PPPEEERRRIIIOOODDDOOONNNTTTIIICCCSSSRRREEEVVVIIISSSIIITTTEEEDDD

Shalu Bathla MDS (Gold Medalist)Reader

Department of Periodontology and Oral ImplantologyMM College of Dental Sciences and Research

Mullana, Ambala, Haryana, India

Assisted byManish Bathla MDAssistant Professor

Department of PsychiatryMM Institute of Medical Sciences and Research

Mullana, Ambala, Haryana, India

Forewords

SG DamleThomas E Van Dyke

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi Panama City London

Uploaded by http://dentalebooksfree.blogspot.com

`i`v*`viivViV>i

/iiVi]\ViVV

INTRODUCTION

Chronic periodontitis is the most common form ofdestructive periodontal disease in adults; it can occur overa wide range of ages. It can occur in both the primary andsecondary dentition. It usually has slow to moderate ratesof progression, but may have periods of rapid progression.Chronic periodontitis is initiated and sustained bybacterial plaque, but host defense mechanism plays anintegral role in its pathogenesis. The progressive natureof the disease can only be confirmed by repeatedexaminations. It is reasonable to assume that the diseasewill progress further if treatment is not provided.

Chronic Periodontitis is defined as an infectious diseaseresulting in inflammation within the supporting tissues ofthe teeth leading to progressive attachment and bone loss. Itis also characterized by pocket formation and/or gingivalrecession. It is recognized as the most frequentlyoccurring form of periodontitis.

CLASSIFICATION

Chronic periodontitis can be further characterized byextent and severity. Extent is the number of sites involvedand can be described as localized or generalized. Localized if 30% of the sites are affected (Fig. 25.1) Generalized if > 30% of the sites are affected (Fig. 25.2)

Severity can be described for the entire dentition orfor individual teeth and sites. As a general guide, severitycan be categorized on the basis of the amount of clinicalattachment loss (CAL) as follows: Slight = 1 to 2 mm CAL Moderate = 3 to 4 mm CAL Severe 5 mm CAL.

CLINICAL FEATURES

1. Amount of destruction is consistent with the presence oflocal factors: Characteristic clinical finding in patientwith chronic periodontitis include supragingival andsubgingival plaque accumulation that is frequentlyassociated with subgingival calculus formation(Fig. 25.3).

2. Gingival inflammation: The gingiva ordinarily isslightly to moderately swollen and exhibitsalterations in color ranging from pale red to magenta.Loss of gingival stippling and changes in the surfacetopography may include blunted or rolled gingivalmargins and flattened or cratered papillae. Gingivalbleeding, either spontaneous or in response toprobing, is frequent, and inflammation relatedexudates of crevicular fluid (Fig. 25.4).

3. Periodontal pocket formation: Pocket depths are variable,and suppuration from the pocket can be found.

1. Introduction2. Classification3. Clinical Features4. Radiographic Features

Chronic Periodontitis

Shalu Bathla, Anish Manocha

5. Progression of Periodontal Disease6. Risk Factors or Susceptibility7. Treatment

2525

PERIO

DO

NTIC

S R

EVIS

ITED

187CHAPTER 25: CHAPTER 25: CHAPTER 25: CHAPTER 25: CHAPTER 25: Chronic Periodontitis

5. Loss of alveolar bone: Resorption of alveolar bone inthe form of both horizontal and vertical bone losscan be seen. There is considerable variation in boththe form, pattern and rate of alveolar boneresorption.

6. Mobility: Tooth mobility often appears in advancedcases when bone loss has been considerable.

7. This type of periodontitis can be associated with localpredisposing factors (e.g. tooth-related or iatrogenicfactors).

8. May be modified by and/or associated withsystemic diseases (e.g. diabetes mellitus, HIV); canbe modified by factors other than systemic diseasesuch as cigarette smoking and emotional stress.

