4th Class Periodontology 2018/2019

Dr. Hadeel Mazin

Terms in periodontology

The term periodontium arises from the greek word “Peri”

meaning around and “odont” meaning tooth, thus it can be simply
defined as “the tissues investing and supporting the teeth”.

The periodontium is composed of the following tissues namely:

 Alveolar bone.
 Root cementum.

 Periodontal ligament (Supporting tissues).

 Gingiva (investing tissue).

The various diseases of the periodontium are collectively termed as

periodontal diseases.

Periodontal therapy: is the treatment of periodontal diseases.

Periodontology: the clinical science that deals with the periodontium in

health and disease.

Periodontics: is the branch of dentistry concerned with prevention and

treatment of periodontal disease.

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The Oral Mucosa

The oral mucosa consists of three zones:

1. Masticatory mucosa: it includes the gingiva and the covering of

the hard palate.

The boundaries are from the free gingival margin to the

mucogingival junction on the facial and lingual surfaces.

The mucogingival junction is a distinct line between the attached

gingiva apically and the alveolar mucosa.

No mucogingival junction on the palatal side because both

gingiva and alveolar mucosa are of the same type which is
masticatory mucosa.

The tissue is firmly attached to the underlying bone and covered

with keratinized epithelium to withstand the frictional forces of
food during mastication.

2. Specialized mucosa: it covers the dorsum of the tongue.

3. Lining mucosa: is the oral mucous membrane that lines the
reminder of the oral cavity. Examples for this type are the tissue
covering the lips, cheeks, floor of the mouth, inferior surface of
the tongue, soft palate and the alveolar mucosa.
Alveolar mucosa: is located apical to the attached gingiva and
extends into the vestibule of the mouth, it is darker red and
movable because it has no elastic fibers.

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Biology of the periodontal tissues

Introduction

Periodontium is the functional unit of tissues supporting the tooth

including gingiva, the periodontal ligament (PDL), the cementum and
the alveolar process.

The tooth and the periodontium are together called the

dentoperiodontal unit.

The main support of the tooth is provided by the periodontal

ligament, which connects the cementum of the root to the alveolar
bone or tooth socket into which the root fits.

The gingiva
Macroscopic features

It is that part of the oral mucosa (masticatory mucosa) that

covers the alveolar process of the jaws and surrounds the neck of the
teeth. The main function of the gingiva is to protect the surrounding
tissues from the oral environment.

Anatomically the gingiva is divided into:

1. Marginal gingiva (free or un-attached gingiva)

2. Attached gingiva
3. Interdental gingiva

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Diagram illustrating anatomic landmarks of the gingiva

Marginal gingiva (free or un-attached gingiva):

It is the terminal edge or border of the gingiva surrounding the

tooth in a collar-like fashion. It is well adapted to the tooth surface but
it is not attached to it. It is separated from the tooth by a fine space
called the gingival sulcus.

The marginal gingiva is separated from the attached gingiva by

the free gingival groove which is (a shallow linear depression on the
faciolingual surface that roughly corresponds to the base off the
gingival sulcus). The free gingival groove is about 1mm wide and it is
only present in about 30-40% of adults.

Gingival sulcus: is defined as the space or shallow crevice between the

tooth and the free gingiva, which extends apical to the junctional
epithelium.

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It is V-shaped and barely permits the entrance of periodontal

probe. Under ideal condition it is about 0mm which is seen only in
germ free animal. The probing depth of normal gingival sulcus is 2-
3mm. in histological section the depth is about 1.8mm.

Attached gingiva:

It is that part of the gingiva which is firm, resilient and tightly

bound to the cervical portion of the tooth and underlying periosteum
of the alveolar bone by the gingival fibers and the junctional
epithelium.

It is demarcated coronally from the free gingiva by the free

gingival groove, and extends apically to the mucogingival junction
where it becomes continuous with the alveolar mucosa. (the junction
between the attached gingiva and the alveolar mucosa is called the
mucogingival line or junction).

The width of attached gingiva is the distance between the

mucogingival junction and the projection of the external surface of
the bottom of the gingival sulcus or the periodontal pocket.

The width of attached gingiva is greater in maxilla than

mandible. Least width in the mandibular 1st premolar area and the
greatest width are in the maxillary incisors region. The width of
attached gingiva increases with age and supra-erupted teeth.

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Interdental gingiva:

It occupies the gingival embrasure. It is of two shapes (Col and

Pyramidal). Col is a valley-like depression that connects the facial and
lingual papilla. It is covered by thin non-keratinized epithelium
representing the most frequent site for initiation of disease process.

Col

The lateral border and tip of the Interdental papilla are formed by
continuation of marginal gingiva and the intervening portion by the
attached gingiva.

In the presence of diastema the Interdental papilla will be absent.

The shape of Interdental gingiva depends on

 The contact relationship between the teeth.

 The width of the proximal tooth surfaces
 The course of the cemento-enamel junction.

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Microscopic features

The gingiva consists of a central core of connective tissue

covered by stratified squamous epithelium.

