Concepts about the etiology, pathogenesis, and treatment of the periodontal infection have changed significantly over the years. New levels ot understanding are reflected in the periodontal disease classification systems for these diseases and conditions.

The two most recent widely accepted classification systems of the periodontal infection and conditions were developed in 1989 and 1999. The current system, more comprehensive than any of its predecessors, is admittedly still a work in progress.

Periodontal infection
Periodontal infection

How Has the Understanding of Periodontal Diseases Changed Over the Years?

For many years, the periodontal infection were thought of as degenerative diseases. Early confirmation of the role of bacterial plaque in the initiation and progression of gingivitis was only presented in the 1 960s. Since that time, many of the earlier tenets have fallen by the wayside.

Currently, it is clear that both gingivitis and periodontal infection in their varied forms are caused by the accumulation of a bacterial plaque biofilms on the teeth and in the subgingival area, the host response to that accumulation, and the various systemic and local factors that may affect the host response.

It is also clear that only a relatively few bacteria are associated with inflammatory periodontal infection. The exact role of these bacteria, their relationship with each other and their interaction with the immune system in the initiation and progression of disease is still not clearly understood.

There also appears to be a genetic component to the initiation and progression of periodontal infection in some patients. At this juncture, controlling the accumulation of plaque is the first line of defense in preventing disease, no matter what other factors may be present.

What Are Some of the Distinguishing Characteristics of Some of the Other Periodontal Diseases and Conditions?

Necrotizing periodontal diseases. This category includes both necrotizing ulcerative gingivitis (NUG) and necrotizing ulcerative periodontitis (NUP). NUG and NUP have been classified together as they may be different stages of the same periodontal infection.

NUG is characterized by necrosis of the tips of the interdental papilla with a pseudomembrane appearance, pain, foul odor, spontaneous bleeding, and possible fever and lymphadenopathy. There is no attachment loss associated with NUG. Fusiforms and spirochetes, as well as Prevotelia intermedia, have been implicated in the etiology of NUG.

Significant contributing factors include stress, fatigue, poor oral hygiene, smoking, and poor nutrition, basically factors associated with immunosuppression. NUG and NUP are also associated with HIV infection. NUP shares many of the clinical characteristics of NUG along with attachment loss.

Abscesses of the periodontium. Periodontal abscesses are local periodontal infection of the gingival or periodontal tissues. The etiology may be a foreign object such as a popcorn hull or loose piece of calculus. This type of abscess is marked by localized swelling and tenderness or pain.

As the marginal gingiva begins to heal with treatment, the orifice to deeper drainage of infection may be closed off. It may be drained either externally or through the wall of the periodontal infection pocket.

Periodontitis associated with endodontic lesions. Endodontic and periodontal lesions may coexist separately associated with the same tooth or may communicate with each other. Two separate lesions may coalesce or there may be a root fracture or root perforation.

Occasionally, an isolated endodontic lesion may masquerade as a periodontal lesion, such as in an isolated furcation defect on a mandibular first molar. In this case, proper endodontic therapy will heal the furcation lesion as well. In a true combined lesion, the endodontic therapy must be performed first in order for the eventual periodontal infection therapy to succeed as well.