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Newman and Carranza's Clinical Periodontology E-Book

Newman and Carranza's Clinical Periodontology E-Book

Michael G. Newman | Henry Takei | Perry R. Klokkevold | Fermin A. Carranza


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Book Details


From basic science and fundamental procedures to the latest advanced techniques in reconstructive, esthetic, and implant therapy, Newman and Carranza's Clinical Periodontology, 13th Edition is the resource you can count on to help master the most current information and techniques in periodontology. Full color photos, illustrations, and radiographs show you how to perform periodontal procedures, while renowned experts from across the globe explain the evidence supporting each treatment and lend their knowledge on how to best manage the outcomes.

  • UNIQUE! Periodontal Pathology Atlas contains the most comprehensive collection of cases found anywhere.
  • Full-color photos and anatomical drawings clearly demonstrate core concepts and reinforce important principles.
  • UNIQUE! Chapter opener boxes in the print book alert readers when more comprehensive coverage of topics is available in the online version of the text.
  • NEW! Chapters updated to meet the current exam requirements for the essentials in periodontal education.
  • NEW! Case-based clinical scenarios incorporated throughout the book mimic the new patient case format used in credentialing exams.
  • NEW! Additional tables, boxes, and graphics highlight need-to-know information.
  • NEW! Two new chapters cover periimplantitis and resolving inflammation.
  • NEW! Section on evidence-based practice consists of two chapters covering evidence-based decision making and critical thinking.

Table of Contents

Section Title Page Action Price
Front Cover cover
Inside Front Cover ifc1
Newman and Carranza's Clinical Periodontology i
Copyright Page iv
Editors v
Contributors vi
About the Book xiii
About The Authors xiv
Michael G. Newman, DDS, FACD xiv
Henry H. Takei, DDS, MS, FACD xiv
Perry R. Klokkevold, DDS, MS, FACD xv
Fermin A. Carranza, DR ODONT, FACD xv
Preface xvi
Acknowledgments xvii
Table Of Contents xix
Video Contents xxiii
Introduction: The Historical Background of Periodontology e.i
Chapter Outline e.i
Early Civilizations e.i
The Classical World e.i
The Middle Ages e.i
The Renaissance e.i
The Eighteenth Century e.iii
The Nineteenth Century e.iii
Necrotizing Ulcerative Gingivitis e.v
The Twentieth Century e.v
Vienna e.v
Berlin e.v
The United States and Other Countries
Focal Infection
Dental Implants
After World War II e.vii
The History of This Book e.viii
References e.viii
1 Evidence-Based Practice 1
1 Evidence-Based Decision Making 1
Abstract 1.e1
Key Words 1.e1
Chapter Outline 1
Background and Definition 1
Principles of Evidence-Based Decision Making 1
Evidence-Based Dentistry 2
Evidence-Based Decision-Making Process and Skills 2
Asking Good Questions: The PICO Process 2
Becoming a Competent Consumer of the Evidence 3
Sources of Evidence 5
Levels of Evidence 6
Searching for and Acquiring the Evidence 7
Appraising the Evidence 7
Common Ways Used to Report Results 8
Applying the Evidence: Evidence-Based Dentistry in Action 8
Evaluating the Outcomes 8
Conclusion 8
References 9
References 9.e1
2 Critical Thinking 10
Abstract 10.e1
Keywords 10.e1
Chapter Outline 10
Twelve Tools for Assessing Evidence 10
Be Skeptical 10
Do Not Trust Biologic Plausibility 11
What Level of Controlled Evidence Is Available? 11
Did the Cause Precede the Effect? 12
No Betting on the Horse After the Race Is Over 12
What Is a Clinically Relevant Pretrial Hypothesis? 13
Clinically Relevant Endpoint 13
Common and Relevant Comparisons 13
Representative Study Sample 13
Small Type I and Type II Error Rates 13
Size Does Matter 13
Is a Better Alternative Explanation Available? 15
Was the Study Properly Randomized? 16
When to Rely on Nonrandomized Evidence 17
Did the Investigators Take Into Account the Placebo or Nocebo Effects? 17
Was Protection in Place Against Conflict of Interest? 18
Conclusion 18
References 18
References 18.e1
2 Biologic Basis of Periodontology 19
I Normal Periodontium 19
3 Anatomy, Structure, and Function of the Periodontium 19
Abstract 19.e1
Key Words 19.e1
Chapter Outline 19
Oral Mucosa 19
Gingiva 19
Clinical Features 19
Marginal Gingiva 19
Gingival Sulcus 19
Attached Gingiva 20
Interdental Gingiva 20
Microscopic Features 21
Gingival Epithelium 21
General Aspects of Gingival Epithelium Biology 21
Structural and Metabolic Characteristics of Different Areas of Gingival Epithelium 24
Oral (Outer) Epithelium 24
Sulcular Epithelium 25
Junctional Epithelium 25
Development of Gingival Sulcus 26
Renewal of Gingival Epithelium 27
Cuticular Structures on the Tooth 27
Gingival Fluid (Sulcular Fluid) 27
Gingival Connective Tissue 27
Gingival Fibers 27
Cellular Elements 28
Repair of Gingival Connective Tissue 28
Blood Supply, Lymphatics, and Nerves 29
Correlation of Clinical and Microscopic Features 30
Color 30
Physiologic Pigmentation (Melanin) 30
Size 31
Contour 31
Shape 31
Consistency 31
Surface Texture 31
Position 32
Continuous Tooth Eruption 32
Periodontal Ligament 32
Periodontal Fibers 33
Cellular Elements 35
Ground Substance 35
Functions of Periodontal Ligament 36
Physical Functions 36
Resistance to Impact of Occlusal Forces (Shock Absorption) 36
Transmission of Occlusal Forces to Bone 36
Formative and Remodeling Function 36
