and lose their nuclei Parakeratinisation when epithelium shows signs of being keratinised, but cells of superficial layers retain their nuclei
The oral epithelium is a stratified squamous epithelium Stratified disposed in layers Squamous epithelium epithelium composed of flattened plate like cells

Composed of 1.keratinocytes- epidermal cells, which synthesizes keratin 2. Non-keratinocytes. It is divided into (Fig.4):

Basal cell (stratum basale). - Situated near a base Prickle cell (stratum spinosum). Granular cell (stratum granulosum). - Presence of granules or grains Keratinised layers (stratum corneum).

Also contains the following cell types:

Melanocytes. Found in basal cell layer Produces melanin Found gingiva, lips, buccal mucosa, and soft palate.

Pigmentation of mouth & kin not necessarily same Langerhans cells. Found in more superficial cells Part of immune system Traps antigens on long dendritic (branched like a tree processes & presents them to lymphocytes Non-specific cells
Junctional epithelium (JE) It separates the periodontal ligament from the oral environment Its function is protection for the attachment of the tooth to the surrounding environment Amelocemental junction where apical limit is found Via hemidesmosomes it is attached to the tooth surface Oral sulcular epithelium. Is distinguished from the JE under microscope Neutrophils- are present in small numbers Passes through gingival crevice Plays a role in host defence Turnover of 4-11 days. JE has rapid turnover Readily permeable- Is r/p to substances Principal function- TO MAINTAIN ATTACHMENT OF JE TO TOOTHSURFACE

The basement membrane (BM) Comprises / consists of: The lamina lucida - electron lucent zone The lamina densa -electron dense zone

From electron dense zone Anchoring fibres Branch out in Fan shape Into Connective tissue

The cell membrane facing Electron lucent zone Harbour hemidesmososmes Are involved in attachment of epithelium To Underlying basement membrane

Differentiation. - Process of acquiring completely individual characters

Cells divide ( basal layer) Move Through epithelium To surface Are shed Shapes change at surface Become flat

Dento - gingival epithelium (DGE) Consists of epithelium facing tooth Non keratinised Stratified sqaumous epithelium It is mechanically very strong



subdivided into 2 parts 1.Sulcular part (sulcular epithelium) Found at level of free gingival Forms gingival crevice Healthy mouth 1-2 mm 2.Junctional epithelium (JE) Adheres to tooth surface Squeezed between enamel facing and connective tissue facing Its continuous with each other Gingival connective tissue Connective tissue beneath gingival called lamina propria Lamina propria made up of 2 layers: Papillary layer immediately beneath epithelium Reticular layer extends to periosteum 60% - CF / 5% - F / 35% - V; N; M Cell types! Fibroblasts; mast cells; macrophages; neutrophils; granulocytes; lymphocytes; plasmacells Connective tissue fibres produced by fibroblasts Can be divided into:

Collagen fibres. Reticulin fibres. Oxytalan fibres. Elastic fibres.

Collagen fibres are arranged in groups and together form a fibrous cuff around the tooth (Fig.6):

Circular fibres (CF)

Encircles tooth coronal to the alveolar crest They support free gingiva

Trans-septal fibres (TF) Attached at most coronal portion of adjacent teeth Ends are inserted into cementum of teeth Probably helps maintain he relationships between teeth Dento-gingival fibres (DGF) Radiates from cementum into free & attached gingival Probably supports the gingiva Dento-periosteal fibres (DPF) Goes from cementum across to the alveolar crest May anchor tooth to bone and protect periodontal ligament Crestal fibres. From the alveolar into attached gingival Probably attaches gingiva to bone


PDL Provides sensory cushion between surface of tooth and bone -Rich nerve supply -Vascular (indicative of copious blood supply) -Is a connective tissue complex primarily filled with fibre bundles and cells? - Contains cells which give rise to cementum and alveolar bone - Specific functions of ligament includes: 1. Tooth anchorage - Attaches tooth to bone - Acts as a shock absorber - Transmits tension to alveolar bone when occlusal forces are generated 2. Fibrous tissue development and maintenance 3. Calcified tissue development and maintenance 4. Nutritive and metabolite transport - Blood supply carries nutrients to the area 5. Sensory functions, incl. Touch, pressure, pain, and proprioception (displacement sensitivity) - Proprioceptive receptors plays NB role in monitoring mandibular function Fibre bundles Are made of collagen Attach tooth to bone Are also believed to:

transmit occlusal forces to bone Resist occusal forces (shock absorber effect) Protect vessels and nerves from injury Are five principle fibre bundles Are attached to cementum with brush like fibres called Sharpeys fibres SF goes from cementum across periodontal ligament and terminates in the alveolar bone as Sharpeys fibres

