Get the full ebook with Bonus Features for a Better Reading Experience on ebookgate.

com

Periodontics Medicine Surgery and Implants 1st

Edition Louis F. Rose

https://ebookgate.com/product/periodontics-medicine-surgery-
and-implants-1st-edition-louis-f-rose/

OR CLICK HERE

DOWLOAD NOW

Download more ebook instantly today at https://ebookgate.com

Instant digital products (PDF, ePub, MOBI) available
Download now and explore formats that suit you...

Neurology of Music 1st Edition F. Clifford Rose

https://ebookgate.com/product/neurology-of-music-1st-edition-f-
clifford-rose/

ebookgate.com

Extracellular Matrix Derived Implants in Clinical Medicine

1st Edition Daniel L Mooradian

https://ebookgate.com/product/extracellular-matrix-derived-implants-
in-clinical-medicine-1st-edition-daniel-l-mooradian/

ebookgate.com

Essentials of Tortoise Medicine and Surgery 1st Edition

Chitty

https://ebookgate.com/product/essentials-of-tortoise-medicine-and-
surgery-1st-edition-chitty/

ebookgate.com

The Neurobiology of Painting 1st Edition F. Clifford Rose

(Eds.)

https://ebookgate.com/product/the-neurobiology-of-painting-1st-
edition-f-clifford-rose-eds/

ebookgate.com
Biology Medicine and Surgery of Elephants 1st Edition
Murray E. Fowler

https://ebookgate.com/product/biology-medicine-and-surgery-of-
elephants-1st-edition-murray-e-fowler/

ebookgate.com

Periodontics The Complete Summary 1st Edition Suarez

https://ebookgate.com/product/periodontics-the-complete-summary-1st-
edition-suarez/

ebookgate.com

Internal Medicine 1st Edition Bruce F. Scharschmidt

(Editor)

https://ebookgate.com/product/internal-medicine-1st-edition-bruce-f-
scharschmidt-editor/

ebookgate.com

Ferret Husbandry Medicine and Surgery Second Edition John

Henry Lewington Bvetmed Mrcvs

https://ebookgate.com/product/ferret-husbandry-medicine-and-surgery-
second-edition-john-henry-lewington-bvetmed-mrcvs/

ebookgate.com

Practical Periodontics 2nd Ed Edition Kenneth A. Eaton

https://ebookgate.com/product/practical-periodontics-2nd-ed-edition-
kenneth-a-eaton/

ebookgate.com
PERIODONTICS MEDICINE, SURGERY, and IMPLANTS
Louis F. Rose, DDS, MD
 Clinical Professor of Periodontics, School of Dental Medicine, University of
Pennsylvania; Professor of Surgery, Drexel University College of Medicine,
Philadelphia, Pennsylvania; Clinical Professor of Periodontics, School of Dental
Medicine, New York University, New York, New York; Faculty, Harvard
University School of Dental Medicine, Boston, Massachusetts

Brian L. Mealey, DDS, MS

Chairman and Graduate Program Director, Department of Periodontics, Wilford

Hall Medical Center, Lackland Air Force Base, Texas; Clinical Assistant Professor,
Department of Periodontics, University of Texas Health Science Center, San
Antonio, Texas; Adjunct Associate Professor, Baylor College of Dentistry, Texas
A&M University System, Dallas, Texas

Robert J. Genco, DDS, PhD

Distinguished Professor and Chair, School of Dental Medicine, Department of Oral

Biology, State University of New York, Buffalo, New York

D. Walter Cohen, DDS

Dean Emeritus and Professor Emeritus of Periodontics, School of Dental Medicine,

University of Pennsylvania, Philadelphia, Pennsylvania

0-8016-7978-8

ELSEVIER MOSBY

ELSEVIER MOSBY

11830 Westline Industrial Drive

St. Louis, Missouri 63146

PERIODONTICS: MEDICINE, SURGERY, AND IMPLANTS ISBN 0-8016-7978-

8

Copyright © 2004 Mosby, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any

means, electronic or mechanical, including photocopying, recording, or any
information storage and retrieval system, without permission in writing from the
publisher. Permissions may be sought directly from Elsevier's Health Sciences Rights
Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238
2239, e-mail: healthpermissions@elsevier.com. You may also complete your request
on-line via the Elsevier homepage (http://www.elsevier.com), by selecting 'Customer
Support' and then 'Obtaining Permissions'.
Notice

Dentistry 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
prescriber, relying on experience and knowledge of the patient, to determine dosages
and the best treatment for each individual patient. Neither the publisher nor the author
assumes any liability for any injury and/or damage to persons or property arising
from this publication.

Library of Congress Cataloging-in-Publication Data

Periodontics: medicine, surgery, and implants/[edited by] Louis F. Rose … [et al.].

p. ; cm.

Includes bibliographical references and index.

ISBN 0-8016-7978-8

1. Periodontics. 2. Periodontal disease. 3. Periodontium—Surgery. 4. Dental implants.

I. Rose, Louis F.

[DNLM: 1. Periodontal Diseases—diagnosis. 2. Periodontal Diseases—surgery. WU

240 P4477 2004]

RK361.P466 2004

617.6'32—dc22

2003065160

Executive Editor: Penny Rudolph

Senior Developmental Editor: Jaime Pendill

Associate Developmental Editor: Julie Nebel

Publishing Services Manager: Melissa Lastarria

Associate Project Manager: Bonnie Spinola

Senior Designer: Julia Dummitt

Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Front Matter

PART I BASIC CONCEPTS IN PERIODONTAL

PATHOBIOLOGY
Gary C. Armitage

1 Anatomy, Development, and Physiology of the

Periodontium

2 Diagnosis and Classification of Periodontal

Diseases

3 Epidemiology of Periodontal Diseases and Risk

Factors

4 Microbiology of Periodontal Diseases

5 Immunoinflammatory Response in Periodontal

Diseases

6 Dental Plaque and Calculus: Microbial Biofilms

and Periodontal Diseases

7 Local Contributing Factors

PART II PERIODONTAL EVALUATION, TREATMENT

PLANNING, AND NONSURGICAL THERAPY
Brian L. Mealey

Louis F. Rose
 8 Clinical Periodontal Examination

9 Radiography for the Periodontal Examination

10 The Electronic Patient Record

11 Formulating a Periodontal Diagnosis and

Prognosis

12 Acute Periodontal Conditions

13 Oral Physiotherapy

14 Nonsurgical Therapy

15 Periodontal and Dental Implant Maintenance

16 Locally Acting Oral Chemotherapeutic Agents

17 Systemic Chemotherapeutic Agents

18 Contemporary Dental Hygiene Care

PART III SURGICAL THERAPY

Leonard S. Tibbetts

19 Conscious Sedation

20 Principles and Practice of Periodontal Surgery*

21 Periodontal Plastic and Reconstructive Surgery

22 Principles of Periodontal Plastic Microsurgery

 23 Resective Periodontal Surgery

24 Treatment of Molar Furcations

25 Periodontal Regeneration and Reconstructive

Surgery

26 Dental Implants in the Periodontally

Compromised Dentition

PART IV MULTIDISCIPLINARY CARE

John Kois

Louis F. Rose

Brian L. Mealey

27 Restoration of the Periodontally Compromised

Dentition

28 Orthodontic Therapy for the Periodontal-

Restorative Patient

29 Role of Occlusion in Periodontal Therapy

30 Endodontic-Periodontal Considerations

PART V PERIODONTAL MEDICINE

Brian L. Mealey

Louis F. Rose

31 Systemic Factors Impacting the Periodontium

 32 Effect of Periodontal Infection on Systemic
Health and Well-Being

33 Medications Impacting the Periodontium

34 Effect of Tobacco Smoking and Alcohol Use on

Periodontal Diseases

35 Selected Soft and Hard Tissue Lesions With

Periodontal Relevance

36 Medical and Dental History

37 Periodontal Treatment of the Medically

Compromised Patient
(Rose, Louis F. Rose. Periodontics: Medicine, Surgery and Implants. Elsevier, 2004.).
<vbk:0-8016-7978-8>

Front Matter

Section Editors
Gary C. Armitage, DDS, MS

R. Earl Robinson Distinguished Professor, UCSF School of Dentistry; Division of

Periodontology, San Francisco, California

John Kois, DMD

Private Practice, Seattle and Tacoma, Washington; Director of Creating Excellence

Center for Dental Learning; Affiliate Professor, University of Washington, Graduate
Restorative Department

Louis F. Rose, DDS, MD

Clinical Professor of Periodontics, School of Dental Medicine, University of

Pennsylvania; Professor of Surgery, Drexel University College of Medicine,
Philadelphia, Pennsylvania; Clinical Professor of Periodontics, School of Dental
Medicine, New York University, New York, New York; Faculty, Harvard University
School of Dental Medicine, Boston, Massachusetts

Brian L. Mealey, DDS, MS

Chairman and Graduate Program Director, Department of Graduate Periodontics,

Wilford Hall Medical Center, Lackland Air Force Base, Texas; Clinical Assistant
Professor, Department of Periodontics, University of Texas Health Science Center,
San Antonio, Texas; Adjunct Associate Professor, Baylor College of Dentistry, Texas
A&M University System, Dallas, Texas

Leonard S. Tibbetts, DDS, MSD

Private Practice and Affiliate Associate Professor of Periodontics, University of

Washington School of Dentistry, Seattle, Washington; Private Practice, Arlington,
Texas

Contributors
Leonard Abrams, DDS

Clinical Professor, Department of Periodontics, School of Dental Medicine,

University of Pennsylvania, Philadelphia, Pennsylvania

Alfredo Aguirre, DDS, MS

Director, Advanced Oral and Maxillofacial Pathology; Professor, Department of Oral

Diagnostic Sciences, School of Dental Medicine, State University of New York,
Buffalo, New York

William F. Ammons, Jr., DDS, MSD

Professor Emeritus, Department of Periodontics, School of Dentistry, University of

Washington, Seattle, Washington

Gary C. Armitage, DDS, MS

R. Earl Robinson Distinguished Professor, USCF School of Dentistry, Division of

Periodontology, San Francisco, California

Sebastian G. Ciancio, DDS, PhD

Distinguished Professor and Chair, Department of Periodontics and Endodontics,

School of Dental Medicine, State University of New York, Buffalo, New York

D. Walter Cohen, DDS

Dean Emeritus and Professor Emeritus of Periodontics, School of Dental Medicine,
University of Pennsylvania, Philadelphia, Pennsylvania; Chancellor Emeritus, Drexel
University College of Medicine, Philadelphia, Pennsylvania.