9. Slow to moderate rate of progression, but may haveperiods of rapid progression also.

Fig. 25.1: OPG showing localized bone loss in localized chronicperiodontitis

Fig. 25.2: OPG showing generalized bone loss in generalizedchronic periodontitis

Fig. 25.3: Increased amount of calculus and plaque associated withchronic periodontitis

Fig. 25.4: Gingival inflammation associated with chronicperiodontitis

Fig. 25.5: Generalized loss of attachment

4. Loss of periodontal attachment: Chronic periodontitiswith slight to moderate loss of periodontalsupporting tissues may be localized or generalized(Fig. 25.5).

PERIO

DO

NTIC

S R

EVIS

ITED

188 SECTION 4: SECTION 4: SECTION 4: SECTION 4: SECTION 4: Pathology of Gingival and Periodontal Diseases

RADIOGRAPHIC FEATURES

Radiographic examination is an essential part ofperiodontal diagnosis and with certain limitationsprovides evidence of the alveolar bone height, extent,form of bone destruction, and the density of cancelloustrabeculation. Various bone loss patterns can be seen inchronic periodontitis patient (Fig. 25.6) and is explainedin chapter 24 Bone defects. In a marginal periodontitis,bone destruction is indicated first by the loss of the densemargin, which delineates the alveolar process in health.As bone density decreases the bone margins becomesradiolucent and indistinct. With continuing boneresorption the height of the alveolar bone is reduced.

Chronic periodontitis is diagnosed by:Chronic inflammatory changes in the gingivaPresence of periodontal pocketsLoss of clinical attachment andAlveolar bone loss

PROGRESSION OF PERIODONTAL DISEASE

Chronic periodontitis does not progress at an equal ratein all affected sites throughout the mouth. Some involvedareas may remain static for long periods of time, whereasothers may progress more rapidly. More rapidlyprogressive lesions occur most frequently in interproximalareas and are usually associated with areas of greaterplaque accumulation and inaccessible areas to plaquecontrol measures (furcation areas, overhanging margins,malposed teeth).

Following are the models that describe the rate ofdisease progression:

i. Continuous disease model: In this model, loss ofattachment has commenced and proceed continuouslyand slowly until tooth loss eventually results. Linearcorrelation between age and loss of attachment,supports this concept of gradual destruction (Fig. 25.7).

ii. Random burst disease model: In 1982, Goodson et alchallenged the continuous disease model and

Fig. 25.6: Radiograph of chronic periodontitis showng various patternof bone loss: 1. Vertical bone loss, 2. Furcation defect, 3. Horizontalbone loss

Fig. 25.7: Continuous disease model

Fig. 25.8: Random burst disease model

PERIO

DO

NTIC

S R

EVIS

ITED

189CHAPTER 25: CHAPTER 25: CHAPTER 25: CHAPTER 25: CHAPTER 25: Chronic Periodontitis

itself greatly increases susceptibility to periodontaldisease. It is more likely that the cumulative effects ofdisease over a lifetime, i.e. deposits of plaque andcalculus, and the increased number of sites capable ofharboring such deposits, as well as attachment and boneloss experience, explain the increased prevalence ofdisease in older people.

Smoking: It is not only the risk of developing thedisease that is enhanced by smoking, but also theresponse to periodontal therapy is impaired in smokers.A further feature in smokers is that their signs andsymptoms of both gingivitis and chronic periodontitis,mainly gingival redness and bleeding on probing, aremasked by the dampening of inflammation.

Stress: Stress and other psychosomatic conditions mayhave direct anti-inflammatory and/or anti-immune effectsand/or behavior mediated effects on the bodys defenses.

Genetics: There is convincing evidence from twinstudies for a genetic predisposition to the periodontaldiseases. The twin studies have indicated that risk ofchronic periodontitis has a high inherited component. Itis likely that chronic periodontitis involves many genes,the composition of which may vary across individuals andraces. Much attention has focused on polymorphismsassociated with the genes involved in cytokineproduction. Such polymorphisms have been linked toan increased risk for chronic periodontitis but thesefindings have yet to be corroborated.