Three types of epithelium exist in the gingiva:

1. The oral or outer epithelium (Keratinized epithelium)

2. The sulcular epithelium
3. The junctional epithelium (Non-keratinized epithelium).

The oral epithelium: it covers the crest and the outer surface of the
marginal and attached gingiva. On average, the oral epithelium is 0.2-
0.3 mm in thickness. It is keratinized or parakeratinized or
combination of both

Keratinization varies in different areas in the following order

 Palate (Most keratinized)

 Gingiva
 Ventral aspect of the tongue
 Cheek (least keratinized)

The boundary between the oral epithelium and the underlying

connective tissue has a wavy course. The projections of epithelial cells
into the connective tissue are known as “Rete Pegs” while the
intervening connective tissue portions which project into the
epithelium are called connective tissue papillae. This alternating
pattern of depression and protuberances of the connective tissue
papillae and epithelial rete pegs is thought to give the attached
gingiva the stippled appearance.
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The oral epithelium has the following cell layers:

1. Basal layer (stratum basale or stratum germintivum): the basal

cells are either cuboidal or cylindrical and posses the ability to
divide. It is called stratum germintivum because it is where the
epithelium renewed.
The basal cells are separated from the connective tissue by a
basement membrane.
2. Spinous layer (Stratum spinosum): consists of large cells with
short cytoplasmic processes resembling spines.
3. Granular layer (stratum granulosum): electron dense
keratohyalin bodies begin to occur. These granules are believed
to be related to synthesis of keratin.
4. Keratinized cell layer (stratum Corneum): This is the most
superficial layer and where both para and ortho-keratinization
occur.

Types of cells in the oral epithelium:

1. Keratinocytes cell: it is the principal cell type of oral epithelium

comprises about 90% of the total cell population, responsible for
the production of keratin which contributes to the protective
function of the epithelium. These cells undergo continuous
proliferation and differentiation from basal cell to the surface of
epithelium. It takes about 3-4 weeks for the keratinocyte to
reach the outer surface where it becomes desquamated from
stratum corneum.

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2. Melanocyte cells: responsible for the production of melanin

pigment and can be found in the basal cell layer.
3. Langerhans cell: they play a role in defense mechanism of the
oral epithelium. They have an immunological function by
recognizing and processing antigens.
4. Merkel cells: they are located in the deeper layers of epithelium,
they have nerve ending and have been identified as tactile
receptors.

The epithelial cells are joined together by structure known as

desmosome, which is composed of two hemidesmosomes separated
from each other by granulated material (GM)

Each hemidesmosome is composed from:

 The outer leaflets (OL): of cell membrane of two adjoining cells.

 The inner leaflet (IL): is the thicker leaflet of cell membrane.
 The attachment plaque (AP): which represent granular and
fibrillar material in the cytoplasm.

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The sulcular epithelium: It lines the gingival sulcus and is thin; non-
keratinized stratified squamous epithelium without rete pegs. It
extends from the coronal limit of the junctional epithelium to the crest
of the gingival margin. Although it contains Keratinocytes they do not
undergo Keratinization. Partial Keratinization may occur in response
to physical stimulation.
The sulcular epithelium is extremely important because it may act as a
semi permeable membrane through which injurious bacterial products
pass into the gingival and tissue fluid from the gingiva seeps into the
sulcus.
The junctional epithelium (JE): The epithelium that attaches the gingiva
to the surface of the tooth. It forms the base of the sulcus.

The junctional epithelium is attached to the tooth surface by

internal basal lamina and hemidesmosome and to the gingival
connective tissue by external basal lamina and hemidesmosome.

The attachment of the JE to the tooth is reinforced by the

gingival fibers; hence, the JE and the gingival fibers are considered a
functional unit, referred to as the dentogingival unit.

The JE consists of a collar like band of stratified squamous non

keratinized epithelium. Thickness varies from 2-3 Layers in early life
and increases with age up to 15-20 layers at the base of the gingival
sulcus. The length of junctional epithelium ranges from 0.25 to
1.35mm. The cells are arranged in basal and suprabasal layer.

The JE assumes a key role in maintenance of periodontal health,

it creates the firm epithelial attachment that connects the soft tissue
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to the tooth surface. It is quite permeable and thus serves as a

pathway for diffusion of the bacterial plaque products to the
connective tissue. There is also a diffusion of host defense substances
in the opposite direction moving towards the sulcus.

Differences between the three types of gingival epithelium:

 The size of the cells in the junctional epithelium is relatively

larger than the oral epithelium.
 The intercellular spaces are wider in the junctional epithelium
than the oral epithelium.
 The number of desmosome is fewer in the junctional epithelium
than the oral epithelium, this could explain the JE susceptibility
to tear during probing and its greater permeability to migrate
cells and fluids.
 No Keratinization,a no rete pegs in the sulcular and junctional
epithelium, so they are thinner than oral epithelium
 Turnover rate is very high in junctional epithelium (4-6 days)
compared to oral epithelium (6-12 days or up to 40 days).
 Junctional epithelium forms the attachment of the gingiva to the
tooth surface while oral and sulcular epithelium have no
attachment to tooth surface.