Connie L. Drisko, DDS

Dean, School of Dentistry, Medical College of Georgia, Augusta, Georgia

Becky DeSpain Eden, BSDH, MEd

Associate Professor, Public Health Sciences, Baylor College of Dentistry, Texas

A&M University System Health Science Center, Dallas, Texas

Cyril I. Evian, DMD

Private Practice, King of Prussia, Pennsylvania; Acting Chair, Department of

Periodontics, University of Pennsylvania School of Dental Medicine, Philadelphia,
Pennsylvania

Mark E. Glover, DDS, MSD

Private Practice, Dallas, Texas

Henry Greenwell, DMD, MSD

Professor, Chairman, and Director, Graduate Periodontics, Department of

Periodontics, Endodontics, and Dental Hygiene, School of Dentistry, University of
Louisville, Louisville, Kentucky

Sara G. Grossi, DDS, MS

Senior Research Scientist, Department of Oral Biology, School of Dental Medicine,

State University of New York, Buffalo, New York

Margaret Hill, DMD

Associate Professor, Department of Periodontics, Endodontics, and Dental Hygiene,

School of Dentistry, University of Louisville, Louisville, Kentucky

Richard T. Kao, DDS, PhD

Associate Adjunct Professor, Department of Periodontology, School of Dentistry,

University of the Pacific, San Francisco, California

David G. Kerns, DMD, MS

Associate Professor and Director of Postdoctoral Periodontics, Department of

Periodontics, Baylor College of Dentistry, Texas A&M University System Health
Science Center, Dallas, Texas
Denis F. Kinane, BDS, PhD

Associate Dean for Research and Enterprise, School of Dentistry, University of

Louisville, Louisville, Kentucky

John Kois, DMD

Private Practice, Seattle and Tacoma, Washington; Director of Creating Excellence

Center for Dental Learning, Affiliate Professor, University of Washington, Graduate
Restorative Department

Vincent G. Kokich, DDS, MSD

Professor, Department of Orthodontics, School of Dentistry, University of

Washington, Seattle, Washington

Vincent O. Kokich, DMD, MSD

Affiliate Assistant Professor, Department of Orthodontics, School of Dentistry,

University of Washington, Seattle, Washington

Peter M. Loomer, DDS, PhD, MRCD (C)

Assistant Professor of Clinical Periodontology, Division of Periodontology, School of

Dentistry, University of California at San Francisco, San Francisco, California

Howard T. McDonnell, DDS, MS

Director of Periodontal Research, United States Air Force Periodontics Residency,

Department of Periodontics, Wilford Hall Medical Center, Lackland Air Force Base,
Texas; Clinical Assistant Professor, Department of Periodontics, University of Texas
Health Science Center, San Antonio, Texas

Brian L. Mealey, DDS, MS

Chairman and Graduate Program Director, Department of Periodontics, Wilford Hall

Medical Center, Lackland Air Force Base, Texas; Clinical Assistant Professor,
Department of Periodontics, University of Texas Health Science Center, San Antonio,
Texas; Adjunct Associate Professor, Baylor College of Dentistry, Texas A&M
University System, Dallas, Texas

Bryan S. Michalowicz, DDS

Associate Professor, Department of Preventive Sciences, School of Dentistry,

University of Minnesota, Minneapolis, Minnesota

Dale A. Miles, DDS, MS

Associate Dean for Clinical Affairs and Faculty Development, Arizona School of
Dentistry and Oral Health, Mesa, Arizona

Michael P. Mills, DMD, MS

Clinical Associate Professor, Department of Periodontics, University of Texas Health

Science Center, San Antonio, Texas

Laura Minsk, DMD

Assistant Professor, Department of Periodontics, School of Dental Medicine,

University of Pennsylvania, Philadelphia, Pennsylvania

Regan L. Moore, DDS, MSD

Associate Professor, Department of Periodontics, Endodontics, and Dental Hygiene,

School of Dentistry, University of Louisville, Louisville, Kentucky

Jacqueline M. Plemons, DDS, MS

Associate Professor, Department of Periodontics, Baylor College of Dentistry, Texas

A&M University Health Science Center, Dallas, Texas

Stephen R. Potashnick, DMD

Private Practice, Chicago, Illinois

John W. Rapley, DDS, MS

Director, Graduate Periodontics and Chairman, Department of Periodontics,

University of Missouri-Kansas City School of Dentistry, Kansas City, Missouri

Terry D. Rees, DDS

Professor and Former Chair, Department of Periodontics, Baylor College of

Dentistry, Texas A&M University System Health Science Center, Dallas, Texas

Jill Rethman, RDH

Clinical Instructor, Department of Dental Hygiene, School of Dental Medicine,

University of Pittsburgh, Pittsburgh, Pennsylvania

Paul Rhodes, DDS, MSD

Private Practice, Walnut Creek, California

Mauricio Ronderos, DDS, MS, MPH

Assistant Professor, Department of Periodontics, School of Dentistry, University of
the Pacific, San Francisco, California

Louis F. Rose, DDS, MD

Clinical Professor of Periodontics, School of Dental Medicine, University of

Pennsylvania; Professor of Surgery, Drexel University College of Medicine,
Philadelphia, Pennsylvania; Clinical Professor of Periodontics, School of Dental
Medicine, New York University, New York, New York; Faculty, Harvard University
School of Dental Medicine, Boston, Massachusetts

Edwin S. Rosenberg, BDS, H.DipDent, DMD

Clinical Professor of Periodontics and Director, Postdoctoral Periodontics,

Periodontal Prosthesis and Implant Dentistry, University of Pennsylvania,
Philadelphia, Pennsylvania

Louis E. Rossman, DMD

Diplomate, American Board of Endodontics; Clinical Associate Professor,

Department of Endodontics, School of Dental Medicine, University of Pennsylvania;
Chairman Emeritus IB Bender Division of Endodontics, Albert Einstein Medical
Center, Philadelphia, Pennsylvania

Randal W. Rowland, MS, DMD, MS

Director, Postgraduate Periodontology, and Professor, Clinical Periodontology,

School of Dentistry, University of California at San Francisco, San Francisco,
California

Mark I. Ryder, DMD

Professor and Chair, Division of Periodontology, School of Dentistry, University of

California at San Francisco, San Francisco, California

Robert E. Schifferle, DDS, MMSc, PhD

Associate Professor, Departments of Periodontics, Endodontics, and Oral Biology,

School of Dental Medicine, State University of New York at Buffalo, Buffalo, New
York

Dennis A. Shanelac, DDS

Director, Microsurgery Training Institute, Santa Barbara, California

Neil L. Starr, DDS

Adjunct Clinical Assistant Professor, Department of Periodontics, School of Dental
Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Private Practice in
Prosthodontics, Washington, DC

Jose Luis Tapia, DDS, MS

Professor, Department of Oral Pathology, Facultad de Odontologia, Universidad

Nacional Autonoma de Mexico

Mark V. Thomas, DMD

Assistant Professor and Division Chief, Department of Periodontics, College of

Dentistry, University of Kentucky, Lexington, Kentucky

Leonard S. Tibbetts, DDS, MSD

Private Practice and Affiliate Associate Professor of Periodontics, University of

Washington School of Dentistry, Seattle, Washington; Private Practice, Arlington,
Texas

Arnold S. Weisgold, DDS, FACD

Clinical Professor and Director of Postdoctoral Periodontal Prosthesis, Department of

Periodontics, School of Dental Medicine, University of Pennsylvania, Philadelphia,
Pennsylvania

M. Robert Wirthlin, DDS

Clinical Professor Emeritus, Division of Periodontology, Department of Stomatology,

School of Dentistry, University of California at San Francisco, San Francisco,
California; Captain (DC) US Navy, retired

Dedication
To my wife and best friend, Claire, who has always supported and encouraged my
desire to pursue every endeavor I dreamed possible. To my wonderful children,
Michael, David, and Hedy, for their ever-present love and devotion. To my beautiful
granddaughters Cameron Sara and Halle Kate, who have brought so much love and
joy into my life, and to the memory of my mother and father and mother-in-law, who
taught me the importance of family.

Also, a special debt of gratitude to D. Walter Cohen, my mentor, friend, and partner
in practice who has shaped my education and continues to do so. His thirst for life-
long learning and commitment to innovation and educational contributions are
second to none.

LFR
To my wife, Carla, and to my wonderful children, Colleen and Patrick, in
appreciation for their constant love and support. I also dedicate the text to my
steadfast mentors, Dr. William W. Hallmon and Dr. Michael P. Mills, whose
encouragement has brought me far and whose powerful intellects have humbled me
and shown me how much farther I have to go.

BLM

To the memory of one of the great leaders in our field, Henry M. Goldman, and in
honor of Dorothy A. Goldman.

DWC

In honor of my wife, Sandra, and my parents; to my children, Deborah, Robert, and

Julie; and to my grandchildren and students.

