Book Review Essentials of Periodontology and Periodontics*

by
TORQUIL M A C P H E E GEOFFREY COWLEY

A discussion of tissue resistance is divided into anatomical barrier, mucous barrier, epithelial barrier, and the local inflammatory response. Concerning the pathology of periodontitis, the authors note that most periodontal disease, both in children and in adults, is inflammatory in nature. Inflammation is discussed i n general and in terms of the tooth-soft tissue interface. Chronic injury to the periodontium is described at tissue and cellular levels. The clinical features of gingival inflammation are described, including discoloration, pitting edema, loss of stippling, gingival retraction, bleeding, and the presence of a visible inflammatory exudate. Histopathologic features are edema, hyperplasia, or recession and atrophy. Both epithelial and connective tissue cellular changes are described in acute and chronic gingival inflammation. The mechanism of extension of the above noted pathology into the deeper tissues and the sequence of tissue changes resulting in pocket formation are clearly explained. Regarding the etiology of periodontal disease, the authors emphasize that failure of biochemical control of tissue metabolism may predispose the tissues to disease in the presence of local factors of low pathogenicity. However, local factors of higher pathogenicity may produce disease in the absence of impaired tissue metabolism. Tooth surface deposits include materia alba (sordes), calculus and plaque. A clear and concise description of plaque composition and the mechanism of its formation is given. Plaque, not the calcified deposits, is the major factor in the etiology of periodontitis. In contrast to the section on plaque, the section on calculus is rather weak, with several important references missing and disproportionately strong emphasis placed on the formation of calculus in germ-free animals. Five theories of calculus formation are explained briefly. Mechanisms of host tissue response to the products of microorganisms are enumerated in more detail than would be anticipated from the briefer coverage usually awarded to background material. Topics include toxins, i m munity, and hypersensitivity; thorough documentation is included. Control of tissue metabolism is a complex phenomenon related to heredity, age, sex, endocrine control, psychosomatic factors, and nutrition. There is no evidence that any single systemic factor is responsible for periodontitis. The most satisfactory system of classification for periodontal disease is one based on the general pathological features of the disease. Primarily such features are inflammation and edema, hyperplasia of the soft connective tissues, or recession and atrophy. Broadly, periodontal disease may be divided into processes which

Critique by William B. Gillette** A.B., D.D.S.

T H E T W O S C O T T I S H A U T H O R S have divided this text into thirteen chapters, the earlier chapters being concerned with background and theory, and the later chapters with diagnosis and treatment. The object of the book as stated by the authors is "to review the present state of knowledge of periodontology as we understand it and to relate this to a programme of patient treatment." The text begins with a description of the periodontium, including alveolar bone, cementum, periodontal membrane, the gingivae, and the reflected (alveolar) mucosa. The gingival cuff epithelium is described and its formation is explained (diagrams complement the description). The periodontal membrane (ligament) is discussed i n a manner somewhat different from that of the standard U . S. textbooks, but the authors leave a fairly clear image. Some general histologic and histochemical features of the periodontal soft tissues are listed, including epithelium, but emphasizing collagen, reticulin and elastic fibers, ground substance, and basement membrane. Emphasis is placed on the necessity of a proper balance between the environment surrounding the crown (oral environment) and that surrounding the root. The microbiological phenomena of the oral cavity include such factors as infectious disease, parasitism, commensalism, antibiosis, symbiosis, and synergism. The formation of dental plaque and subsequent gingivitis are briefly described. In emphasizing the importance of plaque, the authors state, "There is considerable weight of evidence that periodontitis is a direct result of the reaction of the periodontal tissues to the metabolic products of the high concentration of microorganisms in dental plaque." The detrimental effect on the periodontium of mechanically traumatic factors such as food impactions and overhanging restorations is mentioned.
* Blackwell Scientific Publications, Oxford and Edinburgh, 1969. 226 pages, over 350 black and white photographs and drawings. **Staff Periodontist, V . A . Hospital, Indianapolis, Indiana.