Nutritional and Sensory Functions 37
Regulation of Periodontal Ligament Width 38
Cementum 38
Permeability of Cementum 39
Cementoenamel Junction 39
Cementodentinal Junction 39
Thickness of Cementum 39
Cementum Resorption and Repair 39
Ankylosis 41
Exposure of Cementum to the Oral Environment 41
Alveolar Process 41
Cells and Intercellular Matrix 43
Socket Wall 43
Bone Marrow 44
Periosteum and Endosteum 44
Interdental Septum 44
Osseous Topography 44
Fenestration and Dehiscence 45
Remodeling of Alveolar Bone 45
Development of the Attachment Apparatus 46
Cementum 46
Periodontal Ligament 46
Alveolar Bone 47
Physiologic Migration of the Teeth 47
External Forces and the Periodontium 47
Vascularization of the Supporting Structures 48
References 49
References 49.e1
4 Aging and the Periodontium 50
Abstract 50.e1
Key Words 50.e1
Chapter Outline 50
Effects of Aging on the Periodontium 50
Gingival Epithelium 50
Gingival Connective Tissue 52
Periodontal Ligament 52
Cementum 52
Alveolar Bone 52
Bacterial Plaque 52
Immune and Inflammatory Responses 53
Effects of Aging on the Progression of Periodontal Diseases 53
Aging and the Response to Treatment of the Periodontium 54
References 54
References 54.e2
II Classification and Epidemiology of Periodontal Diseases 55
5 Classification of Diseases and Conditions Affecting the Periodontium 55
Abstract 55.e1
Keywords 55.e1
Chapter Outline 55
Gingival Diseases 55
Dental Plaque–Induced Gingival Diseases 55
Gingivitis Associated With Dental Plaque Only 57
Gingival Diseases Modified by Systemic Factors 58
Gingival Diseases Modified by Medications 58
Gingival Diseases Modified by Malnutrition 59
Non–Plaque-Induced Gingival Lesions 59
Gingival Diseases of Specific Bacterial Origin 59
Gingival Diseases of Viral Origin 60
Gingival Diseases of Fungal Origin 60
Gingival Diseases of Genetic Origin 61
Gingival Manifestations of Systemic Conditions 61
Traumatic Lesions 61
Foreign-Body Reactions 61
Periodontitis 62
Chronic Periodontitis 65
Aggressive Periodontitis 65
Periodontitis as a Manifestation of Systemic Disease 68
Medication-Related Osteonecrosis of the Jaw 71
Necrotizing Periodontal Diseases 73
Necrotizing Ulcerative Gingivitis 73
Necrotizing Ulcerative Periodontitis 73
Abscesses of the Periodontium 74
Periodontitis Associated With Endodontic Lesions 74
Endodontic–Periodontal Lesions 74
Periodontal–Endodontic Lesions 75
Combined Lesions 75
Developmental or Acquired Deformities and Conditions 75
Localized Tooth-Related Factors That Modify or Predispose Individuals to Plaque-Induced Gingival Diseases or Periodontitis 75
Tooth Anatomic Factors 75
Dental Restorations and Appliances 75
Root Fractures 76
Cervical Root Resorption and Cemental Tears 76
Mucogingival Deformities and Conditions Around the Teeth 77
Mucogingival Deformities and Conditions of the Edentulous Ridges 77
Occlusal Trauma 77
References 79
References 79.e6
6 Fundamentals in the Methods of Periodontal Disease Epidemiology 80
Abstract 80.e1
Keywords 80.e1
Chapter Outline 80
The Need for Epidemiology 80
Measuring the Occurrence of Conditions or Diseases 81
Periodontal Measures Typically Recorded Clinically 82
Translating Periodontal Measures Into Traditional Epidemiologic Measures of Disease Occurrence 83
True and Surrogate Measures of the Periodontal Condition 83
Challenges of Obtaining Epidemiologic Measures of Periodontal Conditions and Diseases 83
Epidemiologic Study Designs 84
Randomized Controlled Trials 84
Cohort Studies 85
Case–Control Studies 85
Causes 85
Suspected Modifiable Causative Factors for Periodontal Disease 86
Tobacco Smoking 86
Nutrition 86
Dental Plaque 86
The Cause of Periodontal Disease for the Patient Sitting in Your Chair 86
Diagnosis 87
Periodontal Conditions Versus Periodontal Diseases 87
Diagnostic Tests Available to Assess Periodontal Conditions 87
Translating Periodontal Diagnostic Test Results Into Periodontal Disease Diagnosis 87
Normative or Arbitrary Values to Diagnose Periodontal Disease 87
Risk-Based Reference Values to Diagnose Periodontal Disease 87
Therapeutic Reference Values to Diagnose Periodontal Disease 87
Periodontal Disease Diagnoses 87
References 88
References 88.e1
III Etiology of Periodontal Disease 89
7 Periodontal Disease Pathogenesis 89
Abstract 89.e1
Keywords 89.e1
Chapter Outline 89
Histopathology of Periodontal Disease 90
Clinically Healthy Gingival Tissues 90
Histopathology of Gingivitis and Periodontitis 91
The Initial Lesion 92
The Early Lesion 92
The Established Lesion 92
The Advanced Lesion 93
Inflammatory Responses in the Periodontium 94
Microbial Virulence Factors 94
Lipopolysaccharide 94
Bacterial Enzymes and Noxious Products 94
Microbial Invasion 94
Fimbriae 95
Bacterial Deoxyribonucleic Acid and Extracellular Deoxyribonucleic Acid 95
Host-Derived Inflammatory Mediators 96
Cytokines 96
Prostaglandins 96
Matrix Metalloproteinases 96
Role of Specific Inflammatory Mediators in Periodontal Disease 97
Interleukin-1 Family Cytokines 97
Other Interleukin-1 Family Cytokines 98
Tumor Necrosis Factor Alpha 98
Interleukin-6 and Related Cytokines 99
Prostaglandin E2 99
Matrix Metalloproteinases 99
Chemokines 100
Antiinflammatory Cytokines 100
Linking Pathogenesis to Clinical Signs of Disease 100
Alveolar Bone Resorption 101
Receptor Activator of Nuclear Factor-κB Ligand and Osteoprotegerin 102
Resolution of Inflammation 102
Lipoxins 102
Resolvins and Protectins 102
Immune Responses in Periodontal Pathogenesis 103