RJG

Preface
Dental medicine, especially periodontics, has changed dramatically during the past 80
years. Much of this progress has been the result of research findings carried out in
laboratories, dental practices, and clinical research settings around the world.
Investigations in periodontics have been supported by the National Institute for
Dental and Craniofacial Research, industry, foundations, and academic institutions.
The first Department of Periodontics was established at New York University in
1924, and most dental curricula did not include this subject until after World War II.
In 1940, at the age of 39, Dr. Henry M. Goldman published the first edition of
Periodontia. That volume might be considered the great-great ancestor of this text
since D. Walter Cohen joined Dr. Goldman in the fourth edition of Periodontia in
1957, followed by Periodontal Therapy in 1959, which included Saul Schluger and
Lewis Fox as co-authors. In 1990, the book Contemporary Periodontics by Genco,
Goldman, and Cohen continued this lineage. These volumes formed the foundations
upon which this current textbook, Periodontics: Medicine, Surgery, and Implants, is
laid. But this book is not simply a look to the past. Quite the opposite, it embraces a
vision of the future for the practice of periodontics in dentistry. This vision asks not
only "Where are we today in the field of periodontics?" but also "Where are we going
in the next 10 or 20 years?" Guided by a firm understanding of the pathobiology of
periodontal diseases and other oral infections, this book details new knowledge in the
field of periodontal medicine, periodontal surgery and nonsurgical care, oral plastic
and reconstructive surgical techniques, and dental implant therapy.

Dentistry is no longer a profession whose driving force is the "saving of teeth."

Rather, dental diagnosis and treatment is directed toward controlling infection and
establishing an oral environment that is conducive to the overall health and well-
being of the patient. This is particularly true of the field of periodontology. The new
evidence that has been made available to the profession has been the inspiration for
this volume, which is designed for all oral health professionals who have the
opportunity to treat patients. A group of distinguished contributors has made the text
one that can be used by dental students, postdoctoral students, generalists, dental
hygienists, and specialists. The goal of the book is to bring this knowledge into the
dental practice and into the day-to-day activities of all oral health care providers. The
book is about possibilities: possibilities to reinforce what one may already have
learned in the field of periodontology, to examine one's current level of understanding
in light of today's expanded knowledge base, and to look to the future with
confidence that periodontics will play a major role in one's dental practice and will
help address many of the problems cited in the recent Surgeon General's report on the
nation's oral health.

In this textbook, chapters have been grouped into five sections for ease of reference:

Part I, Basic Concepts in Periodontal Pathobiology, introduces the reader to the

anatomy and physiology of the periodontium, the most current diagnoses and
classification of periodontal diseases, epidemiology and risk factors, the microbiology
of periodontal lesions, immunoinflammatory responses in periodontal diseases, dental
plaque and calculus, microbial biofilms, and other factors that contribute to the onset
and progression of periodontal diseases.

Part II, Periodontal Evaluation, Treatment Planning, and Nonsurgical Therapy,

discusses clinical and radiographic diagnostic techniques, management of acute
periodontal conditions, oral physiotherapy, nonsurgical therapy and instrumentation,
periodontal and dental implant maintenance care, and use of locally acting and
systemic chemotherapeutic agents. This section contains a first-of-its-kind chapter on
digital record keeping in the dental practice and serves as a guide to the future
"paperless" dental office.

Part III, Surgical Therapy, addresses the surgical aspects of therapy and includes
principles and practice of periodontal surgery, periodontal plastic and reconstructive
surgery, principles of periodontal microsurgery, resective surgical techniques, and
management of molar furcation problems. Included in this section is a detailed
chapter on conscious sedation and anxiety control. The section ends with an extensive
chapter on dental implant therapy.

Part IV, Multidisciplinary Care, includes several chapters on multidisciplinary dental

therapy, including the topics of diagnosis and treatment planning of the compromised
dentition, periodontal-restorative and periodontal-prosthetic associations, occlusion,
and considerations in the relationships between periodontics, orthodontics, and
endodontics.

Part V, Periodontal Medicine, addresses systemic considerations and contains the

latest information on systemic factors impacting the periodontium, the effects of
periodontal infection on a number of systemic conditions, medications impacting the
periodontium, tumors and other pathology involving the periodontium, the effects of
smoking and other habits on the periodontium and on periodontal therapy, and proper
 execution of the medical/dental history. The final chapter contains a detailed and
exhaustive review of clinical dental/periodontal management of the medically
compromised patient.

Louis F. Rose

Brian L. Mealey

Robert J. Genco

D. Walter Cohen

Acknowledgments
This book came into existence only because of the dedicated efforts of its many
contributors. Each clinician and scientist who played a part in its writing and editing
has given of his or her time and knowledge, exactly as one might expect of these fine
educators. Their efforts are extremely valuable in making this text much more
readable for the numerous audiences that will have this opportunity. We acknowledge
the special efforts of our Section Editors, Drs. John Kois, Leonard Tibbetts, and Gary
Armitage, who provided outstanding review and editorial input.

Two individuals, Dr. Leonard Tibbetts and Dr. Gary Armitage, require exceptional
recognition. As Section Editors of major parts of this book, the work would have
simply been impossible without their commitment and dedication to seeing the
project to its fruition. They served not only as Section Editors but also as counselors
and guides to each of us. They made themselves available at all times of day and
night to give feedback, provide ideas, and spur the project along. Their many years as
clinicians, researchers, and teachers toiling in the field of periodontology were
invaluable, and their broad experience forms the ties that bind this book together. We
can do little more than say, "thank you," but these men know how deeply we
appreciate all of their help.

We are also indebted to Elsevier, and especially to Penny Rudolph, Executive Editor;
Julie Nebel, Associate Developmental Editor; and Jaime Pendill, Senior
Developmental Editor. They were our constant sounding boards, sifting through
countless ideas and separating wheat from chaff. Their attention to detail contributed
immensely to the quality of the book.

ABOUT THE COVER

The theme of the cover reflects the mission of our specialty-advancing oral health and
well-being through expertise in Periodontal Medicine, Plastic and Reconstructive
Surgery, and Implants. The cover drawing was originally conceived and designed by
Dr. Leonard Tibbetts. The editors greatly appreciate his artistic gifts.

(Rose, Louis F. Rose. Periodontics: Medicine, Surgery and Implants. Elsevier, 2004.).
<vbk:0-8016-7978-8>

PERIODONTICS MEDICINE, SURGERY, and IMPLANTS

 Louis F. Rose, DDS, MD

Clinical Professor of Periodontics, School of Dental Medicine, University of

Pennsylvania; Professor of Surgery, Drexel University College of Medicine,
Philadelphia, Pennsylvania; Clinical Professor of Periodontics, School of Dental
Medicine, New York University, New York, New York; Faculty, Harvard
University School of Dental Medicine, Boston, Massachusetts

Brian L. Mealey, DDS, MS

Chairman and Graduate Program Director, Department of Periodontics, Wilford

Hall Medical Center, Lackland Air Force Base, Texas; Clinical Assistant Professor,
Department of Periodontics, University of Texas Health Science Center, San
Antonio, Texas; Adjunct Associate Professor, Baylor College of Dentistry, Texas
A&M University System, Dallas, Texas

Robert J. Genco, DDS, PhD

Distinguished Professor and Chair, School of Dental Medicine, Department of Oral

Biology, State University of New York, Buffalo, New York

D. Walter Cohen, DDS

Dean Emeritus and Professor Emeritus of Periodontics, School of Dental Medicine,

University of Pennsylvania, Philadelphia, Pennsylvania

0-8016-7978-8

ELSEVIER MOSBY

ELSEVIER MOSBY

11830 Westline Industrial Drive

St. Louis, Missouri 63146

PERIODONTICS: MEDICINE, SURGERY, AND IMPLANTS ISBN 0-8016-7978-

8

Copyright © 2004 Mosby, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any

means, electronic or mechanical, including photocopying, recording, or any
information storage and retrieval system, without permission in writing from the
publisher. Permissions may be sought directly from Elsevier's Health Sciences Rights
Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238
2239, e-mail: healthpermissions@elsevier.com. You may also complete your request
on-line via the Elsevier homepage (http://www.elsevier.com), by selecting 'Customer
Support' and then 'Obtaining Permissions'.

Notice

Dentistry 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
prescriber, relying on experience and knowledge of the patient, to determine dosages
and the best treatment for each individual patient. Neither the publisher nor the author
assumes any liability for any injury and/or damage to persons or property arising
from this publication.

Library of Congress Cataloging-in-Publication Data

Periodontics: medicine, surgery, and implants/[edited by] Louis F. Rose … [et al.].

p. ; cm.

Includes bibliographical references and index.

ISBN 0-8016-7978-8

1. Periodontics. 2. Periodontal disease. 3. Periodontium—Surgery. 4. Dental implants.

I. Rose, Louis F.

[DNLM: 1. Periodontal Diseases—diagnosis. 2. Periodontal Diseases—surgery. WU

240 P4477 2004]

RK361.P466 2004

617.6'32—dc22

2003065160

Executive Editor: Penny Rudolph

Senior Developmental Editor: Jaime Pendill

Associate Developmental Editor: Julie Nebel

Publishing Services Manager: Melissa Lastarria

Associate Project Manager: Bonnie Spinola

Senior Designer: Julia Dummitt

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Front Matter

PART I BASIC CONCEPTS IN PERIODONTAL

PATHOBIOLOGY
Gary C. Armitage

1 Anatomy, Development, and Physiology of the

Periodontium

2 Diagnosis and Classification of Periodontal

Diseases

3 Epidemiology of Periodontal Diseases and Risk

Factors

4 Microbiology of Periodontal Diseases

5 Immunoinflammatory Response in Periodontal

Diseases

6 Dental Plaque and Calculus: Microbial Biofilms

and Periodontal Diseases

7 Local Contributing Factors

PART II PERIODONTAL EVALUATION, TREATMENT

PLANNING, AND NONSURGICAL THERAPY
Brian L. Mealey
 Louis F. Rose

8 Clinical Periodontal Examination

9 Radiography for the Periodontal Examination

10 The Electronic Patient Record

11 Formulating a Periodontal Diagnosis and

Prognosis

12 Acute Periodontal Conditions

13 Oral Physiotherapy

14 Nonsurgical Therapy

15 Periodontal and Dental Implant Maintenance

16 Locally Acting Oral Chemotherapeutic Agents

17 Systemic Chemotherapeutic Agents

18 Contemporary Dental Hygiene Care

PART III SURGICAL THERAPY

Leonard S. Tibbetts

19 Conscious Sedation

20 Principles and Practice of Periodontal Surgery*

21 Periodontal Plastic and Reconstructive Surgery

 22 Principles of Periodontal Plastic Microsurgery

23 Resective Periodontal Surgery

24 Treatment of Molar Furcations

25 Periodontal Regeneration and Reconstructive

Surgery

26 Dental Implants in the Periodontally

Compromised Dentition

PART IV MULTIDISCIPLINARY CARE

John Kois

Louis F. Rose

Brian L. Mealey

27 Restoration of the Periodontally Compromised

Dentition

28 Orthodontic Therapy for the Periodontal-

Restorative Patient

29 Role of Occlusion in Periodontal Therapy

30 Endodontic-Periodontal Considerations

PART V PERIODONTAL MEDICINE

Brian L. Mealey

Louis F. Rose

31 Systemic Factors Impacting the Periodontium

 32 Effect of Periodontal Infection on Systemic
Health and Well-Being

33 Medications Impacting the Periodontium

34 Effect of Tobacco Smoking and Alcohol Use on

Periodontal Diseases

35 Selected Soft and Hard Tissue Lesions With

Periodontal Relevance

36 Medical and Dental History

37 Periodontal Treatment of the Medically

Compromised Patient
(Rose, Louis F. Rose. Periodontics: Medicine, Surgery and Implants. Elsevier, 2004.).
<vbk:0-8016-7978-8>