TREATMENT

The goals of periodontal therapy are to alter or eliminatethe microbial etiology and contributing risk factors forperiodontitis, thereby arresting the progression of thedisease and preserving the dentition in a state of health,comfort, and function with appropriate esthetics; and toprevent the recurrence of periodontitis. In addition,regeneration of the periodontal attachment apparatus,where indicated, may be attempted. Clinical judgementis an integral part of the decision making process. Manyfactors affect the decisions for the appropriatetherapy(ies) and the expected therapeutic results.Patient-related factors include systemic health, age,compliance, therapeutic preferences, and patients abilityto control plaque. Other factors include the cliniciansability to remove subgingival deposits, restorative andprosthetic demands, and the presence and treatment ofteeth with more advanced chronic periodontitis.

Treatment considerations for patients with slight tomoderate loss of periodontal support are describedbelow:

proposed that destruction occurs during periods ofexacerbation, interjected with intervals of remission.Breakdown occurs in recurrent acute episodes/burstsof activity over a short time span, interspersed withperiods of quiescence (Fig. 25.8).

iii. Stochastic disease model: In 1989 Manji and Nagelkerkeproposed Stochastic model for periodontalbreakdown that essentially combines both of theabove models. They suggested that, as well as anunderlying slow continuous breakdown (theprogression rate of which depends on host and sites),some sites of some individuals are also undergoingrandom bursts of activity as a result of a combinationof biological events.

RISK FACTORS OR SUSCEPTIBILITY

Prior History of Periodontitis: Although not a true riskfactor for disease but rather a disease predictor, a priorhistory of periodontitis puts patients at a greater risk fordeveloping further loss of attachment and bone, given achallenge from bacterial plaque accumulation. Thismeans that patient with pocket and attachment and boneloss will continue to lose periodontal support if notsuccessfully treated.

Bacterial risk factors: Plaque accumulation on tooth andgingival surfaces at the dentogingival junction isconsidered the primary initiating agent in the etiologyof chronic periodontitis. Specific microorganisms havebeen considered as potential periodontal pathogens butit is clear that although pathogens are necessary, theirmere presence may not be enough for disease activity tooccur. Microbial plaque (biofilm) is a crucial factor ininflammation of the periodontal tissues, but theprogression of gingivitis to periodontitis is largelygoverned by host-based risk factors. Microbial biofilmsof particular compositions will initiate chronicperiodontitis in certain individuals whose host responseand cumulative risk factors predispose them toperiodontal destruction rather than to gingivitis.

Systemic Factors: The rate of progression of plaque-induced chronic periodontitis is generally considered to beslow. However, when chronic periodontitis occurs in apatient who also suffers from a systemic disease thatinfluences the effectiveness of the host response, the rate ofperiodontal destruction may be significantly increased.Diabetes is a systemic condition that can increase the severityand extent of periodontal disease in an affected patient.

Age: Although the prevalence of periodontal diseaseincreases with age it is unlikely that becoming older in

PERIO

DO

NTIC

S R

EVIS

ITED

190 SECTION 4: SECTION 4: SECTION 4: SECTION 4: SECTION 4: Pathology of Gingival and Periodontal Diseases

1. Contributing systemic risk factors may affecttreatment and therapeutic outcomes for chronicperiodontitis. These may include diabetes, smoking,certain periodontal bacteria, aging, gender, geneticpredisposition, systemic diseases and conditions(immunosuppression), stress, nutrition, pregnancy,HIV infection, substance abuse and medications.Elimination, alteration, or control of risk factors whichmay contribute to chronic periodontitis should beattempted. Consultation with the patients physicianmay be indicated.

2. Instruction, reinforcement and evaluation of thepatients plaque control should be performed.

3. Supragingival and subgingival scaling and rootplaning should be performed to remove microbialplaque and calculus. To accomplish this, thefollowing procedures may be considered: Removal or reshaping of restorative overhangs

and over-contoured crowns Correction of ill-fitting prosthetic appliances Restoration of carious lesions Odontoplasty Tooth movement Restoration of open contacts which have resulted

in food impaction Treatment of occlusal trauma.