Innate Immunity 103
Saliva 103
Epithelial Tissues 104
Gingival Crevicular Fluid 105
Pathogen Recognition and Activation of Cellular Innate Responses 105
Neutrophil Function 105
Adaptive Immunity 106
Antigen-Presenting Cells 106
T Cells 106
Antibodies 109
Concept of Host Susceptibility 109
References 111
References 111.e2
8 Biofilm and Periodontal Microbiology 112
Abstract 112.e1
Keywords 112.e1
Chapter Outline 112
The Oral Cavity From a Microbe’s Perspective 112
Bacteria and Their Biofilm Mode of Living 117
Structure of a Mature Dental Plaque Biofilm 119
Accumulation of a Dental Plaque Biofilm 122
Formation of the Pellicle 123
Initial Adhesion/Attachment of Bacteria 124
Phase 1: Transport to the Surface 124.e1
Phase 2: Initial Adhesion 124.e1
Phase 3: Strong Attachment 124.e1
Colonization and Plaque Maturation 124
Factors That Affect Supragingival Dental Plaque Formation 126
Topography of Supragingival Plaque 126
Surface Microroughness 127
Individual Variables That Influence Plaque Formation 127
Variation Within the Dentition 128
Impact of Gingival Inflammation and Saliva 128
Impact of Patient’s Age 128
Spontaneous Tooth Cleaning 129
De Novo Subgingival Plaque Formation 129
Characteristics of Biofilm Bacteria (Life in “Slime City”) 129
Metabolism of Dental Plaque Bacteria 129
Communication Between Biofilm Bacteria 130
Interactions Among Dental Plaque Bacteria 130
Biofilms and Antimicrobial Resistance 131
Bacterial Transmission and Translocation 131
Nonbacterial Inhabitants of the Oral Cavity 133
Viruses 133
Herpesviruses 133.e1
Papillomaviruses 133.e1
Picornaviruses/Enteroviruses 133.e1
Retroviruses 133.e1
Clinical Manifestations of Oral Viral Diseases 133
Oral Ulcers 133
Oral Tumors 133
Other Oral Pathologies 133
Periodontitis 135
Fungi 136
Protozoa 136
Archaea 137
Microbiologic Specificity of Periodontal Diseases 137
Nonspecific Plaque Hypothesis 137
Specific Plaque Hypothesis 138
Ecologic Plaque Hypothesis 138
Keystone Pathogen Hypothesis and Polymicrobial Synergy and Dysbiosis Model 139
Complicating Factors 139
Criteria for the Identification of Periodontopathogens 140.e1
The Transition From Health to Disease 140
Host Susceptibility 141
Pathogenic Bacteria 142
Beneficial Species 143
Periodontal Health 143
Gingivitis 145
Chronic Periodontitis 146
Localized Aggressive Periodontitis 146
Aggressive Periodontitis 147
Necrotizing Periodontal Diseases 147
Abscesses of the Periodontium 147
Peri-implantitis 147
Virulence Factors of Periodontopathogens 148
Adhesive Surface Proteins and Fibrils 149
Tissue Destruction–Promoting Factors 149
Strategies for Evading Host Immunity 149
Future Advances in Periodontal Microbiology 150
References 150
References 150.e4
9 Practical Molecular Biology of Host–Microbe Interactions 151
Abstract 151.e1
Keywords 151.e1
Chapter Outline 151
Microbe-Associated Molecular Patterns 151
Toll-Like Receptors 153
Toll-like Receptor-4–Lipopolysaccharide Recognition 154
Toll-like Receptor-2–Lipoprotein/Lipoteichoic Acid/Peptidoglycan Recognition 154
Toll-like Receptor-9–CpG-DNA Recognition 154
Role of Toll-like Receptors in Periodontitis 154
Nucleotide-Binding Oligomerization Domain–Like Receptors 155
NOD1/NOD2–Peptidoglycan Recognition 155
NLRP3–Inflammasome Complex 155
Role of NOD-like Receptors in Periodontitis 155
Complement System 156
Complement–Pattern-Recognition Receptor Signaling 156
Classical/Lectin/Alternative Pathways 156
Role of Complement in Periodontitis 156
Antimicrobial Peptides 157
Defensins and Cathelicidin LL-37 157
Role of Antimicrobial Peptides in Periodontitis 158
Immunomodulatory Therapies 158
References 158
References 158.e1
10 Resolution of Inflammation 159
Abstract 159.e1
Keywords 159.e1
Chapter Outline 159
Inflammation 159
Acute Inflammation Is Self-Limited 160
Specialized Lipid Mediators 160
Lipoxins 161
Resolvins 161
Protectins 162
Maresins 162
Unresolved Chronic Inflammation in Periodontal Diseases 162
Systemic Link 163.e1
Type 2 Diabetes 163.e1
Cardiovascular Diseases 163.e1
Cancer 163.e2
Pregnancy Outcomes 163.e2
Therapeutic Actions of Resolution Mediators 163
Final Remarks 163
References 165
References 165.e2
11 Precision Dentistry 166
Chapter Outline 166
Genomic Advances in the 21st Century 167
Patterns in Populations and Pedigrees 167
Searching for Answers in the DNA 170
Genetic Basis for Individual Differences in Disease Risk 172
Periodontitis in Genetic Syndromes and Other Diseases 173
Nonsyndromic Aggressive and Chronic Periodontitis 173
Challenges and Opportunities for the Future 177
Precision Dentistry: Using Genetics for Personalized Treatment 179
Pharmacogenomics and Individualized Dentistry 179
Acknowledgments 180
References 180
References 180.e2
12 Smoking and Periodontal Disease 181
Abstract 181.e1
Keywords 181.e1
Chapter Outline 181
The Smoking Epidemic 181
Effects of Smoking on the Prevalence and Severity of Periodontal Diseases 182
Gingivitis 182
Periodontitis 182
Effects of Smoking on the Etiology and Pathogenesis of Periodontal Disease 184
Microbiology 184
Immune–Inflammatory Responses 186
Physiology 186
Effects of Smoking on the Response to Periodontal Therapy 187
Nonsurgical Therapy 187
Surgical Therapy and Implants 187
Maintenance Therapy 188
Effects of Smoking Cessation on Periodontal Treatment Outcomes 188
References 189
References 189.e3
13 The Role of Dental Calculus and Other Local Predisposing Factors 190
Abstract 190.e1
Keywords 190.e1
Chapter Outline 190
Calculus 190
Supragingival and Subgingival Calculus 190