1 Anatomy, Development, and Physiology of the

Periodontium
Mark I. Ryder

This chapter presents an overview and in depth examination of the structure,

development, and physiology of the periodontal tissues. In other texts, these topics are
traditionally divided over several chapters devoted to such areas as the gingiva,
periodontal support, macroanatomy of the periodontium, microanatomy of the
periodontium, and development. Integrating these topics into a single chapter was done
in the hope that the reader will gain a comprehensive understanding of the relations
between these topics. Such an integration is important for our understanding as to how
normal tissues change during the pathologic processes of periodontal diseases. In
addition, by integrating the story of the development of the periodontium into the
macroanatomy and the microanatomy of the periodontium, the reader may understand
the often confusing and complex terminologies used for periodontal tissues. This
integration of the discussion of periodontal development into periodontal anatomy can
also help the reader understand how investigators are developing new regeneration
strategies based on these developmental principles. Thus in this chapter, the
microanatomy, macroanatomy, physiology, and development of the periodontium will
be presented in such a way that the reader can carry this knowledge forward to the
subsequent chapters in this textbook. Therefore, these anatomic, developmental, and
physiologic topics will be presented in the following sequence:

• A description of the normal clinical, radiographic, and gross microscopic

appearance of the periodontal tissues that support, protect, and nourish the tooth.

• An overview of the development of the periodontal attachment.

• A more detailed discussion of the development, structure, and physiology of each

of the principal periodontal tissues: the cementum and alveolar bone, the periodontal
ligament and gingival connective tissues, and the gingival epithelium and epithelial
attachment.

THE NORMAL PERIODONTIUM

The periodontium consists of those tissues that surround and anchor the tooth in the
maxillary and mandibular alveolar process. These tissues include the gingiva and
gingival attachment to the tooth, cementum, periodontal ligament, and alveolar bone.
When viewed clinically, the only portion of periodontium that is visible to the
unaided eye is the oral aspect of the gingival epithelium (Fig. 1-1). When healthy, this
area of gingiva is normally coral pink with variations in melanin pigmentation among
different racial groups.1,2 The firm, pink, coronally located gingiva is distinguished
from the more pliable and more red oral mucosa on the buccal aspect of the maxillary
teeth and on the buccal and lingual aspect of the mandibular teeth by a distinct
mucogingival line or mucogingival junction. On the palatal aspect, the firm pink
gingiva is continuous with the firm pink palatal mucosa. In areas of the dentition
where there is contact between adjacent teeth, the gingiva has a typical scalloped
profile coming to a triangular point in the interproximal embrasure. In areas where
there is no contact between teeth, this gingival profile is flatter in appearance. In cross
section, the margin of the gingiva comes to a tapered point or knife edge. On the
surface of the oral gingival epithelium there is a characteristic dimpled pattern or
stippled pattern formed from invaginations of the oral gingival epithelium into the
underlying connective tissue. A shallow gingival groove is seen on approximately
50% of the gingival surface, which runs a few millimeters below the gingival margin
profile at approximately the level of the base of the gingival sulcus.

The remaining periodontal structures can best be appreciated in low-power buccal-

lingual sections or diagrams of the tooth and surrounding bone (see Fig. 1-1).3,4 In
this type of section, one can discern a thin covering of mineralized tissue over the root
dentin, termed the cementum. Fibers of the periodontal ligament insert into the
cementum on the tooth side and into the alveolar bone on the opposite side. The
periodontal ligament thus provides the principal anchoring mechanism of the tooth to
the alveolar bone. The width of the space occupied by the periodontal ligament often
can be visualized on standard dental radiographs (Fig. 1-2). This width ranges from
0.1 to 0.25 mm and is generally narrowest at the midpoint of the root. The periodontal
ligament space also has a blood supply to provide nutrients to the surface and the
alveolar bone; cells for repair and remodeling the cementum, ligament, and surface of
the alveolar bone; and a sensory nerve network to provide tactile information on the
position of the tooth. Thus the periodontal ligament and associated structures have
supportive, nutritive, regenerative, and sensory functions.

In a buccal-lingual cross section, the gingival epithelium forms a crevice around the
tooth.5 This epithelium can be distinguished into three regions covering the
underlying gingival connective tissue (Fig. 1-3). In all cases, the basal lamina of the
basal epithelial layer attaches to the underlying connective tissue through anchoring
fibrils. The three regions include:

• A thicker keratinized (orthokeratinized) or parakeratinized oral gingival

epithelium (see Fig. 1-3, A).

• A thinner and flatter parakeratinized or nonkeratinized lining of the crevice itself,

termed the crevicular epithelium (see Fig. 1-3, B).

• An area apical to the unattached crevicular epithelium, termed the junctional

epithelium, which forms an epithelial attachment to the tooth surface itself (see Fig.
1-3, C).

This epithelial attachment is therefore the most coronal portion of the periodontal
attachment apparatus. When healthy, the level of the epithelium attachment to the
tooth is usually at or slightly coronal to the level of the border between the apical
extent of the enamel and coronal extent of the cementum. This area on the tooth is
called the cementoenamel junction. The connective tissue underlying the gingival
epithelium can be divided into a less collagen-dense papillary layer directly beneath
the gingival epithelium and a deeper more collagen-dense reticular layer.
Figure 1-1.
 Clinical view and diagrammatic representation of the major elements of the
periodontium. A diagram of what a buccal-lingual cross section of the clinical
view might look like is presented to the right of the clinical photograph. The
buccal-lingual scale is exaggerated to illustrate some of the much thinner regions
of the periodontium. (Redrawn from Rateitschak KH, Rateitschak EM, Wolf HF,
Hassell TM: Color atlas of dental medicine/periodontology, ed 2, New York,
1994, Thieme Medical Publishers.)
Figure 1-2.
 Standard periapical radiograph of the tooth and alveolar bone support. The more
radiodense lamina dura and radiolucent periodontal ligament space can be seen.

The blood supply for the periodontium comes from the inferior and superior alveolar
arteries, respectively.3,5 Branches of these arteries extend coronally into the ligament
from the apices of the teeth and from branches that extend coronally into the central
trabecular areas of the alveolar bone, or over the oral side of the periosteum, and then
penetrate perpendicularly through the alveolar bone and into the periodontal ligament
(Fig. 1-4). When the surface of the bony socket is viewed face on, numerous small
holes can be seen that correspond to the penetration of these small blood vessels and
nerves into the periodontal ligament. This perforated appearance of the alveolar bone
is similar to the appearance of the cribriform plate of the ethmoid bone above the
nasal cavity.

Some branches of the blood supply run directly into the periodontal ligament and into
the alveolar bone. Other branches run along the surface of the bone. These various
arterial branches continue into the gingival tissue and terminate in numerous capillary
loops in the superficial area of the gingival connective tissue adjacent to the gingival
epithelium (the papillary region of the gingival connective tissue) (see Fig. 1-4).
Within the gingival tissue, there are numerous anastomoses among these three blood
supplies. This extensive collateral circulation enables the clinician to perform a
variety of surgical procedures on the gingiva without significantly compromising its
blood supply.
Figure 1-3.
The three major types of epithelial organization within the gingival epithelium. a,
The four layers characteristic of orthokeratinized gingiva are seen. These include
the cuboidal cells of the basal layer (BL), a prickle cell layer or spinous layer
(PL), a granular layer (GL) with flattened cells containing keratohyaline granules,
and a keratinized layer (KL) with flattened cells packed with keratin filaments.
When dark nuclei are present in the KL, the epithelium is termed parakeratinized.
When no nuclei can be seen in the KL, the epithelium is "orthokeratinized." b,
Nonkeratinized epithelium. Although a BL and PL are still present, the cells in the
more superficial layers (SL) are not as flat as the parakeratinized or
orthokeratinized epithelium, contain fewer keratin filaments, and still have nuclei.
c, Junctional epithelium. Only two layers are seen: a BL and a PL. The cells of the
most SL of the PL attach to the tooth in part through hemidesmosomes. Note that
in all types of epithelium (a, b, and c), the basal layer is anchored to the
underlying connective tissue through hemidesmosomes, which interdigitate with
anchoring collagen fibrils extending from the connective tissue.
The nerve supply to the periodontium is derived from branches of the trigeminal
nerve and thus is sensory in function. Nerve branches terminate in the periodontal
ligament, surface of the alveolar bone, and within the gingival connective tissue in
four different morphologies of nerve endings that receive stimuli for pain
(nociceptors) and position and pressure (mechanoreceptors or proprioreceptors).