4. Antimicrobial agents or devices may be used asadjuncts.

5. Evaluation of the initial therapys outcomes shouldbe performed after an appropriate interval forresolution of inflammation and tissue repair. Aperiodontal examination and re-evaluation may beperformed with the relevant clinical findingsdocumented in the patients record. These findingsmay be compared to initial documentation to assistin determining the outcome of initial therapy as wellas the need for and the type of further treatment.

6. For reasons of health, lack of effectiveness or non-compliance with plaque control, patient desires, ortherapists decision, appropriate treatment to controlthe disease may be deferred or declined.

7. If the results of initial therapy res olve the periodontalcondition, periodontal maintenance should bescheduled at appropriate intervals.

8. If the results of initial therapy do not resolve theperiodontal condition, periodontal surgery should beconsidered to resolve the disease process and/orcorrect anatomic defects.

9. Periodontal Surgery: A variety of surgical treatmentmodalities may be appropriate in managing thepatient.

Gingival augmentation therapy. Regenerative therapy: Bone replacement grafts,

Guided tissue regeneration and Combinedregenerative techniques.

Resective therapy: Flaps with or without osseoussurgery and Gingivectomy.

11. The desired outcome of nonsurgical and surgicalperiodontal therapy in patients with chronicperiodontitis should result in: Significant reductionof clinical signs of gingival inflammation; reductionof probing depths; stabilization or gain of clinicalattachment and reduction of clinically detectableplaque to a level compatible with gingival health.

12. Compromised therapy: In certain cases, because ofthe severity and extent of disease and the age andhealth of the patient, treatment that is not intendedto attain optimal results may be indicated. In thesecases, initial therapy may become the end point. Thisshould include timely periodontal maintenance.

BIBLIOGRAPHY

1. Chronic Periodontitis. In, Manson JD. Periodontics 4th edWright 1980 Henry Kimpton Publishers; 97-117.

2. Kinane DF and Lindhe J. Chronic Periodontitis. In, Lindhe J,Karring T, Lang NP. Clinical Periodontology and Implantdentistry. 4th ed Blackwell Munksgaard 2003;209-15.

3. Nagy RJ, Novak MJ. Chronic periodontitis. In, Newman, Takei,Carranza. Clinical Periodontology 9th ed WB Saunders 2003;398-402.

4. Periodontitis. In, Grant DA, Stern IB, Listgarten MA.Periodontics. 6th ed CV Mosby Company 1988;348-75.

MCQs

1. To be diagnosed as localized form of chronicperiodontitis, the number of sites involved shouldbe less than:A. 10%B. 20%C. 30%D. 40%