Prevalence 190
Composition 191
Inorganic Content 191
Organic Content 192
Attachment to the Tooth Surface 192
Formation 192
Theories Regarding the Mineralization of Calculus 194
Role of Microorganisms in the Mineralization of Calculus 194
Etiologic Significance 194
Materia Alba, Food Debris, and Dental Stains 195
Other Predisposing Factors 195
Iatrogenic Factors 195
Margins of Restorations 196
Retained Cement and Periimplantitis 197
Contours and Open Contacts 198
Materials 199
Design of Removable Partial Dentures 199
Restorative Dentistry Procedures 199
Malocclusion 199
Periodontal Complications Associated With Orthodontic Therapy 200
Plaque Retention and Composition 200
Gingival Trauma and Alveolar Bone Height 200
Tissue Response to Orthodontic Forces 201
Extraction of Impacted Third Molars 202
Habits and Self-Inflicted Injuries 203
Trauma Associated With Oral Jewelry 203
Toothbrush Trauma 203
Chemical Irritation 204
Smokeless Tobacco 204
Radiation Therapy 206
References 207
References 207.e2
IV Relationship between Periodontal Disease and Systemic Heath 208
14 Influence of Systemic Conditions 208
Abstract 208.e1
Keywords 208.e1
Chapter Outline 208
Endocrine Disorders and Hormonal Changes 208
Diabetes Mellitus 208
Oral Manifestations 209
Bacterial Pathogens 210
Polymorphonuclear Leukocyte Function 211
Altered Collagen Metabolism 211
Metabolic Syndrome 212
Female Sex Hormones 212
Puberty 212.e1
Menstruation 212.e1
Pregnancy 212.e1
Hormonal Contraceptives 212.e2
Menopause 212.e2
Hyperparathyroidism 212.e2
Hematologic Disorders and Immune Deficiencies 213
Leukocyte (Neutrophil) Disorders 213
Neutropenia 213
Agranulocytosis 213
Leukemia 214
The Periodontium in Leukemic Patients 214
Leukemic Infiltration 214
Bleeding 216
Oral Ulceration and Infection 216
Anemia 218.e1
Thrombocytopenia 218.e1
Antibody Deficiency Disorders 218.e2
Genetic Disorders 218
Chédiak–Higashi Syndrome 218.e2
Lazy Leukocyte Syndrome 218.e2
Leukocyte Adhesion Deficiency 218.e2
Papillon–Lefèvre Syndrome 218.e2
Down Syndrome 218.e3
Stress and Psychosomatic Disorders 218
Psychosocial Stress, Depression, and Coping 218
Stress-Induced Immunosuppression 219
Influence of Stress on Periodontal Therapy Outcomes 219
Psychiatric Influence of Self-Inflicted Injury 219
Nutritional Influences 219
Fat-Soluble Vitamin Deficiency 220.e1
Vitamin A Deficiency 220.e1
Vitamin D Deficiency 220.e1
Vitamin E Deficiency 220.e1
Water-Soluble Vitamin Deficiency 220.e1
B-Complex Deficiency 220.e1
Vitamin C Deficiency 220.e2
Possible Etiologic Factors 220.e2
Epidemiologic Studies 220.e2
Gingivitis 220.e2
Periodontitis 220.e2
Summary 220.e3
Protein Deficiency 220.e3
Medications 220
Bisphosphonates 220
Bisphosphonates and Periodontal Bone Loss 223
Corticosteroids 223
Other Systemic Conditions 224.e1
Osteoporosis 224.e1
Congenital Heart Disease 224.e2
Tetralogy of Fallot 224.e2
Eisenmenger Syndrome 224.e2
Hypophosphatasia 224.e2
Metal Intoxication 224.e3
Bismuth Intoxication 224.e3
Lead Intoxication 224.e3
Mercury Intoxication 224.e3
Other Chemicals 224.e3
Conclusion 224
References 224
References 224.e5
15 Impact of Periodontal Infection on Systemic Health 225
Chapter Outline 225
Pathobiology of Periodontitis 225
Focal Infection Theory Revisited 226
Evidence-Based Clinical Practice 226
Subgingival Environment as a Reservoir for Bacteria 228
Periodontal Disease and Mortality 228
Periodontal Disease, Coronary Heart Disease, and Atherosclerosis 228
Effects of Periodontal Infection 229
Ischemic Heart Disease 229
Systemic Infections 230
Daily Activity 230
Thrombogenesis 230
Atherosclerosis 231
Role of Periodontal Disease in Atherosclerotic Myocardial or Cerebral Ischemia 231
Role of Periodontal Disease in Erectile Dysfunction 233
Periodontal Disease and Stroke 233
Periodontal Infection Associated With Stroke 233
Periodontal Disease and Diabetes Mellitus 233
Periodontal Infection Associated With Glycemic Control in Diabetes 234
Periodontal Disease and Pregnancy Outcome 235.e1
Bacterial Vaginosis 235.e1
Role of Periodontitis 235.e2
Periodontal Disease and Chronic Obstructive Pulmonary Disease 235.e3
Periodontal Disease and Acute Respiratory Infections 235.e4
Periodontal Disease and Asthma 235
Periodontal Medicine in Clinical Practice 235
Periodontal Disease and Systemic Health 235
Patient Education 235
Conclusions 236
References 236
References 236.e3
V Gingival Pathology 237
16 Defense Mechanisms of the Gingiva 237
Abstract 237.e1
Keywords 237.e1
Chapter Outline 237
Sulcular Fluid 237
Methods of Collection 237
Permeability of Junctional and Sulcular Epithelia 237
Amount 238
Composition 238
Cellular Elements 239
Electrolytes 239
Organic Compounds 239
Cellular and Humoral Activity in Gingival Crevicular Fluid 239
Clinical Significance 239
Circadian Periodicity 239
Sex Hormones 239
Mechanical Stimulation 239
Smoking 239
Periodontal Therapy 239
Drugs in Gingival Crevicular Fluid 239
Leukocytes in the Dentogingival Area 240
Saliva 240
Antibacterial Factors 241
Salivary Antibodies 241
Enzymes 241
Salivary Buffers and Coagulation Factors 241
Leukocytes 241
Role in Periodontal Pathology 242
References 242
References 242.e2
17 Gingival Inflammation 243
Abstract 243.e1
Keywords 243.e1
Chapter Outline 243
Stage I Gingival Inflammation: The Initial Lesion 243
Stage II Gingival Inflammation: The Early Lesion 244
Stage III Gingival Inflammation: The Established Lesion 244
Stage IV Gingival Inflammation: The Advanced Lesion 247
