carranza's clinical periodontology

2308 Pages·2014·21.76 MB·English

CARRANZA’S
CLINICAL
PERIODONTOLOGY

TENTH EDITION
MICHAEL G. NEWMAN, DDS
Adjunct Professor, Section of Periodontics University of California Los Angeles—School of
Dentistry Los Angeles, California
HENRY H. TAKEI, DDS, MS
Clinical Professor, Section of Periodontics University of California, Los Angeles—School of
Dentistry Los Angeles, California
PERRY R. KLOKKEVOLD, DDS, MS
Associate Professor, Section of Periodontics University of California, Los Angeles—School of
Dentistry Los Angeles, California
EDITOR EMERITUS
FERMIN A. CARRANZA, DR ODONT
Professor Emeritus, Section of Periodontics University of California, Los Angeles—School of
Dentistry Los Angeles, California

1-4160-2400-X
SAUNDERS ELSEVIER
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CARRANZA’S CLINICAL PERIODONTOLOGY ISBN 13 978-1-4160-2400-2
Tenth Edition ISBN 10 1-4160-2400-X
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NOTICE
Periodontology is an ever-changing field. Standard safety precautions must be followed, but
as new research and clinical experience broaden our knowledge, changes in treatment and
drug therapy may become necessary or appropriate. Readers are advised to check the most
current product information provided by the manufacturer of each drug to be administered to
verify the recommended dose, the method and duration of administration, and
contraindications. It is the responsibility of the licensed health care provider, relying on
experience and knowledge of the patient, to determine dosages and the best treatment for
each individual patient. Neither the publisher nor the editors assume any liability for any
injury and/or damage to persons or property arising from this publication.
The Publisher
International Standard Book Number 1-4160-2400-X
Publishing Director: Linda Duncan
Executive Editor: John Dolan
Developmental Editors: Jaime Pendill and John Dedeke
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Book Designer: Julia Dummitt
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Front
Matter

PART
1

 Evidence­Based
Decision
Making

Jane L. Forrest and Philippe P. Hujoel
The principles of evidence-based methodologies provide a systematic framework for relying on
scientific evidence in conjunction with clinical experience and judgment to answer questions and stay
current with innovations in dentistry.
Learning and mastering the critical thinking skills associated with evidence-based methodologies is a
key component in translating the discoveries of basic and clinical research found in this book into the
realities of practice.
The three chapters in Part 1 provide an introduction to evidence-based decision making. Perspectives
on the determination of clinical significance and examples of how to integrate the knowledge into
practice are presented.
CHAPTER
1

 Introduction
to
Evidence‐Based
Decision
Making

CHAPTER
2

 Assessing
Evidence

CHAPTER
3

 Implementing
Evidence‐Based
Decisions
in
Clinical

Practice

PART
2

 The
Normal
Periodontium

Michael G. Newman
The periodontium consists of the investing and supporting tissues of the tooth: gingiva, periodontal
ligament, cementum, and alveolar bone. It has been divided into two parts: the gingiva, the main
function of which is protecting the underlying tissues, and the attachment apparatus, composed of the
periodontal ligament, cementum, and alveolar bone. The cementum is considered a part of the
periodontium because, with the bone, it serves as the support for the fibers of the periodontal
ligament.
The periodontium is subject to morphologic and functional variations as well as changes associated
with age. This section deals with the normal features of the tissues of the periodontium, since this
knowledge is necessary for an understanding of periodontal disease.
The soft and hard tissues surrounding dental implants have many similar features and some important
differences with the periodontal tissues, as discussed in Chapter 73.
CHAPTER
4

 The
Gingiva

CHAPTER
5

 The
Tooth‐Supporting
Structures

CHAPTER
6

 Aging
and
the
Periodontium

PART
3

 Classification
and
Epidemiology
of
Periodontal

Diseases
Michael G. Newman
Periodontal disease classifications are useful to help establish diagnosis, determine prognosis, and
facilitate treatment planning. Different classifications of periodonta l diseases have been used over the
years and have been replaced as new knowledge has improved our understanding of the etiology and
pathology of the diseases of the periodontium, as discussed in Chapter 7
Also, as covered in Chapter 8, Part 3 includes information about the epidemiology of periodontal
diseases that will help the student and clinician analyze a disease and base their diagnostic and
therapeutic decisions on its prevalence, incidence, and distribution in large populations or groups.
Knowledge of the epidemiology of a disease improves our understanding and sharpens our decisions
in individual cases.
CHAPTER
7