2. In chronic periodontontitis:A. Amount of destruction is consistent with the

presence of local factorsB. Amount of destruction is inconsistent with the

presence of local factorsC. It depends upon ageD. None of the above

Answers

1. C 2. A

PrelimsChapter-01_GingivaChapter-02_Periodontal LigamentChapter-03_CementumChapter-04_Alveolar BoneChapter-05_Aging and PeriodontiumChapter-06_Classification of Periodontal DiseasesChapter-07_Epidemiology of Gingival and Periodontal DiseasesChapter-08_Periodontal MicrobiologyChapter-09_Dental PlaqueChapter-10_Dental Calculus and Other Contributing FactorsChapter-11_Immunity and InflammationChapter-12_Pathogenesis of Periodontal Diseases and Host ResChapter-13_Genetic Basis of Periodontal DiseasesChapter-14_Effect of Systemic Factors Over the PeriodontiumChapter-15_Effect of Periodontal Diseases on Systemic HealthChapter-16_Smoking and PeriodontiumChapter-17_Defense Mechanisms of GingivaChapter-18_Gingival InflammationChapter-19_Gingival EnlargementChapter-20_Acute Gingival ConditionsChapter-21_Soft and Hard Tissue Lesions with Periodontal RelChapter-22_Periodontal PocketChapter-23_Periodontal AbscessChapter-24_Bone DefectsChapter-25_Chronic PeriodontitisChapter-26_Aggressive PeriodontitisChapter-27_AIDS and PeriodontiumChapter-28_Trauma from Occlusion and Pathologic Tooth MigratChapter-29_Female Sex Hormones and PeriodontiumChapter-30_Clinical DiagnosisChapter-31_Radiographic Diagnostic AidsChapter-32_Microbiological and Immunological Diagnostic AidsChapter-33_HalitosisChapter-34_Dentin HypersensitivityChapter-35_PrognosisChapter-36_Treatment PlanChapter-37_Mechanical Plaque ControlChapter-38_Chemotherapeutic AgentsChapter-39_Host Modulatory TherapyChapter-40_Periodontal InstrumentsChapter-41_General Principles of InstrumentationChapter-42_SplintingChapter-43_General Principles of Periodontal SurgeryChapter-44_Gingival CurettageChapter-45_GingivectomyChapter-46_Periodontal FlapChapter-47_Resective Osseous SurgeryChapter-48_Regenerative Osseous SurgeryChapter-49_Furcation Involvement and ManagementChapter-50_Periodontal Plastic SurgeryChapter-51_Periodontal MicrosurgeryChapter-52_Periodontics-ProsthodonticsChapter-53_Periodontic-EndodonticsChapter-54_Periodontics-Restorative DentistryChapter-55_Periodontics-OrthodonticsChapter-56_Periodontics-Oral SurgeryChapter-57_Periodontics-PsychiatryChapter-58_Basic Aspects of ImplantsChapter-59_Surgical Aspects of ImplantsChapter-60_Advanced Implant SurgeryChapter-61_Peri-implantitisChapter-62_Recent AdvancementsChapter-63_Supportive Periodontal Therapy (Maintenance PhaseChapter-64_MiscellaneousAnnexuresIndexPrelimsChapter-01_GingivaChapter-02_Periodontal LigamentChapter-03_CementumChapter-04_Alveolar BoneChapter-05_Aging and PeriodontiumChapter-06_Classification of Periodontal DiseasesChapter-07_Epidemiology of Gingival and Periodontal DiseasesChapter-08_Periodontal MicrobiologyChapter-09_Dental PlaqueChapter-10_Dental Calculus and Other Contributing FactorsChapter-11_Immunity and InflammationChapter-12_Pathogenesis of Periodontal Diseases and Host ResChapter-13_Genetic Basis of Periodontal DiseasesChapter-14_Effect of Systemic Factors Over the PeriodontiumChapter-15_Effect of Periodontal Diseases on Systemic HealthChapter-16_Smoking and PeriodontiumChapter-17_Defense Mechanisms of GingivaChapter-18_Gingival InflammationChapter-19_Gingival EnlargementChapter-20_Acute Gingival ConditionsChapter-21_Soft and Hard Tissue Lesions with Periodontal RelChapter-22_Periodontal PocketChapter-23_Periodontal AbscessChapter-24_Bone DefectsChapter-25_Chronic PeriodontitisChapter-26_Aggressive PeriodontitisChapter-27_AIDS