Because the alveolar bone that lines the tooth socket has numerous small perforations
and is mixed in with calcified fiber bundles of the periodontal ligament, it is termed
woven bone. The buccal and lingual plates on the buccal or lingual external surface of
the alveolar process is composed of compact bone (see Fig. 1-1). Between the buccal
or lingual plates and the alveolar bone socket, the bone is more trabecular in
appearance. These three bone regions are usually clearly visible on standard dental
radiographs (see Fig. 1-2). The height of this alveolar bone or alveolar crest is usually
1.0 to 1.5 mm apical to the radiographic cementoenamel junction. In conventional
radiographs of teeth and the supporting alveolar bone, the alveolar bone that lines the
bony socket and extends over the alveolar crest often appears as a radiodense line,
termed the lamina dura. The appearance of this radiodense lamina dura may be
because of an increased density of bone in this area, or superimposition of the bony
curvatures of the bony socket, or both. In periodontal diseases accompanied by loss of
alveolar bone, this radiographic lamina dura is often not seen.
Figure 1-4.

Blood supply of the periodontal tissues. From the apical aspect of the periodontal
tissues, arterial branches course through the periodontal ligament (1), through the
alveolar bone (2), and along the surface of the periosteum (3). The terminal
 branches of each of the three arterial sources form numerous anastomoses and
capillary loops. These arterial loops are especially prominent within the
connective tissue that interdigitates with the oral gingival epithelium (inset
enlargement).

DEVELOPMENT OF THE PERIODONTAL ATTACHMENT

The story of the development of the periodontal attachment and supporting tissues
begins at the earliest stages of tooth development at 4 to 5 weeks gestation.5–7 At this
stage, the oral cavity consists of a simple cavity known as the primitive stomatodeum.
This primitive stomatodeum is lined by a single layer of ectoderm with an underlying
ectomesenchyme. At 4 to 5 weeks, a horseshoe-shaped thickening of this ectoderm
can be seen along the developing mandibular and maxillary arches. This thickening is
formed through the focal division of the ectoderm and is called the primary epithelial
band. At the site of each developing primary tooth, this primary epithelial band will
extend as a dental lamina into the underlying ectomesenchyme and will form a
knoblike projection or tooth bud at its terminal end (Fig. 1-5, A). Deeper within this
ectomesenchyme, rudimentary woven bone will begin to form around each of these
developing tooth buds. This first woven bone will be the structural framework for the
developing alveolar bone support. The epithelium of the tooth bud will begin to
differentiate into a dental organ with four distinct layers (see Fig. 1-5, B): an inner
enamel epithelium that will first differentiate into a columnar secretory ameloblast
layer, an overlying layer of one to two cells of stratum intermedium, a wide area of
stellate reticulum, and an outer enamel epithelium.

Directly beneath this dental organ, the underlying ectomesenchyme will condense
into a dental papilla, which will give rise to the crown and root dentin and most of the
cellular elements of the pulp (see Fig. 1-5, B). At this time, a second spherical
condensation of ectomesenchyme will form to surround the developing dental organ
and dental papilla (see Fig. 1-5, B). This surrounding spherical condensation is called
the dental follicle. Cells of the dental follicle will eventually differentiate into
cementoblasts to lay down cementum, periodontal ligament fibroblasts to lay down
the fibers of the periodontal ligament, and osteoblasts to lay down the alveolar bone
adjacent to the periodontal ligament. The central question of development of the
periodontal attachment is how the root dentin, cementum, periodontal ligament, and
alveolar bone integrate to form this critical anchor for the tooth in the supporting
bone. To understand this process, the development of the root dentin and cementum
will be presented first.
Figure 1-5.
 Two early stages of the development of the tooth and periodontium. A, At
approximately 4 to 5 weeks into development there is downgrowth of the
ectoderm of the primitive oral stomatodeum into the underlying ectomesenchyme.
At the terminal end of this downgrowth, the cells form a knoblike structure or
bud. Cells in the surrounding ectomesenchyme begin to concentrate around this
bud. B, Several weeks later, this ectodermal bud has developed into a caplike
structure with four distinct layers: an outer enamel epithelium (OEE), an inner
enamel epithelium (IEE), a stellate reticulum (SR), and a stratum intermedium
(SI). Directly beneath the inner enamel epithelium, cells of the underlying
ectomesenchyme have condensed into a dental papilla (DP). Surrounding these
two structures is a third condensation, the dental follicle (DF), which will give
rise to most of the cementum, periodontal ligament, and alveolar bone.
Figure 1-6.
Developing root and periodontal structures. At the apical extent of the root, the
inner and outer enamel epithelium have fused to form the Hertwig's epithelial root
sheath (HES). More coronally, this root sheath breaks down to form islands of
epithelial cells in the developing periodontal ligament space, the epithelial rests of
Malassez (ERM). The breakdown of the root sheath and subsequent exposure of
the dentin (D) to the dental follicle allows cells in the dental follicle nearest the
 developing root surface to differentiate into cementoblasts (CB) and lay down the
first cementum matrix (CM). Further away from the tooth follicle, cells
differentiate into fibroblasts and lay down the first bundles of collagen in the
periodontal ligament (PDL).

At the apical extent of the developing crown, the inner and outer epithelium come
together in close apposition. The loop formed by the inner and outer enamel
epithelium is termed the cervical loop and will play a pivotal role in directing the
formation of both the root dentin and the periodontal attachment (Fig. 1-6 and Fig. 1-
7). As the dental organ begins to assume a more bell shape and then lays down the
first enamel and dentin matrix at the incisal tip area, cells in the cervical loop begin to
divide and extend apically as a cylindrical sheath called Hertwig's epithelial root
sheath (see Fig. 1-6 and Fig. 1-7). This root sheath migrates apically around the
dental papilla. Cells in the dental papilla in direct contact with the sheath differentiate
into odontoblasts and lay down the first dentin matrix of the surface of the root. At
about the same time, the root sheath secretes an amorphous hyaline-like layer that
contains among other things, embryonic enamel proteins. This protein is similar to the
protein laid down more coronally by the inner enamel epithelium. After this initial
secretion of dentin matrix by cells of the dental papilla and the amorphous enamel-
like matrix of the root sheath, this root sheath breaks down to form small islands of
epithelial cells in the developing periodontal ligament space called the epithelial rests
of Malassez (see Fig. 1-6).
Figure 1-7.

Low-power micrograph of the apical extent of a developing human root. At the

apical extent of the developing root dentin is Hertwig's epithelial root sheath
(HES). On the more coronal aspect of the root dentin (D), this sheath has been
replaced by cementoblasts (CB) derived from the dental follicle. Odontoblasts
 (OB) derived from the dental papilla (DP) produce dentin matrix, whereas
cementoblasts (CB) from the dental follicle produce cementum. (Courtesy Dr.
Max Listgarten, Foster City, Calif.)

When this root sheath breaks down, it leaves the developing root in direct contact
with the cells of the surrounding dental follicle.8–11 Cells nearest the developing root
dentin will differentiate into a layer of cementoblasts that will lay down a fibrillar
cementum matrix. This layer of cementoblasts will move away from the tooth leaving
a layer of calcifying cementum that slowly grows in thickness. Meanwhile, cells in
the dental follicle nearest the developing alveolar process will differentiate into a
layer of osteoblasts and will lay down bone matrix over the developing alveolar bone
process. Between the developing root and alveolar bone, cells of the dental follicle
will differentiate into fibroblasts and will lay down the first short lengths of
periodontal ligament fibers (see Fig. 1-6). Periodontal ligament fibroblasts will
continuously remodel lengths of ligament fibers into longer and thicker bundles. As
the cementum and alveolar bone both thicken by apposition of their respective
matrices and narrow the periodontal ligament space, periodontal ligament fibers will
become trapped and will calcify within these thickening matrices (Fig. 1-8). These
trapped calcified bundles of collagen fibers are termed Sharpey's fibers. It is primarily
through the entrapment of these ligament fibers by the bone and cementum matrices
that a periodontal connection is made between the root of the tooth and the supporting
alveolar bone.

At first the orientation of these early bundles of collagen fibers is nearly parallel to
the longitudinal root surface, with fibers oriented in a steep oblique angle coronally
from the alveolar bone to apically into the root cementum. Fibroblasts within this
steep oblique orientation are attached, through the adhesion protein fibronectin, to the
segments of collagen bundles through a specialized attachment called the fibronexus.
These periodontal ligament fibroblasts have the ability to contract, and thereby bring
these collagen fibers closer together. Because the alveolar bone is fixed in the
developing mandible and maxilla relative to the unanchored developing root, this
action on the segments of periodontal ligament fibers has the effect of pulling the
developing tooth upward toward the oral cavity. This phenomenon has been shown to
be the primary force for tooth eruption and is called active eruption.

As discussed in the overview section, the most coronal portion of the periodontal
attachment is the epithelial attachment extending apically from the base of the
gingival crevice. The development of this unique attachment begins at the completion
of enamel formation.7 At this stage, the columnar layer of inner enamel epithelium
differentiates into a flat layer of reduced enamel epithelium (Fig. 1-9). This layer of
reduced enamel epithelium attaches to the entire enamel surface of the crown through
"spot weld"-like attachments along the epithelial cell membrane called
hemidesmosomes. These hemidesmosomes appear as thickenings in the cell
membrane that are anchored to the underlying cell structure through intermediate
filaments. Above this layer of reduced enamel epithelium, the more superficial
stratum intermedium and stellate reticulum break down. This results in the outer
enamel epithelium coming in direct contact with the reduced inner enamel epithelium.
This attachment of the inner enamel epithelium to the enamel surface is called the
primary epithelial attachment.
Figure 1-8.

Low-power light micrograph showing the insertion of periodontal ligament fiber

bundles into root cementum on the left and alveolar bone on the right in a
monkey. The ligament fibers insert in thicker and more widely spaced bundles on
the alveolar bone side, whereas fiber bundles are smaller but more numerous on
the cementum side. (Courtesy Dr. Max Listgarten, Foster City, Calif.)