References 247
References 247.e1
18 Clinical Features of Gingivitis 248
Keywords 248.e1
Chapter Outline 248
Course and Duration 248
Description 248
Clinical Findings 249
Gingival Bleeding on Probing 249
Gingival Bleeding Caused by Local Factors 250
Chronic and Recurrent Bleeding 250
Gingival Bleeding Associated With Systemic Changes 251
Color Changes in the Gingiva 251
Color Changes With Gingivitis 251
Metallic Pigmentation 252
Color Changes Associated With Systemic Factors 252
Changes in Gingival Consistency 252
Calcified Masses in the Gingiva 252
Toothbrushing 253
Changes in Gingival Surface Texture 253
Changes in Gingival Position 253
Traumatic Lesions 253
Gingival Recession 254
Positions of the Gingiva 254
Clinical Significance 255
Changes in Gingival Contour 255
References 255
References 255.e3
19 Gingival Enlargement 256
Abstract 256.e1
Keywords 256.e1
Chapter Outline 256
Terminology and Classification 256
Diagnosis 257
Types of Gingival Enlargement 257
Inflammatory Enlargement of Gingiva Due to Gingivitis 257
Clinical Manifestations 257
Etiology 257
Histopathology 258
Treatment 259
Drug-Induced Overgrowth of Gingiva 259
Anticonvulsants 260
Calcium Channel Blockers 260
Immunosuppressants 260
Histopathology 260
Pathogenesis of Drug-Induced Gingival Overgrowth 260
Treatment 261
Gingival Overgrowth Associated With Systemic Conditions 262
Pregnancy-Associated Gingival Overgrowth 262
Clinical Manifestations 262
Etiology 262
3 Clinical Periodontics 374
I Diagnosis, Prognosis, and Treatment Plan 374
31 Levels of Clinical Significance 374
Abstract 374.e1
Keywords 374.e1
Chapter Outline 374
Tangible Versus Intangible Benefits 374
Size of the Treatment Effect 375
Defining Four Levels of Clinical Significance 375
Clinical Significance Level 1 375
Clinical Significance Level 2 376
Clinical Significance Level 3 376
Clinical Significance Level 4 377
Summary 377
References 377
References 377.e1
32 Periodontal Examination and Diagnosis 378
Abstract 378.e1
Keywords 378.e1
Chapter Outline 378
Overall Appraisal of the Patient 378
Health History 378
Dental History 381
Chief Complaint and Current Illness 381
Photographic Documentation 381
Clinical Examination 381
Examination of Extraoral Structures 381
Examination of the Oral Cavity 382
Examination of the Periodontium 382
Visual Periodontal Examination 383
Visual Examination of Biofilm and Calculus 383
Visual Examination of the Gingiva 383
Gingival Recession 384
Tactile Periodontal Examination 385
Tactile Examination of the Marginal Gingiva 385
Marginal Bleeding 386
Suppuration 386
Tactile Examination of the Gingival Crevice 387
Probing Around Implants 387
When Not to Probe 387
Probing Depth 387
Automatic and Electronic Periodontal Probing 388.e1
Probing Force 388.e1
Probe Angulation 388.e1
Bleeding on Probing 388
Pain on Probing 389
Attachment Loss 389
Attachment Level 389
Attached Gingiva 389
Periodontal Charting 390.e1
Use of Clinical Indices in Dental Practice 390.e1
Periodontal Pockets 390.e1
Signs and Symptoms 390.e1
Detection of Periodontal Pockets 390.e1
Determination of Disease Activity 390.e1
Alveolar Bone Loss 390.e1
Furcation Invasion 390.e1
Periodontal Abscess 390.e3
Periodontal Abscess and Gingival Abscess 390.e3
Periodontal Abscess and Periapical Abscess 390.e3
Examination of the Teeth and Implants 390
Wasting Disease of the Teeth 390
Dental Stains 391
Hypersensitivity 391
Proximal Contact Relations 391
Tooth Mobility 391
Trauma From Occlusion 392
Pathologic Migration of the Teeth 392
Sensitivity to Percussion 392
Dentition With the Jaws Closed 392
Functional Occlusal Relationships 393
Radiographic Examination 393
Laboratory Aids to Clinical Diagnosis 393
Periodontal Diagnosis 393
Assessment of Biofilm Control and Patient Education 396
Conclusion 396
References 396
References 396.e2
33 Radiographic Aids in the Diagnosis of Periodontal Disease 397
Abstract 397.e1
Keywords 397.e1
Chapter Outline 397
Normal Interdental Bone 397
Radiographic Techniques 397
Bone Destruction in Periodontal Disease 398
Bone Loss 399
Amount 399
Distribution 399
Pattern of Bone Destruction 399
Radiographic Appearance of Periodontal Disease 402
Periodontitis 402
Interdental Craters 402
Furcation Involvement 403
Periodontal Abscess 403
Clinical Probing 404
Localized Aggressive Periodontitis 405
Trauma From Occlusion 405
Digital Intraoral Radiography 406
Advanced Imaging Modalities 406
Conclusion 408
References 409
References 409.e3
34 Clinical Risk Assessment 410
Abstract 410.e1
Keywords 410.e1
Chapter Outline 410
Definitions 410
Risk Factors for Periodontal Disease 410
Tobacco Smoking 410
Diabetes 410
Pathogenic Bacteria and Microbial Tooth Deposits 410
Risk Determinants/Background Characteristics for Periodontal Disease 411
Genetic Factors 411
Age 411
Gender 411
Socioeconomic Status 412
Stress 412
Risk Indicators for Periodontal Disease 412.e1
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome 412.e1
Osteoporosis 412.e1
Infrequent Dental Visits 412.e1
Risk Markers/Predictors for Periodontal Disease 412.e1
Previous History of Periodontal Disease 412.e1
Bleeding on Probing 412.e1
Clinical Risk Assessment for Periodontal Disease 412.e1
Conclusion 412
References 412
References 412.e4
35 Determination of Prognosis 413
Abstract 413.e1
Keywords 413.e1
Chapter Outline 413
Definitions 413
Types of Prognosis 413
Overall Versus Individual Tooth Prognosis 414
Factors in Determination of Prognosis 414
Overall Clinical Factors 414
Patient Age 414