 Classification
of
Diseases
and
Conditions
Affecting
the

Periodontium

CHAPTER
8

 Epidemiology
of
Gingival
and
Periodontal
Diseases

PART
4

 Etiology
of
Periodontal
Diseases

William V. Giannobile
As many as 600 different species of bacteria that colonize the oral cavity can affect the delicate
balance of host-bacterial interactions leading to health or disease. Periodontal infection is initiated by
specific invasive oral pathogens that colonize dental plaque biofilms on the tooth root surface. Local
and systemic factors can also modulate an individual′s susceptibility to periodontitis. This chronic
challenge of virulent microorganisms leads to destruction of tooth-supporting soft and hard tissues of
the periodontium, including alveolar bone, tooth root cementum, and periodontal ligament (PDL).
Although periodontitis is initiated by the subgingival microbiota, it is generally accepted that
mediators of connective tissue breakdown are generated to a large extent by the host′s response to the
pathogenic infection. In a susceptible host, microbial virulence factors trigger the release of host-
derived enzymes and proinflammatory cytokines that can lead to periodontal tissue destruction. The
implications of periodontal microbiota-associated byproducts such as endotoxin on induction of the
innate immune response, toll-like receptor (TLR) signaling, generation of pathogen-associated
molecular patterns (PAMPs), and their role in periodontal disease pathogenesis are crucial to the
extent of disease severity.
Elevated levels of tissue-destructive enzymes such as collagenases and other host-derived
proinflammatory cytokines initiated by periodontal pathogens have been detected in inflamed gingiva
and in oral fluids such as gingival crevicular fluid and saliva. In addition to antimicrobials
traditionally used to manage bacterial infections in periodontitis, alternative adjunctive approaches to
manage the disease target the blockade of host response modifiers such as inhibitors of proteases or
proinflammatory cytokines such as tumor necrosis factor alpha and interleukin-1 beta.
The role of host genes in the etiology and pathogenesis of the periodontal diseases is critically
important to the determination of patient risk for periodontal tissue breakdown. Genetic tests may
prove useful for identifying patients who are most likely to develop disease, suffer from recurrent
disease, or experience tooth loss as a result of disease. Given the complex etiology of the periodontal
diseases, it is likely that any genetic test will be useful in only a subset of patients or populations.
Knowledge of specific genetic risk factors or inflammatory biomarkers could enable clinicians to
direct environmentally based prevention and treatments to individuals who are most susceptible to
disease.
Furthermore, associations between periodontal infection and systemic diseases such as cardiovascular
disease, osteoporosis, or other diseases highlight the view that periodontitis represents a polygenic
disease with multiple etiologies with interactions with other chronic inflammatory illnesses.
CHAPTER
9

 Microbiology
of
Periodontal
Diseases

CHAPTER
10

 The
Role
of
Dental
Calculus
and
Other
Predisposing

Factors

CHAPTER
11

 Genetic
Factors
Associated
with
Periodontal
Disease

CHAPTER
12

 Immunity
and
Inflammation:
Basic
Concepts

CHAPTER
13

 Microbial
Interactions
with
the
Host
in
Periodontal

Diseases

CHAPTER
14

 Smoking
and
Periodontal
Disease

CHAPTER
15

 Molecular
Biology
of
the
Host‐Microbe
Interaction
in

Periodontal
Diseases:
Selected
Topics:
Molecular
Signaling
Aspects
of

Pathogen‐Mediated
Bone
Destruction
in
Periodontal
Diseases

CHAPTER
16

 Host
Modulation

PART
5

 Relationship
between
Periodontal
Disease
and

Systemic
Health

Perry R. Klokkevold
An interrelationship between periodontal disease and systemic health has been suspected for centuries,
but evidence to explain the connection has only been elucidated in the past few decades.
Inflammation is the primary pathologic feature of periodontal disease, and bacterial plaque is the
essential etiologic factor responsible for inducing the host inflammatory process. However, it is host
susceptibility and ability of the host defense to respond appropriately to the bacterial challenge that
results in differences in the severity of periodontal disease from one individual to another. Thus,
individual susceptibility to periodontitis is influenced by a number of factors, including systemic
diseases and conditions. Conversely, recent evidence indicates that the presence of chronic
inflammatory periodontal disease may significantly affect systemic health conditions such as coronary
heart disease, stroke, or adverse pregnancy outcomes.
Consequently, the relationship between periodontal disease and systemic health is a two-way road,
with systemic host factors acting locally to reduce resistance to periodontal destruction and the local
bacterial challenge generating widespread effects with the potential to induce adverse systemic
outcomes. This part describes the influence of systemic disease and conditions on the periodontium
and the role of inflammatory periodontal disease on systemic conditions. The relationship of oral
malodor to oral, periodontal, and systemic disease is also described.
CHAPTER
17

 Influence
of
Systemic
Disorders
and
Stress
on
the

Periodontium

CHAPTER
18

 Periodontal
Medicine:
Impact
of
Periodontal
Infection

on
Systemic
Health

CHAPTER
19

 Oral
Malodor

PART
6

 Periodontal
Pathology

Thorough knowledge of the microscopic tissue changes in disease is essential to comprehend the
biologic nature of the periodontal responses to injury and healing. This knowledge also provides an
indispensable basis for the understanding and interpretation of the clinical and radiographic findings
encountered in dental patients.
This part of the text provides information of the gingival diseases (Section I) and periodontal diseases
(Section II). The latter section also includes chapters with detailed descriptions of the different
diseases that can affect the periodontium.
SECTION I Gingival Disease
CHAPTER
20