As the tooth erupts toward the oral cavity, this bilayer of reduced enamel epithelium
derived from the dental organ makes contact with epithelium originating from the
lining of the oral cavity. This epithelium from the oral cavity extends into the
connective tissue by cell division (Fig. 1-10). The epithelial cells of the primary
epithelial attachment begin to break down (see Fig. 1-9) and are replaced by these
epithelial cells from the oral cavity (see Fig. 1-10). These oral epithelial cells migrate
from the cusp tips in an apical direction down the enamel crown to the
cementoenamel junction. The result is a multilayered covering of the crown with oral
epithelial cells that are attached to the tooth through hemidesmosomes (Fig. 1-11).
This attachment of oral epithelium to the tooth surface is called the secondary
epithelial attachment.
Figure 1-9.
 Transmission electron microscopic view of the primary epithelial attachment. In
this section of demineralized tissue, two reduced enamel epithelial (REE) cells
that derive from the inner enamel epithelium attach to the demineralized enamel,
which appears as an enamel space (ES). Directly above these reduced enamel
epithelial cells, cells of the original outer enamel epithelium (OEE) are juxtaposed
directly adjacent to these REE cells. (Courtesy Dr. Max Listgarten, Foster City,
Calif.)

As the tooth erupts into the oral cavity, this multilayered secondary epithelial
attachment will split between its layers, leaving a layer or several layers adjacent to
the tooth surface, which will abrade off the tooth surface. The layer of cells on the
opposite side of the split will recede away in an apical direction along with the
underlying connective tissue. This splitting and recession of the epithelial cell layers
more distant from the tooth results in more clinical exposure of the crown. Because
this process does not involve an actual displacement of the tooth as in active eruption,
it is called passive eruption. In the normal passive eruption process, this epithelial
splitting process will continue in a coronal direction until the split approaches the
normal clinical attachment level at the cementoenamel junction. The epithelium on
the opposite side of the split will continue to recede until it is slightly coronal to the
cementoenamel junction. This splitting and recession thus results in the formation of
the gingival crevice.
Figure 1-10.

Diagrammatic representation of the formation of the primary and secondary

epithelial attachment. At the more apical aspect of the tooth crown, the epithelial
attachment is formed by cells of the inner enamel epithelium (the primary
epithelial attachment). As the enamel crown approaches the oral cavity, epithelial
cells from the oral cavity grow downward, replace these inner enamel epithelial
cells from the cusp tips to the cemento-enamel junction, and form the secondary
epithelial attachment.
Figure 1-11.
High-power transmission electron microscopic view of the junctional epithelium
at the region of the epithelial attachment to a section of enamel. In this
demineralized section, the enamel matrix can still be seen covered by a fine
cuticle layer. On the epithelial cell side, numerous hemidesmosomal attachment
complexes can be seen. They appear as small, dark "spot welds." When numerous
hemidesmosomes lie side-by-side, they may appear as a more continuous dark
line (see hemidesmosomes, bottom left). (Courtesy Dr. Max Listgarten, Foster
City, Calif.)
CEMENTUM AND ALVEOLAR BONE: FORMATION,
STRUCTURE, AND PHYSIOLOGY
The deposition of cementum on the root surface that gradually thickens toward the
periodontal ligament space is somewhat similar to the deposition of alveolar bone that
thickens the alveolar bone support from the opposite side of the ligament space. As a
result, the cementum does have some structural and biochemical similarities (as well
as some critical differences) with alveolar bone.9–11 As with the development of the
alveolar bone proper, an organic matrix of cementum composed primarily of type I
and type III collagen is secreted by a layer of formative cells (the cementoblasts) over
the thin hyaline-like layer secreted by Hertwig's epithelial root sheath covering the
root dentin. This fine fibrillar matrix calcifies to form a relatively uniform and well
organized layer of cementum free of cellular elements called primary acellular
cementum.10 This first thin layer of mineralized cementum contains only the fibrillar
matrix from the cementoblasts themselves. These fibers are therefore called intrinsic
fibers of cementum.

As the cementum continues to thicken by apposition of cementum by the

cementoblast layers, this thickening cementum will encounter and incorporate
bundles of the forming periodontal ligament. These ligament bundles incorporated
into the cementum surface will calcify along with the surrounding intrinsic fibers to
form a significant portion of the more superficial layers of the cementum. These
insertions of calcified ligament fibers are termed extrinsic fibers of the cementum.11
A similar entrapment and calcification process occurs on the forming alveolar bone
side. The general term for these calcified insertions of bundles of ligament fibers into
the cementum and bone are Sharpey's fibers. On the cementum side, these Sharpey's
fibers are much thinner in diameter and insert at closer intervals when compared with
the alveolar bone side (see Fig. 1-8). These differences in the pattern of insertion have
clinical importance in the distribution of forces that are generated within the
periodontal ligament during occlusion, tooth movement, and traumatic forces.
Specifically, these forces are more evenly distributed along the cementum surface and
are more concentrated along the more widely spaced insertions on the alveolar bone
side. As a result, in response to mechanical forces, there is generally a remodeling of
the periodontal housing on the alveolar bone side and not on the cementum side. This
prevents the possibility of significant cementum and root resorption. In addition, the
root cementum is protected from this relatively extensive remodeling because it is
avascular, and therefore not as exposed to osteoclast-like precursor cells in the
circulation. Although small areas of microscopic cementum resorption and repair
have been frequently observed in histologic sections, more extensive resorption of
cementum is usually not seen unless there is a force on the tooth of a high enough
magnitude, or duration, or both, that cannot be accommodated by the remodeling of
the alveolar bone.

As the tooth completes active eruption into the oral cavity and meets its opposing
tooth in the other arch, the formation of cementum becomes somewhat less regular
and organized. This type of cementum formation that occurs over the more organized
primary cementum is called secondary cementum. It occurs mainly along the apical
one third of the root. During the formation of secondary cementum, cells in the layer
of secreting cementoblasts will often become entrapped within the cementum matrix
(Fig. 1-12). These entrapped cementoblasts become cementocytes similar in
appearance to the entrapped osteoblasts that become osteocytes on the alveolar bone
side (Fig. 1-13). These areas of cementum that contain cementocytes are called
cellular cementum. Layers of cellular cementum are generally seen in the apical one
third of the root surface. In secondary cementum, these layers of cellular cementum
often alternate with layers of acellular cementum.

By understanding how cementum forms, it can be understood how areas of cementum

can be termed acellular or cellular cementum, primary or secondary cementum, and
can contain intrinsic fibers, extrinsic fibers, or a mixture of these fibers. There is one
final terminology of cementum that needs to be introduced to complete this
discussion: the formation of a thin layer of cementum at the junction of the enamel
and the root surface.12 This form of cementum lacks a fibrillar organization and is
therefore called afibrillar cementum. It is usually formed after root eruption when the
connective tissue comes in direct contact with the enamel and dentin at the
cementoenamel junction without an intervening layer of cementoblasts. In
approximately 30% of teeth, the coronal extent of the cementum ends in a "butt" joint
adjacent to the enamel, whereas in 60% to 65% of teeth, the cementum may overlap
the enamel, and in 5% to 10% of teeth, the cementum will end short of the enamel
thereby exposing the root surface dentin. This latter situation may have clinical
importance in that patients with this type of gap may experience root sensitivity
during instrumentation or exposure to extreme temperatures.
Figure 1-12.
 Low-power light micrograph of an area of cementum between root dentin (D) and
periodontal ligament (PDL). Numerous cementoblasts can be seen lining the
cementum surface (CB). In some areas (arrowheads), the cementoblasts appear
partially trapped in the cementum. (Courtesy Dr. Gary Armitage, San Francisco,
Calif.)
Figure 1-13.
 Light micrograph section through an area of cellular cementum in a monkey. The
dentin (D) and granular layer of tomes (GLT) are on the left and the periodontal
ligament space on the right. Numerous cementocytes (CY) are seen within this
layer of cellular cementum. Note the orientation of the cementocyte cell processes
toward the periodontal ligament side. (Courtesy Dr. Max Listgarten, Foster City,
Calif.)

From the time the tooth has erupted to the occlusal plane, cementum will continue to
be deposited throughout life.13 This thickening of cementum with age is usually
greatest around the apical one third of the tooth. This apical thickening may partially
maintain the overall length of the tooth during the natural attrition of the crown and
may therefore retard the collapse of the vertical bite dimension with aging. Abnormal
thickening of the cementum is often observed in certain metabolic bone diseases such
as Paget's disease.14
Figure 1-14.
 Low-power trypan blue stained section from an advanced periodontal lesion in the
rice rat. Several multinucleated osteoclasts are seen on the bone surface.
Polymorphonuclear leukocytes (PMN) can be seen in the adjacent blood vessel
(BV) and in the connective tissue.

On the other side of the future periodontal ligament, the alveolar bone is forming.15
The alveolar bone is similar in chemical composition to fibrillar cementum,
particularly cellular fibrillar cementum. As discussed in the overall development
section, the alveolar bone begins to first form by an intramembranous ossification
within the ectomesenchyme surrounding the developing tooth. This first bone formed
is less organized woven bone that will be replaced with a more organized lamellar
bone. Within this forming lamellar bone, individual osteons with blood and nerve
supplies can be observed. As cells in the dental follicle between this first alveolar
bone and developing root differentiate into cementoblasts on the root dentin side and
fibroblasts in the future periodontal ligament space, the cells in the dental follicle near
the alveolar bone side differentiate into osteoblasts. This layer of osteoblasts will lay
down bone matrix to form the outer wall of the alveolar bone support.

During the life of the periodontium, the alveolar bone continuously remodels its
shape in response to mechanical forces on the tooth and inflammation. As a result, on
the surface of the alveolar bone the following can be observed:

1. Bone synthesis with areas of bone covered with cuboidal-shaped

osteoblasts secreting bone matrix,
 2. Bone resorption with areas of bone covered by multinucleated bone
resorbing osteoclasts (Fig. 1-14), and

3. Areas of no synthetic or resorptive activity with bone covered by flattened

cells.