Disease Severity 414
Biofilm Control 417
Patient Compliance and Cooperation 418
Systemic and Environmental Factors 418
Smoking 418
Systemic Disease or Condition 418
Genetic Factors 418
Stress 418
Local Factors 418
Biofilm and Calculus 418
Subgingival Restorations 419
Anatomic Factors 419
Tooth Mobility 419
Caries, Tooth Vitality, and Root Resorption 419
Prosthetic and Restorative Factors 419
Prognosis of Specific Periodontal Diseases 421
Prognosis for Patients With Gingival Disease 422
Biofilm-Induced Gingival Diseases 422
Gingivitis Associated With Dental Plaque Only 422
Biofilm-Induced Gingival Diseases Modified by Systemic Factors 422
Biofilm-Induced Gingival Diseases Modified by Medications 422
Gingival Diseases Modified by Malnutrition 423
Non–Biofilm-Induced Gingival Lesions 423
Prognosis for Patients With Periodontitis 423
Chronic Periodontitis 423
Aggressive Periodontitis 423
Periodontitis as a Manifestation of Systemic Diseases 423
Necrotizing Periodontal Disease 424
Determination and Reassessment of Prognosis 424
Conclusion 425
References 425
References 425.e1
36 The Treatment Plan 426
Abstract 426.e1
Keywords 426.e1
Chapter Outline 426
Overall Treatment Plan 427
Extracting or Preserving a Tooth 427
Sequence of Therapy 427
Explaining the Treatment Plan to the Patient 427
Conclusion 429
37 Electronic Dental Records and Decision Support Systems e1
Abstract e1.e1
Keywords e1.e1
Chapter Outline e1
Functionalities and Components Available in Electronic Dental Records e1
Patient Registration e1
Periodontal Chart e1
Electronic Dental Record Use in Dental Practices e1
Commonly Used Electronic Dental Records e3
Barriers to Using Electronic Dental Records e3
Limited Functionality for Communication and Collaboration e4
Suboptimal Usability and Steep Learning Curve e4
Insufficient Reliability of Electronic Dental Records and Infection Control Issues e4
Challenges to Realizing the Full Potential of Electronic Dental Records e4
Standards for the Information Content of Electronic Dental Records e4
Data Representation and Interoperability e4
Benefits of Using Electronic Dental Records e4
Reusing Electronic Dental Records Data for Research Purposes e4
Clinical Decision Support Systems e4
Decision Support System Types e4
Risk-Based Decision Support Systems for Periodontal Disease e5
Barriers to the Adoption of Clinical Decision Support Systems e5
Factors That Improve the Adoption of Clinical Decision Support Systems e5
Future of Electronic Dental Records and Decision Support Systems in Dentistry e5
References e5
II Management of Patients with Special Needs 431
38 Conscious Sedation 431
Abstract 431.e1
Keywords 431.e1
Chapter Outline 431
Rationale for Sedation During Periodontal and Implant Surgical Procedures 431
American Dental Association Policy Statement and Guidelines for Conscious Sedation 431
4 Oral Implantology 732
I Biology, Diagnosis, Biomechanics, and Treatment Plan 732
74 Peri-implant Anatomy, Biology, and Function 732
Abstract 732.e1
Key Words 732.e1
Chapter Outline 732
Implant Geometry (Macrodesign) 732
Blade Implants 733.e1
Pins 733.e1
Disk Implants 733.e1
Root Form (Cylindrical) Implants 733.e1
Transmandibular Implants 733.e2
Subperiosteal Implants 733.e2
Implant Surface Characteristics (Microdesign) 733.e2
Additive Processes 733.e3
Subtractive Processes 733.e4
Implant Surface Chemical Composition 733.e4
Implant Surface Free Energy and Microscopic Roughness 733.e6
Hard Tissue Interface 733
Initial Bone Healing 733
Bone Remodeling and Function 734
Soft Tissue Interface 735
Epithelium 735
Connective Tissue 735
Keratinized Tissue 736
Vascular Supply and Inflammation 738
Clinical Comparison of Teeth and Implants 739
Conclusion 740
References 740
References 740.e2
75 Clinical Evaluation of the Implant Patient 741
Abstract 741.e1
Keywords 741.e1
Chapter Outline 741
Case Types and Indications 741
Edentulous Patients 741
Partially Edentulous Patients 742
Multiple Teeth 742
Single Tooth 744
Aesthetic Considerations 744
Pretreatment Evaluation 744
Chief Complaint 745
Medical History 745
Dental History 746
Intraoral Examination 746
Diagnostic Study Models 746
Hard Tissue Evaluation 746
Radiographic Examination 749
Soft Tissue Evaluation 749
Risk Factors and Contraindications 749
Medical and Systemic Health–Related Issues 749
Diabetes Mellitus 749
Bone Metabolic Disease 750
Bisphosphonate Therapy 750
Immune Compromise and Immune Suppression 751
Radiation Therapy 751
Psychological and Mental Conditions 751
Habits and Behavioral Considerations 751
Smoking and Tobacco Use 751
Parafunctional Habits 751
Substance Abuse 751
Posttreatment Evaluation 751
Conclusion 752
References 752
References 752.e2
76 Diagnostic Imaging for the Implant Patient 753
Abstract 753.e1
Key Words 753.e1
Chapter Outline 753
Standard Projections 753
Periapical Radiographs 753
Occlusal Radiographs 753
Panoramic Radiographs 754
Cross-Sectional Imaging 755
Cone-Beam Computed Tomography 755
Multislice Computed Tomography 755
Interactive “Simulation” Software Programs 757
Patient Evaluation 757
Exclude Pathology 762
Identify Anatomic Structures 762
Assess Bone Quantity, Quality, and Volume 762
Evaluate Relation of Alveolar Ridge With Existing Teeth and Desired Implant Position 764
Clinical Selection of Diagnostic Imaging 764
Clinical Examination 764
Screening Radiographs 766
Fabrication of Radiographic and Surgical Guides 766
Cross-Sectional Imaging 766
Intraoperative and Postoperative Radiographic Assessment 766