Fibre bundles include:

Alveolar crest fibres (ACF) Runs from cementum to ridge of ridge of alveolar bone Are thought to oppose lateral forces Also to retain tooth in bone Horizontal fibres (HF) Runs horizontally between alveolar bone and cementum Apical Fibres (APF) Runs from apex of root into alveolar bone Both apical and lateral to root apex Do not occur in partially erupted teeth Oblique fibres Run in an oblique direction across periodontal ligament space into alveolar bone Are largest group Are believed to transform occusal stresses on to alveolar bone Interadicular fibres
Only present in multirooted teeth Spreads apically into bone, from the furcation In addition there are also: Collagen fibresruns in all directions in periodontal ligament Referred to as indifferent fibre plexus Function is unknown

Fig.7 Periodontal ligament fibres. Oxytalan fibres found in PDL Are elastic fibres, which are inserted into cementum Function not really known Seen in teeth that bears abnormal loads May be associated with preservation of blood vessels The principal cells found in the PDL include: Undifferentiated mesenchymal cells. * Fibroblasts. * * Involved in destruction of & formation of PDL, Cementum, alveolar bone proper tissues Osteoblasts. * Osteoclasts. * Cementoblasts. * Epithelial rests of Malassez.

Epithelial rests of Malassez (remnants of Hertwig's root sheath) Function unknown Possibly maintains integrity of PDL Prevents ankylosis (prevents fusion)

ROOT CEMENTUM Is a calcified structure? Covers entire root surface Is avascular there are no vascular or nerve connections So the cementum cannot transmit pain sensations It anchors teeth Maintains occlusal relationships Firmly bound to the underlying dentine Does not undergo physiological resorption and remodelling. Acellular or primary cementum It covers the entire root surface. Characterized by dense layers of calcified collagen fibres Runs II to long axis of tooth Cellular or secondary cementum forms after tooth eruption responds to functional demands found near the apex of the tooth Laid down on top of the primary cementum throughout the functional / final period of the tooth.

ALVEOLAR BONE Lines the sockets of teeth Provides bony support for the sockets ## Alveolar process is the support system of teeth It consists of cancellous (medullary) bone covered by a thin of layer of compact (cortical bone). The fibres of the PDL inserts into the alveolar bone. It can re-model in response to functional demands.

In fact is in constant state of remodelling Remodelling accommodates the - Physiologic tooth migration - Bone apposition - Resorption that are constantly occurring at a slow rate


Are tooth sockets Accommodates the roots of teeth

Alveolar bone proper or the cribriform plate, Lines the alveoli Have thousands of pores through which the tooth and PL are supplied with nerves and blood vessels Supporting alveolar bone. Surrounds alveolar bone proper or cribriform plate Interproximal bone or the interdental septum. Bone found between roots of adjacent teeth Interradicular bone. Bone found between roots of multirooted teeth Radicular bone. Alveolar process found on facial or lingual surfaces of roots

There are 2 variations of normal bone structure that are non-pathogenic and of importance to periodontal health. They are:

1. Dehiscence 2.Fenestration
These areas have no alveolar bone So course of periodontal disease differs from other areas

DEHISCENCE A resorbed area of bone over facial surface of root FENESTRATION An isolated area (window or opening) in bone, which covers the facial surface of a root


Fig.8 Buccal view of the alveolar process.

BLOOD SUPPLY OF THE PERIODONTIUM Supra-periosteal vessels SUPPLIES BLOOD TO GINGIVA Are terminal branches of? Sublingual, Mental, Buccal

Facial, Greater palatine Posterior superior dental arteries. LYMPHATIC SYSTEM OF THE PERIODONTIUM Lymphatic supply parallels that of vascular I.e. Supply to gingival and periosteal tissues Major portion of lymph drainage goes to submandibular nodes NERVES OF THE PERIODONTIUM Innervation (distribution or supply) of gingiva is derived from: 1. Maxillary and mandibular branches of the trigeminal nerve. 2. The buccal gingiva (maxillary posterior teeth) - supplied by the superior alveolar nerve, 3. Facial gingiva (maxillary incisors / cuspids) - supplied by the labial branch of the infra-orbital nerve. 4. The nasopalatine nerve supplies - palatal gingiva of the maxillary anterior teeth 5. Anterior palatal nerve supplies - -maxillary posterior teeth. 6. The buccal gingiva (mandibular molars / premolars) - supplied by the long buccal nerve, 7. Facial gingiva - supplied by the mental nerve. 8. The lingual gingiva (all the mandibular teeth)- supplied by the lingual nerve.