PERIODONTAL LIGAMENT AND GINGIVAL

CONNECTIVE TISSUE: FORMATION, STRUCTURE, AND
PHYSIOLOGY
In this section, the periodontal ligament and gingival connective tissue structures will
be considered together because there is some overlap in their respective structure and
function. When the early development of the periodontal ligament was discussed
previously, the ligament per se was in the form of short lengths of collagen bundles
oriented in a near parallel direction to the tooth surface. As discussed in the previous
section on the development of cementum, the bundles closest to the developing and
expanding cementum on one side and alveolar bone on the other side are incorporated
into the matrix of these forming hard tissues. The fibroblasts that form the collagen in
these ligament bundles will continue to extend and remodel these ligament fiber
bundles, through secretion of new collagen and resorption of older collagen, until
they form a continuous network of fibers between the cementum and bone. As the
tooth erupts into the oral cavity by the process of active eruption, the erupting root
connected to the ligament fibers will move the orientation of the fibers to a generally
more perpendicular orientation to the root surface (Fig. 1-15).5 At the coronal extent
of the ligament near the alveolar crest, the ligament will be oriented more obliquely
from an apical insertion at the alveolar crest to a coronal insertion at the root near the
cementoenamel junction (see Fig. 1-15). More apically these fibers will orient in a
more horizontal and perpendicular direction to the root surface, whereas near the root
apex and within the furcations of molars, these fibers will orient more vertically and
perpendicularly to the root surface. Thus periodontal ligament fiber groups can be
classified based on their orientation (see Fig. 1-15). However, these distinct fiber
orientations are not always observed on routine histologic sections.
Figure 1-15.
 The major periodontal ligament and gingival fiber groups. A, In this low-power
diagram, periodontal ligament fibers can be divided into several groupings
depending on their orientation. These include: (1) an alveolar crest group, (2) a
horizontal fiber group, (3) an oblique fiber group, (4) an apical group, and (5) a
radicular group. B, In this magnified view of the alveolar crest, the gingival fibers
can also be classified based on their orientation, origin, and insertion. These
groups include: (a) fibers that run from the root surface and over the oral
periosteum, (b) fibers that run from the root surface and into the gingiva, and (c)
fibers that run from the alveolar bone and into the gingiva. Not shown are fibers
that run in a circumferential or semicircumferential direction around the tooth
within the gingiva, as well as the transseptal fiber group that runs from the root
surface of one tooth over the alveolar crest and into the root surface of the
adjacent tooth.

The collagen fiber bundles themselves are made up primarily of type I collagen
(80%) with a smaller percentage of type III collagen (20%).7 As with collagen fiber
structures in other connective tissues of the body, each fiber bundle is composed of
smaller diameter collagen fibrils (Fig. 1-16). Each collagen fibril is in turn composed
of individual bundles of collagen molecules that are secreted by the fibroblasts as
procollagen α helices. These procollagen molecules are assembled and modified
extracellularly into bundles that are staggered in a regular linear manner to give the
characteristic cross-banding pattern seen in the collagen fibril.

In addition, the periodontal ligament also contains immature forms of other

connective tissue fibers, such as an immature form of elastin fiber known as elaunin,
and oxytalan fibers. Elaunin fibers and oxytalan fibers form a more reticular-like
network that is generally oriented perpendicular to the collagen fiber bundles.
Although the role of these elaunin and oxytalan fibers still remains unknown, they
may play a role in the spatial organization of the principal collagen fibers and blood
vessel elements in the periodontal ligament. At intervals along the periodontal
ligament near the root surface, remnants of Hertwig's epithelial root sheath, the
epithelial rests of Malassez, can be observed (see Fig. 1-6). Although several theories
regarding the future fate of these cells in periodontal development and periodontal
disease have been proposed, the significance of these epithelial remnants has yet to be
determined.7
Figure 1-16.
High-power transmission electron microscopic view of a periodontal ligament in
the rice rat. Bundles of collagen fibrils that make up collagen fibers are seen
running parallel to elongated fibroblasts. FC, fibroblast cytoplasm; FN, fibroblast
nucleus.
Between the fiber elements of the ligament, there is a ground substance consisting of
glycosaminoglycans, laminin, and fibronectin. The ground substance itself has the
potential to retain aqueous fluid and is composed of 70% water. As an aqueous
"cushion," the ground substance may help the ligament absorb mechanical forces
placed on the tooth and periodontal support.

As discussed in the overview of the periodontium, the gingival connective tissue

coronal to the periodontal ligament area is called the reticular area of the gingival
connective tissue. This area shares many of the same structural features as the
periodontal ligament. It is an area composed of a dense network of collagen fibers
(primarily of type I) surrounded by a similar composition of ground substance seen in
the periodontal ligament. As with the periodontal ligament, these bundles of collagen
fibers have distinct orientations that can be classified as gingival fiber groups (see
Fig. 1-15). These groups include fibers that run from the alveolar crest into the
gingiva; fibers that run from the tooth surface and over the buccal or lingual
periosteum; fibers that run in a circular or semicircular pattern around the tooth; and
fibers that run interproximally from the root surface of one tooth, over the alveolar
crest, and into the root surface of the adjacent tooth (the transseptal fibers).1,5 These
organized gingival fiber groups enable the gingiva to form a rigid cuff around the
tooth that can add stability, especially when a significant portion of the periodontal
ligament and alveolar support is lost. This may explain in part the increased mobility
in periodontally involved teeth immediately after surgical procedures because these
procedures often significantly disrupt or remove these gingival fiber groups. In
addition, after tooth movement, these fiber groups may exert forces on the tooth to
move it toward its original position. Therefore, after tooth movement procedures, a
"fiberotomy" to cut the gingival fiber attachments to the tooth is sometimes
performed.16

The portion of the gingival connective tissue above the dense reticular layer and
underlying the gingival epithelium itself is called the papillary layer of the gingival
connective tissue. In this layer, the distribution of collagen is sparser and less
organized than in the reticular layer. Between the epithelial cells and the connective
tissue lies the basal lamina (basement membrane), which is critical to the attachment
between the two tissues.7 At the electron microscopic level, the basal lamina consists
of a dark band called the lamina densa and a more translucent band known as the
lamina lucida. The portion of the papillary layer adjacent to the basal lamina has
small anchoring fibrils of type IV collagen that anchor the lamina densa of the basal
lamina of the gingival epithelium (also composed of type IV collagen) to the gingival
connective tissue. In addition to the collagen types I, III, and IV, ground substance,
blood vessels, neural and lymphatic elements, and small numbers of inflammatory
cells such as neutrophils, monocytes, lymphocytes, mast cells, and macrophages are
routinely observed. During the inflammatory process of periodontal diseases, the
number of these cells increases within this papillary layer. The clinical importance of
this inflammatory cell infiltrate is discussed in later chapters.
GINGIVAL EPITHELIUM: FORMATION, STRUCTURE,
AND PHYSIOLOGY
As described in the section on development of the periodontium, the erupting enamel
crown of the tooth is covered with several layers of epithelium that are first derived
from the inner enamel epithelium (the primary epithelial attachment) and are then
replaced from the incisal tips to the cementoenamel junction with epithelial cells from
the oral cavity (the secondary epithelial attachment) (see Fig. 1-10). During the
process of passive eruption, a natural gingival crevice is formed around the
circumference of the tooth. Within this gingival crevice, three distinct zones of
epithelium can be seen on routine buccal-lingual sections of the tooth and
surrounding periodontal tissues (see Fig. 1-3). These include a thick orthokeratinized
or parakeratinized oral gingival epithelium that faces the oral cavity, an unattached
thinner and parakeratinized or nonkeratinized crevicular epithelium, and an area of
junctional epithelium where the gingiva actually attaches to the tooth through
hemidesmosomes and adhesion proteins such as laminins (Fig. 1-17, see also Fig. 1-3
and Fig. 1-11). Each of these three zones of gingival epithelium is distinct in the
organization, stratification, and characteristics of the keratinocytes that make up each
strata.

The oral gingival epithelium resembles the epidermis in structure and has multiple
layers (see Fig. 1-3).5–7 The basal layer has one or two layers of cuboidal-shaped cells
that divide and migrate toward the superficial layers of epithelium. Outside of the
basal layers is the prickle layer consisting of more spinous-shaped cells with large
intercellular spaces (also known as the spinous layer, or stratum spinosum). Cells of
both the basal and prickle cell layers attach to each other in part through desmosomes.
These desmosome "spot-weld" junctions appear on transmission electron micrographs
as thickenings of the inner membranes of both apposing cells. In the intercellular
space between these membrane thickenings, a central dark line is often discernible,
which may be an area of protein links between the two cell membranes. As with
hemidesmosomes, these membrane thickenings are anchored to the underlying cell
structures through intermediate filaments. Above the prickle layer there is a layer of
flattened granular cells with flattened and condensed nuclei, increased accumulation
of intracellular keratin within keratin filaments and keratohyaline granules, and
intracellular and extracellular membrane-coated granules (also known as the stratum
granulosum). Above the granular layer there is a keratinized layer of flattened cells
packed with keratin (also known as the stratum corneum). In some instances, the cells
of the keratinized layer have no discernible nuclei (orthokeratinized), whereas in
others, dense nuclei are visible (parakeratinized). The superficial cells of this
keratinized layer will continuously slough off into the oral cavity to be replaced by
cells migrating from the deeper layers.

Within the oral gingival epithelium, there are several other cells not derived from
keratinocytes. These include melanocytes that transfer melanin pigment granules to
the surrounding basal layer of keratinocytes, Langerhans cells that are part of the
reticuloendothelium system and are responsible for processing and presenting foreign
antigens to the immune system, and Merkel cells that may be responsible for
perception of sensation in the gingiva.
Figure 1-17.

Low-power transmission electron micrograph of the junctional epithelium in the

rice rat. As in humans, this junctional epithelium consist of solely two layers: a
basal layer and a prickle (spinous) layer. In this view, the most superficial layer of
the prickle layer is seen to attach to the root cementum (arrowheads), which has
been decalcified in the preparation of this section. In humans, this attachment
level can be on enamel alone, the junction of enamel and root cementum or root
dentin, or on the root cementum or dentin alone. The basal layer has numerous
desmosomes between the individual cells, making intercellular spaces very
narrow and almost indistinguishable. Conversely, the cells of the prickle layer
have fewer desmosomal attachments (small arrows) and wider, more visible
intercellular spaces.