and PeriodontiumChapter-28_Trauma from Occlusion and Pathologic Tooth MigratChapter-29_Female Sex Hormones and PeriodontiumChapter-30_Clinical DiagnosisChapter-31_Radiographic Diagnostic AidsChapter-32_Microbiological and Immunological Diagnostic AidsChapter-33_HalitosisChapter-34_Dentin HypersensitivityChapter-35_PrognosisChapter-36_Treatment PlanChapter-37_Mechanical Plaque ControlChapter-38_Chemotherapeutic AgentsChapter-39_Host Modulatory TherapyChapter-40_Periodontal InstrumentsChapter-41_General Principles of InstrumentationChapter-42_SplintingChapter-43_General Principles of Periodontal SurgeryChapter-44_Gingival CurettageChapter-45_GingivectomyChapter-46_Periodontal FlapChapter-47_Resective Osseous SurgeryChapter-48_Regenerative Osseous SurgeryChapter-49_Furcation Involvement and ManagementChapter-50_Periodontal Plastic SurgeryChapter-51_Periodontal MicrosurgeryChapter-52_Periodontics-ProsthodonticsChapter-53_Periodontic-EndodonticsChapter-54_Periodontics-Restorative DentistryChapter-55_Periodontics-OrthodonticsChapter-56_Periodontics-Oral SurgeryChapter-57_Periodontics-PsychiatryChapter-58_Basic Aspects of ImplantsChapter-59_Surgical Aspects of ImplantsChapter-60_Advanced Implant SurgeryChapter-61_Peri-implantitisChapter-62_Recent AdvancementsChapter-63_Supportive Periodontal Therapy (Maintenance PhaseChapter-64_MiscellaneousAnnexuresIndexPrelimsChapter-01_GingivaChapter-02_Periodontal LigamentChapter-03_CementumChapter-04_Alveolar BoneChapter-05_Aging and PeriodontiumChapter-06_Classification of Periodontal DiseasesChapter-07_Epidemiology of Gingival and Periodontal DiseasesChapter-08_Periodontal MicrobiologyChapter-09_Dental PlaqueChapter-10_Dental Calculus and Other Contributing FactorsChapter-11_Immunity and InflammationChapter-12_Pathogenesis of Periodontal Diseases and Host ResChapter-13_Genetic Basis of Periodontal DiseasesChapter-14_Effect of Systemic Factors Over the PeriodontiumChapter-15_Effect of Periodontal Diseases on Systemic HealthChapter-16_Smoking and PeriodontiumChapter-17_Defense Mechanisms of GingivaChapter-18_Gingival InflammationChapter-19_Gingival EnlargementChapter-20_Acute Gingival ConditionsChapter-21_Soft and Hard Tissue Lesions with Periodontal RelChapter-22_Periodontal PocketChapter-23_Periodontal AbscessChapter-24_Bone DefectsChapter-25_Chronic PeriodontitisChapter-26_Aggressive PeriodontitisChapter-27_AIDS and PeriodontiumChapter-28_Trauma from Occlusion and Pathologic Tooth MigratChapter-29_Female Sex Hormones and PeriodontiumChapter-30_Clinical DiagnosisChapter-31_Radiographic Diagnostic AidsChapter-32_Microbiological and Immunological Diagnostic AidsChapter-33_HalitosisChapter-34_Dentin HypersensitivityChapter-35_PrognosisChapter-36_Treatment PlanChapter-37_Mechanical Plaque ControlChapter-38_Chemotherapeutic AgentsChapter-39_Host Modulatory TherapyChapter-40_Periodontal InstrumentsChapter-41_General Principles of InstrumentationChapter-42_SplintingChapter-43_General Principles of Periodontal SurgeryChapter-44_Gingival CurettageChapter-45_GingivectomyChapter-46_Periodontal FlapChapter-47_Resective Osseous SurgeryChapter-48_Regenerative Osseous SurgeryChapter-49_Furcation Involvement and ManagementChapter-50_Periodontal Plastic SurgeryChapter-51_Periodontal MicrosurgeryChapter-52_Periodontics-ProsthodonticsChapter-53_Periodontic-EndodonticsChapter-54_Periodontics-Restorative DentistryChapter-55_Periodontics-OrthodonticsChapter-56_Periodontics-Oral SurgeryChapter-57_Periodontics-PsychiatryChapter-58_Basic Aspects of ImplantsChapter-59_Surgical Aspects of ImplantsChapter-60_Advanced Implant SurgeryChapter-61_Peri-implantitisChapter-62_Recent