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CRITIQUEGILLETTE

are inflammatory, degenerative, or neoplastic. The authors concur with the 1966 World Workshop i n Periodontics in the belief that the concept of a pure periodontosis has not been substantiated and therefore that the term should be abandoned. The specific classification advocated, i n simplified terms, then is gingivitis (acute or chronic), and periodontitis (acute nonspecific or chronic nonspecific). Chronic nonspecific gingivitis is divided into periodontitis simplex and periodontitis complex. N o provision is made for separate recognition of gingival abscess nor occlusal traumatism. The term "gingivitis" is reserved for those instances in which inflammation does not extend past the gingiva itself. There can be false pockets (pseudopockets) but no true pockets i n such cases. In "periodontitis," i n flammation is not restricted to the gingiva; true pockets are always present, as are alveolar bone resorption and loss of attachment. Periodontitis is divided into the simplex type (an inflammatory condition caused by local irritants), and the complex type (primarily a degenerative condition with an etiology containing strong systemic overtones). Periodontitis complex occurs infrequently, is seen more frequently in younger patients, and may be associated with deep, irregular pockets, drifting teeth, extreme vertical bone loss, and occasionally lack of clinical inflammation. In the discussion of acute inflammatory periodontal conditions, the more prevalent current concepts are given. Discussed under this category are acute ulceromembranous gingivitis, primary herpetic gingivostomatitis, erythema multiforme, aphthous stomatitis, herpangina, acute coccal gingivitis, acute nonspecific gingivitis, periodontal abscess (including gingival abscess), and pericoronitis. This section is outstanding from the clinician's standpoint i n terms of clarity, brevity, and totality of coverage. The authors designate the severity of cases of chronic gingivitis and periodontitis as one of five stages, similar to the major stages i n the Russell Index. A novel system of charting the periodontal tissues is suggested i n which each tooth is scored using one of the five stages aforementioned. The location of gingival inflammation around each tooth is also described. F r o m a clinical standpoint, such a system merits consideration. Appropriate treatment cannot be instituted without adequate diagnosis, which requires the following evaluations: pocket depth (including support remaining) and contour, percussion, soft tissue color, form and texture, and patient self-care status. The treatment of periodontal pirical and is generally limited to and symptoms rather than being inating the cause. Prevention is disease is largely emtreatment of the signs directed toward elimsuperior to any form

of treatment but requires a high standard of patient self-care. The first essential of any course of therapy is to reduce the bacterial population of the crevice. C o m prehensive periodontal therapy may be divided into the hygiene phase, the corrective phase, and the maintenance phase (hygiene phase care at the necessary intervals). Hygiene phase therapy consists of the patient's selfcare and the practitioner's removal of deposits from the teeth. In addition, the use of packs and splints in the reduction of nonspecific inflammation is included in this phase. Three toothbrushing methods are described and illustrated, with the suggestion that a brush of medium bristle texture is suitable for all techniques. The electric toothbrush is discussed and the pro's and con's weighed. The use of woodsticks and disclosing agents is advocated. Dental floss and tape are felt to be contraindicated since damage can occur from their improper use. The removal of soft and calcified deposits from the teeth by the practitioner is described and illustrated i n adequate detail. Specific hand instruments and the precise technique of their use are shown. In addition, the history, theory, parts, and use of the ultrasonic scaling unit are elucidated. In cases where inflammation persists in spite of adequate home care and scaling and polishing procedures, it is recommended that a zinc oxide-eugenol type periodontal pack be placed for seven days. In this instance, "the role of a pack is to protect the swollen tissues from the trauma of normal function." Such reasoning is not universally accepted, but if good results validate the technique, then perhaps the reason is not critical. The initial objective of "corrective phase therapy" is the elimination of local factors which are detrimental to the periodontal tissues. Such factors include, but are not limited to, malpositioned teeth, lack of contact points or marginal ridges, and poorly designed restorations and prostheses. Correction of such factors should precede any attempt at the surgical elimination of pockets. Of particular importance in restorations is the design of the contact area, surface smoothness, and contour and position of the cervical margin. Deficient restorations should be corrected or replaced. Poorly designed or ill-fitting prostheses should likewise be corrected or replaced. The indications for and technique of placement of intracoronal amalgam and acrylic splints as well as extracoronal fixed and removable splints are described. The relationships of teeth to each other within an arch merit as much consideration as their interarch relationships. The proper requirement for alteration of tooth relationships depends upon the health and function of each tooth to tooth occlusal system, disregarding formal prosthetic and orthodontic concepts of ideal

