Gingiva

• Marginal gingiva: Unattached coronal portion
• Attached gingiva: Firmly bound to bone
• Interdental papilla: Fills embrasure space

Periodontal Ligament

• Connects tooth to alveolar bone
• Contains fibers (Sharpey's fibers)
• Provides shock absorption

Alveolar Bone

• Cortical plates
• Trabecular bone
• Alveolar process proper

Cementum

• Avascular mineralized tissue
• Attaches PDL fibers
• Continuous deposition

Primary Etiologic Factors

• Dental plaque biofilm:
  • Gram-negative anaerobic bacteria
  • Porphyromonas gingivalis
  • Aggregatibacter actinomycetemcomitans
  • Tannerella forsythia
  • Treponema denticola
• Calculus:
  • Mineralized plaque
  • Provides biofilm retention

Host Response

• Inflammatory cascade
• Cytokine release (IL-1β, TNF-α, PGE2)
• Matrix metalloproteinases (MMPs)
• Connective tissue destruction
• Alveolar bone resorption

Modifiable Factors

• Smoking:
  • Vasoconstriction
  • Impaired healing
  • Altered microbiota
• Diabetes:
  • Increased inflammation
  • Impaired neutrophil function
  • Advanced glycation end-products
• Stress:
  • Cortisol effects
  • Behavioral changes

Non-Modifiable Factors

• Genetics:
  • IL-1 gene polymorphisms
  • Familial aggregation
• Age:
  • Cumulative effects
• Gender:
  • Hormonal influences

Other Factors

• Medications (phenytoin, CCBs)
• Nutritional deficiencies
• Occlusal trauma
• Immunosuppression

Clinical Examination

• Probing depths:
  • 6 sites per tooth
  • Williams probe
• Clinical attachment level:
  • CEJ to base of pocket
• Bleeding on probing:
  • 30 sec after probing
• Mobility:
  • Miller classification

Radiographic Assessment

• Horizontal bone loss
• Vertical defects
• Furcation involvement
• Crown-to-root ratio

Advanced Diagnostics

• Microbial testing
• Genetic testing
• Cone-beam CT

Scaling and Root Planing

• Goals:
  • Remove calculus
  • Remove bacterial toxins
  • Smooth root surfaces
• Instruments:
  • Ultrasonic scalers
  • Curettes (Gracey, universal)
• Technique:
  • Systematic approach
  • Light pressure
  • Multiple strokes

Adjunctive Therapies

• Local antimicrobials:
  • Chlorhexidine chips
  • Doxycycline gel
  • Minocycline microspheres
• Systemic antibiotics:
  • Amoxicillin + metronidazole
  • Doxycycline
• Host modulation:
  • Subantimicrobial doxycycline
  • NSAIDs
  • Bisphosphonates

Gingival Augmentation

• Free gingival graft:
  • Palatal donor site
  • Increases keratinized tissue
• Connective tissue graft:
  • Subepithelial palatal tissue
  • Root coverage procedures

Root Coverage

• Coronally advanced flap
• Lateral sliding flap
• Tunnel technique
• Pouch procedure

Frenectomy

• Remove/reposition frenum
• Prevent recession
• Improve orthodontic results

Vestibular Extension

• Increase attached gingiva
• Improve prosthesis fit

Types of Lasers

• Diode:
  • Soft tissue procedures
  • Bacterial reduction
• Nd:YAG:
  • Pocket therapy
  • Hemostasis
• Er:YAG:
  • Hard and soft tissue
  • Calculus removal
• CO₂:
  • Soft tissue surgery
  • Vaporization

Applications

• LANAP:
  • Laser-assisted new attachment procedure
• Decontamination:
  • Pocket disinfection
• Biostimulation:
  • Low-level laser therapy
  • Promotes healing

Advantages

• Minimal bleeding
• Reduced postoperative pain
• Selective calculus ablation

Recall Intervals

• Health/gingivitis:
  • 6-12 months
• Periodontitis:
  • 3-4 months
• High-risk patients:
  • 2-3 months

Components

• Re-evaluation
• Reinforcement of oral hygiene
• Scaling/root planing
• Polishing
• Topical fluoride
• Radiographs as needed

Monitoring

• Probing depths:
  • Compare to baseline
• Bleeding on probing:
  • Indicator of inflammation
• Plaque control:
  • Plaque indices
• Radiographic changes

Peri-Implant Mucositis

• Reversible inflammation
• Bleeding on probing
• No bone loss
• Plaque-induced

Peri-Implantitis

• Inflammation + bone loss
• Probing depths >5mm
• Suppuration
• Progressive if untreated

Risk Factors

• History of periodontitis
• Poor plaque control
• Smoking
• Diabetes
• Excess cement
• Occlusal overload

Treatment

• Mechanical debridement
• Antimicrobial therapy
• Surface decontamination
• Regenerative/resective surgery

Cardiovascular Disease

• 1.5-2x increased risk
• Inflammation → atherosclerosis
• Bacteremia → endocarditis

Diabetes

• Bidirectional relationship
• Severity ↑ with poor glycemic control
• Treatment improves HbA1c

Adverse Pregnancy Outcomes

• Preterm low birth weight
• Preeclampsia
• Mechanisms:
  • Inflammatory mediators
  • Bacterial dissemination

Respiratory Diseases

• Aspiration of pathogens
• COPD exacerbation
• Pneumonia

Other Conditions

• Rheumatoid arthritis
• Chronic kidney disease
• Alzheimer's disease
• Cancer (oral, pancreatic)

Clinical Implications

• Medical history review
• Interdisciplinary care
• Patient education

Biologic Agents

• Growth factors:
  • PDGF
  • IGF
  • FGF
• Cytokine modulation:
  • IL-1 antagonists
  • TNF inhibitors
• Stem cell therapy:
  • Periodontal ligament stem cells
  • Bone marrow mesenchymal cells

Novel Materials

• 3D scaffolds:
  • Guided tissue regeneration
• Smart biomaterials:
  • Controlled drug release
• Gene-activated matrices

Diagnostic Advances

• Salivary biomarkers
• Microbial profiling
• AI-based risk assessment