Conclusion 768
References 768
References 768.e3
77 Prosthetic Considerations for Implant Treatment 769
Abstract 769.e1
Keywords 769.e1
Chapter Outline 769
Implant Considerations 769
Understanding the Anticipated Load on the System and Its Relation to Implant Diameter 769
Number of Implants 770
Implant-Abutment Connection 770
Abutment/Prosthesis Considerations for Single Units 774
Retention Method for Partially Edentulous Treatment: Cemented Prostheses, Screw-Retained Porcelain-Fused-to-Metal Options, Screw-Retained Full Contour Zirconia, and Hybrid Designs 774
Abutment Material Selection 777
Abutment Design and Emergence Profile 779
Covering the Screw Access 780.e1
Splinting Adjacent Implants 780
Management of Partially Edentulous Implant Treatment in the Aesthetic Zone 781
Diagnosis and Treatment Planning 781
Implant-Retained Provisional Restorations 782.e1
Tissue Shaping and Management 782
Customized Impression Copings 783.e1
Fully Edentulous: Prosthetic Considerations 783.e1
Edentulous Maxilla 783.e1
Edentulous Mandible 783.e4
Conclusion 783
References 783
References 783.e8
II Surgical Procedures 784
78 Basic Implant Surgical Procedures 784
Abstract 784.e1
Keywords 784.e1
Chapter Outline 784
General Principles of Implant Surgery 784
Patient Preparation 784
Implant Site Preparation 784
One-Stage Versus Two-Stage Implant Placement Surgery 784
Two-Stage “Submerged” Implant Placement 785
Flap Design, Incisions, and Elevation 786
Implant Site Preparation 788
Round Bur 788
The 2-mm Twist Drill 788
Pilot Drill 788
The 3-mm Twist Drill 788
Countersink Drill (Optional) 789
Bone Tap (Optional) 789
Implant Placement 789
Flap Closure and Suturing 789
Postoperative Care 790
Second-Stage Exposure Surgery 790
Simple Circular “Punch” or Crestal Incision 790
Partial-Thickness Repositioned Flap 790
Postoperative Care 792
One-Stage “Nonsubmerged” Implant Placement 792
Flap Design, Incisions, and Elevation 792
Implant Site Preparation 792
Flap Closure and Suturing 793
Postoperative Care 793
Conclusion 793
References 793
References 793.e2
79 Localized Bone Augmentation and Implant Site Development 794
Abstract 794.e1
Keywords 794.e1
Chapter Outline 794
Guided Bone Regeneration 794.e2
Barrier Membranes 794.e2
Nonresorbable Barrier Membranes 794.e2
Resorbable Barrier Membranes 794.e3
Bone Graft Materials 794.e3
Autogenous Bone 794.e3
Localized Ridge Augmentation 794
Flap Management 794
Horizontal Bone Augmentation 795
Particulate Bone Graft 795
Monocortical Block Graft 795
Procedure 797
Simultaneous Implant Placement 797
Complications 799
Alveolar Ridge Preservation/Management of Extractions 802
Delayed Implant Placement 802
Staged Implant Placement 803
Delayed Versus Staged Technique 803
Immediate Implant Placement 803
Conclusion 805
References 805
References 805.e2
80 Advanced Implant Surgical Procedures 806
Abstract 806.e1
Key Words 806.e1
Chapter Outline 806
Maxillary Sinus Elevation and Bone Augmentation 806
Indications and Contraindications 806
Surgical Procedures for Sinus Elevation 807
Presurgical Evaluation of Maxillary Sinus 807
Simultaneous Implant Placement 807
Bone Graft Materials 808
Crestal Osteotomy Technique 808
Procedure 808
Lateral Window Technique 809
Risks and Complications 812
Supracrestal/Vertical Bone Augmentation 813
Guided Bone Regeneration 813
Distraction Osteogenesis 815.e1
Growth Factors in Bone Augmentation 815.e1
Bone Morphogenetic Proteins 815.e1
Autologous Platelet Concentration 815.e1
Conclusion 815
References 816
References 816.e2
81 Aesthetic Management of Difficult Cases (Minimally Invasive Approach) 817
Abstract 817.e1
Keywords 817.e1
Chapter Outline 817
Surgical Strategy for Predictable Aesthetics 818
Determine the Level of Surgical Aesthetic Goal 818.e1
Visualize the Final Outcome 818.e1
Preserve Existing Tissues Important for Aesthetics 818.e1
Always Overbuild Bone and Soft Tissue in Augmentation Surgery 818.e1
Immediate Implant Placement for Predictability and Aesthetics 818
Surgical Management of Difficult Cases (Minimally Invasive Approach) 820
Components of Aesthetic Examination 820
Case Presentation 1 820
Patient Dental History and Chief Complaint 820
Examination and Diagnosis 820
Treatment Objectives 820
Treatment Options 820
Surgical Strategy for Predictable Aesthetics 821
Treatment Plan and Rationale 822
Treatment Sequence 822
Surgical Procedure 822
Results 822
Case Presentation 2 823.e1
Dental History and Chief Complaint 823.e1
Examination and Diagnosis 823.e1
Treatment Objectives 823.e1
Treatment Options 823.e1
Surgical Strategy for Predictable Aesthetics 823.e2
Treatment Plan and Rationale 823.e3
Treatment Sequence 823.e3
Surgical Procedure 823.e3
Results 823.e4
Case Presentation 3 823.e4
Dental History and Chief Complaint 823.e4
Examination and Diagnosis 823.e4
Treatment Objectives 823.e6
Treatment Options 823.e6
Treatment Plan and Rationale 823.e6
Treatment Sequence 823.e6
Surgical Procedure 823.e6
Results 823.e6
Conclusion 823
References 823
References 823.e8
82 Dental Implant Microsurgery 824
Abstract 824.e1
Key Words 824.e1
Chapter Outline 824
Implant Microsurgery 824
Microsurgical Tooth Extraction 824
Implant Drilling in the Extraction Site 824
Bone Grafting 825
Buccal Gingival Grafting 826
Immediate Provisional Fabrication 826
Immediate Implant Occlusion 827
Custom Impression Transfer Coping 827
Final Implant Restoration 828
Conclusion 829
References 829
References 829.e1
83 Piezoelectric Bone Surgery 830