ESSENTIALS O F PERIODONTOLOGY A N D PERIODONTICS

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occlusion. Occlusal forces which are within physiologic limits for the healthy periodontium may be hyperfunctional (traumatogenic) if tissue resistance is reduced, as in disease. The physiology of occlusion is discussed as is the pathology of the abnormal occlusal tooth contact. A practical system of occlusal adjustment is presented, and the subject of occlusion is supported by an excellent bibliography. For the selection of the surgical technique appropriate i n a given situation, a system matching technique with severity of disease is proposed. Techniques discussed are subgingival curettage, gingivoplasty, gingivectomy, frenectomy, and repositioned, retracted, m u cosal, and replaced flaps. With the exception of the retracted flap, these techniques are i n general use in the United States. The distinctions between gingivectomy and gingivoplasty, and between ostectomy and osteoplasty are not clearly explained. The authors state that periodontal surgery should be carried out only on patients who have demonstrated a high level of self-care; to do otherwise is to invite failure. It is essential that the operator be aware of the full medical history prior to undertaking surgical procedures. The surgical technique section is written clearly and thoroughly. While some of the latest and most sophisticated "frills," and a few important bibliographic citations are missing, this section can be highly recommended. The chapter on the contribution of systemic conditions to periodontal disturbances must be considered below the standards established by the rest of the book. While certain topics such as blood dyscrasias are amply covered, the discussion of nutritional deficiencies and diabetes, for example, is not adequate for the serious

student. The space allocated to this general subject might have been adequate had priorities been different. The recurrent theme throughout the text is the dynamic balance required i n the periodontal host-parasite relationships and the manifestations resulting from i m balance. Readers educated i n the United States will find differences i n spellings (as fibres for fibers), differences i n terminology (as reflected mucosa for alveolar mucosa), and differences from some traditional U . S . viewpoints. While these factors slow the reader's progress slightly, the net result is probably a wider field of view. The book suffers i n some areas from lack of continuity, and could be strengthened by reorganization. Most sections, by contrast, are clear and well organized. The illustrations are appropriate and very well reproduced, in addition to being placed on the proper page. A s is usually the case, even the clinical photographs are reproduced i n black and white. While diagrams and x-rays may be effectively reproduced i n such manner without loss of essential detail, clinical photos of the periodontal soft tissues cannot be effective i n black and white. But unfortunately, as other authors have learned, the costs of color reproduction are prohibitive. The type is large and clear. Since Essentials of Periodontology and Periodontics is an abbreviated text (226 pages), it may be appropriately used i n abbreviated courses attended by dental students or general practitioners. It also has much value as a comparison text i n graduate studies, and this reviewer will consider it an asset i n his personal library. However, due to its concise nature, this text would be inappropriate as a single reference text or as the sole text i n courses of standard length enrolled for credit.

Announcements
UNIVERSITY O F SOUTHERN CALIFORNIA SCHOOL OF DENTISTRY The University of Southern California, School of Dentistry, announces that applications are being accepted for advanced training in Endodontics, Orthodontics, Pedodontics, Periodontics and Prosthodontics. A l l programs will be of 24 months' duration and will lead to a Certificate of Study. The programs are designed to prepare the student for examination by the appropriate American Board. Deadline for the completed applications and records will be November 2,1970. For further information please address communications to D r . Hugh M . Kopel, Director of Advanced Dental Education, University of Southern California, School of Dentistry, 925 W . Thirty-fourth Street, Los Angeles, California 90007. CREIGHTON UNIVERSITY The School of Dentistry and the Graduate School of Creighton University, Omaha, Nebraska, announce a two-year (24 month) postdoctoral program in Periodontology. A basic core program of biological and clinical science studies, combined with research and intensive specialty training, lead to the Master of Science (M.S.) degree. Each graduate student's course of study will be designed to fulfill eligibility requirements for the American Board of Periodontology, but will also be fluid enough to satisfy the student's desires and potentials for academic or clinical careers in Periodontology. Applications are now being accepted for the class beginning September 1970. F o r further information concerning applications write to: Admissions Office, Creighton University, 24th and California Street, Omaha, Nebraska 68131.