 Defense
Mechanisms
of
the
Gingiva

CHAPTER
21

 Gingival
Inflammation

CHAPTER
22

 Clinical
Features
of
Gingivitis

CHAPTER
23

 Gingival
Enlargement

CHAPTER
24

 Acute
Gingival
Infections

CHAPTER
25

 Gingival
Diseases
in
Childhood

CHAPTER
26

 Desquamative
Gingivitis
SECTION II Periodontal Disease
CHAPTER
27

 The
Periodontal
Pocket

CHAPTER
28

 Bone
Loss
and
Patterns
of
Bone
Destruction

CHAPTER
29

 Periodontal
Response
to
External
Forces

CHAPTER
30

 Masticatory
System
Disorders

CHAPTER
31

 Chronic
Periodontitis

CHAPTER
32

 Necrotizing
Ulcerative
Periodontitis

CHAPTER
33

 Aggressive
Periodontitis

CHAPTER
34

 Pathology
and
Management
of
Periodontal
Problems

in
Patients
with
HIV
Infection

PART
7

 Treatment
of
Periodontal
Disease

Henry H. Takei
Periodontal treatment requires an interrelationship between the care of the periodontium and other
phases of dentistry. The concept of total treatment is based on the elimination of gingival
inflammation and the factors that lead to it (e.g., plaque accumulation favored by calculus and pocket
formation, inadequate restorations, areas of food impaction).
Total treatment requires consideration of systemic aspects, including the possibility of interaction of
periodontal disease with other diseases, systemic adjuncts to local treatment, and special precautions
in patient management necessitated by systemic conditions. It may also entail consideration of
functional aspects for the establishment of optimal occlusal relationships for the entire dentition.
All these aspects are embodied in a master plan, which consists of a rational sequence of dental
procedures that includes periodontal and other measures necessary to create a well-functioning
dentition in a healthy periodontal environment.
SECTION I Diagnosis, Prognosis, and Treatment Plan
Henry H. Takei
CHAPTER
35

 Clinical
Diagnosis
CHAPTER
36

 Radiographic
Aids
in
the
Diagnosis
of
Periodontal

Disease

CHAPTER
37

 Advanced
Diagnostic
Techniques

CHAPTER
38

 Risk
Assessment

CHAPTER
39

 Levels
of
Clinical
Significance

CHAPTER
40

 Determination
of
Prognosis

CHAPTER
41

 The
Treatment
Plan

CHAPTER
42

 Rationale
for
Periodontal
Treatment

CHAPTER
43

 Periodontal
Therapy
in
the
Female
Patient

CHAPTER
44

 Periodontal
Treatment
of
Medically
Compromised

Patients

CHAPTER
45

 Periodontal
Treatment
for
Older
Adults

CHAPTER
46

 Treatment
of
Aggressive
and
Atypical
Forms
of

Periodontitis

SECTION II Treatment of Periodontal Emergencies
Henry H. Takei
CHAPTER
47

 Treatment
of
Acute
Gingival
Disease

CHAPTER
48

 Treatment
of
Periodontal
Abscess

SECTION III Nonsurgical Therapy
Henry H.Takei
CHAPTER
49

 Phase
I
Periodontal
Therapy

CHAPTER
50

 Plaque
Control
for
the
Periodontal
Patient
CHAPTER
51

 Scaling
and
Root
Planing

CHAPTER
52

 Chemotherapeutic
Agents

CHAPTER
53

 Host
Modulation
Agents

CHAPTER
54

 Sonic
and
Ultrasonic
Instrumentation

CHAPTER
55

 Supragingival
and
Subgingival
Irrigation

CHAPTER
56

 Occlusal
Evaluation
and
Therapy

CHAPTER
57

 Adjunctive
Role
of
Orthodontic
Therapy

CHAPTER
58

 The
Periodontic‐Endodontic
Continuum

SECTION IV Surgical Therapy
Henry H. Takei
CHAPTER
59

 Phase
II
Periodontal
Therapy

CHAPTER
60

 General
Principles
of
Periodontal
Surgery

CHAPTER
61

 Surgical
Anatomy
of
the
Periodontium
and
Related

Structures

CHAPTER
62

 Gingival
Surgical
Techniques

CHAPTER
63

 Treatment
of
Gingival
Enlargement

CHAPTER
64

 The
Periodontal
Flap

CHAPTER
65

 The
Flap
Technique
for
Pocket
Therapy

CHAPTER
66

 Resective
Osseous
Surgery

CHAPTER
67

 Reconstructive
Periodontal
Surgery

CHAPTER
68

 Furcation:
Involvement
and
Treatment