AdvancementsChapter-63_Supportive Periodontal Therapy (Maintenance PhaseChapter-64_MiscellaneousAnnexuresIndexPrelimsChapter-01_GingivaChapter-02_Periodontal LigamentChapter-03_CementumChapter-04_Alveolar BoneChapter-05_Aging and PeriodontiumChapter-06_Classification of Periodontal DiseasesChapter-07_Epidemiology of Gingival and Periodontal DiseasesChapter-08_Periodontal MicrobiologyChapter-09_Dental PlaqueChapter-10_Dental Calculus and Other Contributing FactorsChapter-11_Immunity and InflammationChapter-12_Pathogenesis of Periodontal Diseases and Host ResChapter-13_Genetic Basis of Periodontal DiseasesChapter-14_Effect of Systemic Factors Over the PeriodontiumChapter-15_Effect of Periodontal Diseases on Systemic HealthChapter-16_Smoking and PeriodontiumChapter-17_Defense Mechanisms of GingivaChapter-18_Gingival InflammationChapter-19_Gingival EnlargementChapter-20_Acute Gingival ConditionsChapter-21_Soft and Hard Tissue Lesions with Periodontal RelChapter-22_Periodontal PocketChapter-23_Periodontal AbscessChapter-24_Bone DefectsChapter-25_Chronic PeriodontitisChapter-26_Aggressive PeriodontitisChapter-27_AIDS and PeriodontiumChapter-28_Trauma from Occlusion and Pathologic Tooth MigratChapter-29_Female Sex Hormones and PeriodontiumChapter-30_Clinical DiagnosisChapter-31_Radiographic Diagnostic AidsChapter-32_Microbiological and Immunological Diagnostic AidsChapter-33_HalitosisChapter-34_Dentin HypersensitivityChapter-35_PrognosisChapter-36_Treatment PlanChapter-37_Mechanical Plaque ControlChapter-38_Chemotherapeutic AgentsChapter-39_Host Modulatory TherapyChapter-40_Periodontal InstrumentsChapter-41_General Principles of InstrumentationChapter-42_SplintingChapter-43_General Principles of Periodontal SurgeryChapter-44_Gingival CurettageChapter-45_GingivectomyChapter-46_Periodontal FlapChapter-47_Resective Osseous SurgeryChapter-48_Regenerative Osseous SurgeryChapter-49_Furcation Involvement and ManagementChapter-50_Periodontal Plastic SurgeryChapter-51_Periodontal MicrosurgeryChapter-52_Periodontics-ProsthodonticsChapter-53_Periodontic-EndodonticsChapter-54_Periodontics-Restorative DentistryChapter-55_Periodontics-OrthodonticsChapter-56_Periodontics-Oral SurgeryChapter-57_Periodontics-PsychiatryChapter-58_Basic Aspects of ImplantsChapter-59_Surgical Aspects of ImplantsChapter-60_Advanced Implant SurgeryChapter-61_Peri-implantitisChapter-62_Recent AdvancementsChapter-63_Supportive Periodontal Therapy (Maintenance PhaseChapter-64_MiscellaneousAnnexuresIndexPrelimsChapter-01_GingivaChapter-02_Periodontal LigamentChapter-03_CementumChapter-04_Alveolar BoneChapter-05_Aging and PeriodontiumChapter-06_Classification of Periodontal DiseasesChapter-07_Epidemiology of Gingival and Periodontal DiseasesChapter-08_Periodontal MicrobiologyChapter-09_Dental PlaqueChapter-10_Dental Calculus and Other Contributing FactorsChapter-11_Immunity and InflammationChapter-12_Pathogenesis of Periodontal Diseases and Host ResChapter-13_Genetic Basis of Periodontal DiseasesChapter-14_Effect of Systemic Factors Over the PeriodontiumChapter-15_Effect of Periodontal Diseases on Systemic HealthChapter-16_Smoking and PeriodontiumChapter-17_Defense Mechanisms of GingivaChapter-18_Gingival InflammationChapter-19_Gingival EnlargementChapter-20_Acute Gingival ConditionsChapter-21_Soft and Hard Tissue Lesions with Periodontal RelChapter-22_Periodontal PocketChapter-23_Periodontal AbscessChapter-24_Bone DefectsChapter-25_Chronic PeriodontitisChapter-26_Aggressive PeriodontitisChapter-27_AIDS and PeriodontiumChapter-28_Trauma from Occlusion and Pathologic Tooth MigratChapter-29_Female Sex Hormones and