Abstract 830.e1
Key Words 830.e1
Chapter Outline 830
Clinical Characteristics of Ultrasonic Cutting 831
Microprecision 831
Selective Cutting 831
Maximum Visibility 832
Excellent Healing 833
Improved Hard Tissue Healing 833
Improved Soft Tissue Healing 833
Clinical Applications 833
Periodontal Surgery 833
Crown Lengthening 834
Tooth Extraction 836
Implant Site Preparation 837
Advanced Clinical Applications 839.e1
Sinus Lift 839.e1
Ridge Expansion 839.e1
Bone Harvesting 839.e3
Particulate Bone Chip Harvesting Technique 839.e3
Clinical Note 839.e4
Block Harvesting Technique 839.e4
Conclusion 839
References 839
References 839.e7
84 Digitally Assisted Implant Surgery 840
Abstract 840.e1
Keywords 840.e1
Chapter Outline 840
Digitally Assisted Implant Surgery 840
Real-Time Micro Positioning Implant Surgery: Overview 840
Uses and Requirements 840
Sequence of Steps 841
Data Acquisition and Registration 842
Navigation and Positional Tracking 842
External Viewer, Augmented Reality, and Three-Dimensional Projection Screens 842
Technical Principles and Limitations 844.e1
Cone Beam Computed Tomography and Computed Tomography Scan Limitations 844.e1
Trackers 844.e1
Registration: A Mathematical Complexity 844
Tracking Device 845
Clinical Advantages of RTMIS 845
Challenges With RTMIS 845
Benefit of Ultrasound Mapping 845
Advantages and Limitations of Bone Ultrasound Mapping 845.e1
System Risk Analysis 845.e2
Safety 845.e2
Availability 845.e2
Robustness or Accuracy of the Whole System 845.e2
Conclusion 845
References 845
References 845.e4
III Complications 846
85 Implant-Related Complications and Failures 846
Abstract 846.e1
Keyword 846.e1
Chapter Outline 846
Definitions of Implant Survival and Success 846
Types and Prevalence of Implant Complications 847
Types of Dental Implants 848
Surgical Complications 848
Hemorrhage and Hematoma 848
Neurosensory Disturbances 849
Implant Malposition 850
Biologic Complications 852
Inflammation and Proliferation 852
Dehiscence and Recession 852
Peri-Implantitis and Bone Loss 853
Implant Loss or Failure 854
Complications Related to Augmentation Procedures 856.e1
Autogenous Bone Harvesting and Grafting 856.e1
Guided Bone Regeneration 856.e1
Sinus Bone Augmentation 856.e1
Lateral Window Sinus Lift 856.e1
Crestal (Osteotome) Sinus Lift 856.e2
Complications Related to Placement and Loading Protocols 856.e3
Immediate Implant Placement 856.e3
Immediate Loading After Implant Placement 856.e3
Implant Placement Using a Flapless Approach 856.e3
Prosthetic or Mechanical Complications 856
Screw Loosening and Fracture 856
Implant Fracture 856
Fracture of Restorative Materials 856
Aesthetic and Phonetic Complications 856
Aesthetic Complications 856
Phonetic Problems 858
Conclusions 858
References 858
References 858.e2
IV Supportive Care and Results of Implant Treatment 859
86 Supportive Implant Treatment 859
Abstract 859.e1
Keywords 859.e1
Chapter Outline 859
Rationale for Supportive Implant Treatment 859
Examination of Implants 859
Peri-implant Probing 860
Microbial Testing 861
Stability Measures 861
Implant Percussion 862
Radiographic Examination 862
Assessment of Peri-Implant Health 862
Evaluation of Biofilm Control 862
Evaluation of Peri-Implant Health and Disease 862
Evaluation of Implant Osseointegration 863
Evaluation of Implant Restorations 864
Implant Maintenance 864
Methods for Patient Oral Hygiene 864
Methods for Professional Recall Maintenance 864
Treatment of Peri-Implant Diseases 865
Peri-Implant Mucositis 865
Peri-Implantitis 865
Referral of Patients to the Periodontist 866
References 866
References 866.e2
87 Results of Implant Treatment 867
Abstract 867.e1
Key Words 867.e1
Chapter Outline 867
Defining Implant Outcomes 867
Factors That Influence Implant Outcomes 869
Anatomic Location 869
Implant Design 869
Placement and Loading Protocols 870
Immediate Implant Placement 870
Immediate Occlusal Loading 870
Bone Augmentation 870
Risk Factors 870
Smoking 871
Diabetes 871
Periodontitis 871
Aesthetic Results and Patient Satisfaction 871
Conclusions 872
References 872
References 872.e2
5 Atlas of Periodontal Diseases e48
88 Atlas of Periodontal Diseases e48
Chapter Outline e48
Plaque-Induced Gingival Diseases e49
Clinical Features of Gingivitis e49
Melanin Pigmentation e51
Causes of Periodontal Diseases e52
Gingival Diseases Modified by Systemic Factors e59
Endocrine System e59
Sex Hormones e59
Gingival Diseases Associated With Blood Dyscrasias e62
Leukemia e62
Anemia e62
Drug-Induced Gingival Diseases e64
Non–Plaque-Induced Gingival Lesions e65
Streptococcus Species Infections e65
Herpesvirus Infections e66
Gingival Diseases of Fungal Origin e67
Gingival Lesions of Genetic Origin e69
Hereditary Gingival Fibromatosis e69
Gingival Manifestations of Systemic Conditions e71
Mucocutaneous Lesions e71
Other Systemic Diseases e74
Allergies e78
Traumatic Lesions: Factitious, Iatrogenic, and Accidental e79
Cysts and Tumors e83
Chronic Periodontitis e85
Chronic Periodontitis Modified by Systemic Factors e88
Diabetes Mellitus e88
Aggressive Periodontitis e92
Periodontitis as a Manifestation of Systemic Diseases e97
Leukemias e97
Genetic Disorders e99
Necrotizing Periodontal Diseases e104
Bisphosphonates e106
Abscesses of Periodontium e108
Endodontic-Periodontal Lesions e110
Index 873
A 873
B 876
C 878
D 881
E 883
F 884
G 885
H 888
I 889
J 892
K 892
L 892
M 893
N 896
O 897
P 899
Q 906
R 906
S 907
T 911
U 912
V 913
W 913
X 913
Y 913
Z 913
Inside Back Cover ibc1