Epithelial connective tissue interface:

Basement membrane forms a continuous sheet that connects the

epithelium and connective tissue. Electron microscope reveals a faintly

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fibrillar structure, called as the basal lamina which is a part of the

basement membrane. This structure has

 Lamina lucida adjacent to the basal epithelial cell.

 Lamina densa which is located beneath the lamina lucida from
this structure and there are anchoring fibrils that project into the
connective tissue.

The gingival connective tissue (CT)

The connective tissue supporting the oral epithelium is termed

as lamina properia and can be divided into two layers:

 The superfacial papillary layer: This has papillary projections

between the epithelial rete pegs.
 The deep reticular layer: that lies between the papillary layer and
the underlying structures.

The lamina properia consists of cells, fibers, blood vessels embedded

in amorphous ground substances.

Cells of the connective tissue:

 Fibroblast: the most predominant cells of the CT (65%). They

synthesize collagen, elastic fibers and the connective tissue
matrix, and they regulate collegen degredation.
 Mast cells: it is responsible for the production of certain
components of the matrix, and they produces vasoactive
substances which may control the flow of blood through the
tissue.

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 Macrophages: They have a phagocytic action and involved in the

defense mechanism.
 Inflammatory cells: they have different immunological functions
such as polymorphonuclear leukocytes, lymphocytes and plasma
cells.

The connective tissue fibers: which are formed by the fibroblasts cells

 Collagen fibers: which is the most predominant type of fibers

 Reticulin fibers
 Oxytalan fibers
 Elastin fibers

The functions of gingival fibers:

1. It braces the marginal gingiva firmly against the tooth.

2. It helps to withstand the forces exerted by mastication
3. It unites the free gingiva to the root cementum and the adjacent
attached gingiva.

The arrangement of the gingival fibers is described as principal group

fibers which are:

1. Dentogingival fibers: they project from the cementum in a fan-

like conformation towards the crest and outer surface of the
marginal gingiva. They provide support to the gingiva by
attaching it to the tooth.
2. Alveolar gingival fibers: they extend from the periosteum of the
alveolar crest coronally into the lamina properia. Their function is
to attach the gingiva to the alveolar bone.
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3. Dentoperiosteal fibers: they arise from the cementum near the

cementoenamel junction and insert into the periosteum of the
alveolar bone and protect the periodontal ligament.
4. Circular fibers: they surround the tooth in a cuff or ring like
fashion and course through the connective tissue of the
marginal and attached gingiva.
5. Trans-septal fibers: they are located interproximally, they extend
from cementum of one tooth to the cementum of neighbouring
tooth. They protect the interproximal bone and maintain tooth
to tooth contact.

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Connective tissue ground substances:

It is produced by fibroblast, followed by mast cells and other

components derived from the blood. The matrix is the medium in
which the connective tissue cells are embedded and is essential for
the maintenance of the normal function of the connective tissue.
Thus, the transportation of water, electrolytes, nutrients, metabolites
etc.. to and from the individual connective tissue cells occurs within
the matrix.

The main constituents are proteoglycans and glycoproteins.

Blood supply and nerves:

Gingival tissue has rich vascular supply from internal maxillary artery.

Blood supply is from:

 Supraperiosteal arteriols.
 Vessels of periodontal ligaments.
 Arterioles emerging from the crest of the Interdental septa.

Nerve supply is derived from the terminal branches of the maxillary

and mandibular branches of the trigeminal nerve.

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Clinical descriptive criteria of clinically healthy gingiva and

inflamed one:

1. Gingival color:

The normal color of gingiva is coral pink with some variations

depending on:

 The amount of melanin in the tissues.

 The thickness of the epithelium.

 The degree of the Keratinization.
 The vascularity of the connective tissue.

Dark skinned people often exhibit dark blue or brown color. Melanin,
a non-hemoglobin-derived brown pigment, is responsible for the
normal pigmentation of the skin, gingiva and remainder of the oral

mucous membrane. It is present in all normal individuals, often not in

sufficient quantities to be detected clinically but in black individuals it
is prominent in the oral cavity.

The color of inflamed gingiva may vary from red to bluish red
due to vasodilatation which leads to bleeding tendency.

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2. Gingival contour.

The gingiva usually ends coronally in knife edged margins and

scalloped in contour. In inflamed gingiva, the contours are often
rounded and enlarged because of vascular stagnation and increases
formation of collagen fibers.

3. Gingival consistency.

The gingiva is usually resilient, firm and bound down to the

underlying bone because of the dense collagenous nature of the
gingival connective tissue.

In inflamed gingiva, the consistency may be soft and spongy

because of the vascular stagnation and decrease in the amount of
gingival collagen fibers or extremely firm because of excessive

formation of collagen (fibrosis), this is in case of chronic

inflammation.

4. Gingival surface texture:

Gingiva may have either stippled or smooth and shiny surface,

the attached gingiva is stippled, while the free gingiva is smooth. In
inflamed gingiva, reduction or lack of stippling is not an indicator of
health nor is the absence of stippling an indicator of disease .Hence,
stippling frequently begins to disappear in old age.

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5. Size:
The size of the gingiva corresponds with the sum total of the bulk of
cellular and intercellular elements and their vascular supply.
Alteration in size is a common feature of gingival disease.

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