PeriodontiumChapter-30_Clinical DiagnosisChapter-31_Radiographic Diagnostic AidsChapter-32_Microbiological and Immunological Diagnostic AidsChapter-33_HalitosisChapter-34_Dentin HypersensitivityChapter-35_PrognosisChapter-36_Treatment PlanChapter-37_Mechanical Plaque ControlChapter-38_Chemotherapeutic AgentsChapter-39_Host Modulatory TherapyChapter-40_Periodontal InstrumentsChapter-41_General Principles of InstrumentationChapter-42_SplintingChapter-43_General Principles of Periodontal SurgeryChapter-44_Gingival CurettageChapter-45_GingivectomyChapter-46_Periodontal FlapChapter-47_Resective Osseous SurgeryChapter-48_Regenerative Osseous SurgeryChapter-49_Furcation Involvement and ManagementChapter-50_Periodontal Plastic SurgeryChapter-51_Periodontal MicrosurgeryChapter-52_Periodontics-ProsthodonticsChapter-53_Periodontic-EndodonticsChapter-54_Periodontics-Restorative DentistryChapter-55_Periodontics-OrthodonticsChapter-56_Periodontics-Oral SurgeryChapter-57_Periodontics-PsychiatryChapter-58_Basic Aspects of ImplantsChapter-59_Surgical Aspects of ImplantsChapter-60_Advanced Implant SurgeryChapter-61_Peri-implantitisChapter-62_Recent AdvancementsChapter-63_Supportive Periodontal Therapy (Maintenance PhaseChapter-64_MiscellaneousAnnexuresIndexPrelimsChapter-01_GingivaChapter-02_Periodontal LigamentChapter-03_CementumChapter-04_Alveolar BoneChapter-05_Aging and PeriodontiumChapter-06_Classification of Periodontal DiseasesChapter-07_Epidemiology of Gingival and Periodontal DiseasesChapter-08_Periodontal MicrobiologyChapter-09_Dental PlaqueChapter-10_Dental Calculus and Other Contributing FactorsChapter-11_Immunity and InflammationChapter-12_Pathogenesis of Periodontal Diseases and Host ResChapter-13_Genetic Basis of Periodontal DiseasesChapter-14_Effect of Systemic Factors Over the PeriodontiumChapter-15_Effect of Periodontal Diseases on Systemic HealthChapter-16_Smoking and PeriodontiumChapter-17_Defense Mechanisms of GingivaChapter-18_Gingival InflammationChapter-19_Gingival EnlargementChapter-20_Acute Gingival ConditionsChapter-21_Soft and Hard Tissue Lesions with Periodontal RelChapter-22_Periodontal PocketChapter-23_Periodontal AbscessChapter-24_Bone DefectsChapter-25_Chronic PeriodontitisChapter-26_Aggressive PeriodontitisChapter-27_AIDS and PeriodontiumChapter-28_Trauma from Occlusion and Pathologic Tooth MigratChapter-29_Female Sex Hormones and PeriodontiumChapter-30_Clinical DiagnosisChapter-31_Radiographic Diagnostic AidsChapter-32_Microbiological and Immunological Diagnostic AidsChapter-33_HalitosisChapter-34_Dentin HypersensitivityChapter-35_PrognosisChapter-36_Treatment PlanChapter-37_Mechanical Plaque ControlChapter-38_Chemotherapeutic AgentsChapter-39_Host Modulatory TherapyChapter-40_Periodontal InstrumentsChapter-41_General Principles of InstrumentationChapter-42_SplintingChapter-43_General Principles of Periodontal SurgeryChapter-44_Gingival CurettageChapter-45_GingivectomyChapter-46_Periodontal FlapChapter-47_Resective Osseous SurgeryChapter-48_Regenerative Osseous SurgeryChapter-49_Furcation Involvement and ManagementChapter-50_Periodontal Plastic SurgeryChapter-51_Periodontal MicrosurgeryChapter-52_Periodontics-ProsthodonticsChapter-53_Periodontic-EndodonticsChapter-54_Periodontics-Restorative DentistryChapter-55_Periodontics-OrthodonticsChapter-56_Periodontics-Oral SurgeryChapter-57_Periodontics-PsychiatryChapter-58_Basic Aspects of ImplantsChapter-59_Surgical Aspects of ImplantsChapter-60_Advanced Implant SurgeryChapter-61_Peri-implantitisChapter-62_Recent AdvancementsChapter-63_Supportive Periodontal Therapy (Maintenance PhaseChapter-64_MiscellaneousAnnexuresIndex