The crevicular epithelium is generally nonkeratinized, although some parakeratinized

cells may be seen in the most coronal region. As with the oral gingival epithelium, the
crevicular epithelium has a basal layer and a prickle layer; however, a distinct
granular layer and keratinized layer are not present (see Fig. 1-3). Rather the most
Other documents randomly have
different content
 *** END OF THE PROJECT GUTENBERG EBOOK SURVIVAL ***

Updated editions will replace the previous one—the old editions will
be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States copyright in
these works, so the Foundation (and you!) can copy and distribute it
in the United States without permission and without paying
copyright royalties. Special rules, set forth in the General Terms of
Use part of this license, apply to copying and distributing Project
Gutenberg™ electronic works to protect the PROJECT GUTENBERG™
concept and trademark. Project Gutenberg is a registered trademark,
and may not be used if you charge for an eBook, except by following
the terms of the trademark license, including paying royalties for use
of the Project Gutenberg trademark. If you do not charge anything
for copies of this eBook, complying with the trademark license is
very easy. You may use this eBook for nearly any purpose such as
creation of derivative works, reports, performances and research.
Project Gutenberg eBooks may be modified and printed and given
away—you may do practically ANYTHING in the United States with
eBooks not protected by U.S. copyright law. Redistribution is subject
to the trademark license, especially commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
 PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the free

distribution of electronic works, by using or distributing this work (or
any other work associated in any way with the phrase “Project
Gutenberg”), you agree to comply with all the terms of the Full
Project Gutenberg™ License available with this file or online at
www.gutenberg.org/license.

Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand, agree
to and accept all the terms of this license and intellectual property
(trademark/copyright) agreement. If you do not agree to abide by all
the terms of this agreement, you must cease using and return or
destroy all copies of Project Gutenberg™ electronic works in your
possession. If you paid a fee for obtaining a copy of or access to a
Project Gutenberg™ electronic work and you do not agree to be
bound by the terms of this agreement, you may obtain a refund
from the person or entity to whom you paid the fee as set forth in
paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only be

used on or associated in any way with an electronic work by people
who agree to be bound by the terms of this agreement. There are a
few things that you can do with most Project Gutenberg™ electronic
works even without complying with the full terms of this agreement.
See paragraph 1.C below. There are a lot of things you can do with
Project Gutenberg™ electronic works if you follow the terms of this
agreement and help preserve free future access to Project
Gutenberg™ electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright law
in the United States and you are located in the United States, we do
not claim a right to prevent you from copying, distributing,
performing, displaying or creating derivative works based on the
work as long as all references to Project Gutenberg are removed. Of
course, we hope that you will support the Project Gutenberg™
mission of promoting free access to electronic works by freely
sharing Project Gutenberg™ works in compliance with the terms of
this agreement for keeping the Project Gutenberg™ name associated
with the work. You can easily comply with the terms of this
agreement by keeping this work in the same format with its attached
full Project Gutenberg™ License when you share it without charge
with others.

1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside the
United States, check the laws of your country in addition to the
terms of this agreement before downloading, copying, displaying,
performing, distributing or creating derivative works based on this
work or any other Project Gutenberg™ work. The Foundation makes
no representations concerning the copyright status of any work in
any country other than the United States.

1.E. Unless you have removed all references to Project Gutenberg:

1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project Gutenberg™
work (any work on which the phrase “Project Gutenberg” appears,
or with which the phrase “Project Gutenberg” is associated) is
accessed, displayed, performed, viewed, copied or distributed:
 This eBook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it away
or re-use it under the terms of the Project Gutenberg License
included with this eBook or online at www.gutenberg.org. If you
are not located in the United States, you will have to check the
laws of the country where you are located before using this
eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is derived

from texts not protected by U.S. copyright law (does not contain a
notice indicating that it is posted with permission of the copyright
holder), the work can be copied and distributed to anyone in the
United States without paying any fees or charges. If you are
redistributing or providing access to a work with the phrase “Project
Gutenberg” associated with or appearing on the work, you must
comply either with the requirements of paragraphs 1.E.1 through
1.E.7 or obtain permission for the use of the work and the Project
Gutenberg™ trademark as set forth in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is posted

with the permission of the copyright holder, your use and distribution
must comply with both paragraphs 1.E.1 through 1.E.7 and any
additional terms imposed by the copyright holder. Additional terms
will be linked to the Project Gutenberg™ License for all works posted
with the permission of the copyright holder found at the beginning
of this work.

1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files containing a
part of this work or any other work associated with Project
Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute this

electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1
with active links or immediate access to the full terms of the Project
Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form,
including any word processing or hypertext form. However, if you
provide access to or distribute copies of a Project Gutenberg™ work
in a format other than “Plain Vanilla ASCII” or other format used in
the official version posted on the official Project Gutenberg™ website
(www.gutenberg.org), you must, at no additional cost, fee or
expense to the user, provide a copy, a means of exporting a copy, or
a means of obtaining a copy upon request, of the work in its original
“Plain Vanilla ASCII” or other form. Any alternate format must
include the full Project Gutenberg™ License as specified in
paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,

performing, copying or distributing any Project Gutenberg™ works
unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or providing

access to or distributing Project Gutenberg™ electronic works
provided that:

• You pay a royalty fee of 20% of the gross profits you derive
from the use of Project Gutenberg™ works calculated using the
method you already use to calculate your applicable taxes. The
fee is owed to the owner of the Project Gutenberg™ trademark,
but he has agreed to donate royalties under this paragraph to
the Project Gutenberg Literary Archive Foundation. Royalty
payments must be paid within 60 days following each date on
which you prepare (or are legally required to prepare) your
periodic tax returns. Royalty payments should be clearly marked
as such and sent to the Project Gutenberg Literary Archive
Foundation at the address specified in Section 4, “Information
 about donations to the Project Gutenberg Literary Archive
Foundation.”

• You provide a full refund of any money paid by a user who

notifies you in writing (or by e-mail) within 30 days of receipt
that s/he does not agree to the terms of the full Project
Gutenberg™ License. You must require such a user to return or
destroy all copies of the works possessed in a physical medium
and discontinue all use of and all access to other copies of
Project Gutenberg™ works.

• You provide, in accordance with paragraph 1.F.3, a full refund of

any money paid for a work or a replacement copy, if a defect in
the electronic work is discovered and reported to you within 90
days of receipt of the work.

• You comply with all other terms of this agreement for free
distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project Gutenberg™

electronic work or group of works on different terms than are set
forth in this agreement, you must obtain permission in writing from
the Project Gutenberg Literary Archive Foundation, the manager of
the Project Gutenberg™ trademark. Contact the Foundation as set
forth in Section 3 below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend

considerable effort to identify, do copyright research on, transcribe
and proofread works not protected by U.S. copyright law in creating
the Project Gutenberg™ collection. Despite these efforts, Project
Gutenberg™ electronic works, and the medium on which they may
be stored, may contain “Defects,” such as, but not limited to,
incomplete, inaccurate or corrupt data, transcription errors, a
copyright or other intellectual property infringement, a defective or
damaged disk or other medium, a computer virus, or computer
codes that damage or cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for

the “Right of Replacement or Refund” described in paragraph 1.F.3,
the Project Gutenberg Literary Archive Foundation, the owner of the
Project Gutenberg™ trademark, and any other party distributing a
Project Gutenberg™ electronic work under this agreement, disclaim
all liability to you for damages, costs and expenses, including legal
fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR
NEGLIGENCE, STRICT LIABILITY, BREACH OF WARRANTY OR
BREACH OF CONTRACT EXCEPT THOSE PROVIDED IN PARAGRAPH
1.F.3. YOU AGREE THAT THE FOUNDATION, THE TRADEMARK
OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL
NOT BE LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT,
CONSEQUENTIAL, PUNITIVE OR INCIDENTAL DAMAGES EVEN IF
YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you

discover a defect in this electronic work within 90 days of receiving
it, you can receive a refund of the money (if any) you paid for it by
sending a written explanation to the person you received the work
from. If you received the work on a physical medium, you must
return the medium with your written explanation. The person or
entity that provided you with the defective work may elect to provide
a replacement copy in lieu of a refund. If you received the work
electronically, the person or entity providing it to you may choose to
give you a second opportunity to receive the work electronically in
lieu of a refund. If the second copy is also defective, you may
demand a refund in writing without further opportunities to fix the
problem.

1.F.4. Except for the limited right of replacement or refund set forth
in paragraph 1.F.3, this work is provided to you ‘AS-IS’, WITH NO
OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED,
INCLUDING BUT NOT LIMITED TO WARRANTIES OF
MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied

warranties or the exclusion or limitation of certain types of damages.
If any disclaimer or limitation set forth in this agreement violates the
law of the state applicable to this agreement, the agreement shall be
interpreted to make the maximum disclaimer or limitation permitted
by the applicable state law. The invalidity or unenforceability of any
provision of this agreement shall not void the remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation,

the trademark owner, any agent or employee of the Foundation,
anyone providing copies of Project Gutenberg™ electronic works in
accordance with this agreement, and any volunteers associated with
the production, promotion and distribution of Project Gutenberg™
electronic works, harmless from all liability, costs and expenses,
including legal fees, that arise directly or indirectly from any of the
following which you do or cause to occur: (a) distribution of this or
any Project Gutenberg™ work, (b) alteration, modification, or
additions or deletions to any Project Gutenberg™ work, and (c) any
Defect you cause.

Section 2. Information about the Mission

of Project Gutenberg™
Project Gutenberg™ is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new computers.
It exists because of the efforts of hundreds of volunteers and
donations from people in all walks of life.

Volunteers and financial support to provide volunteers with the

assistance they need are critical to reaching Project Gutenberg™’s
goals and ensuring that the Project Gutenberg™ collection will
remain freely available for generations to come. In 2001, the Project
Gutenberg Literary Archive Foundation was created to provide a
secure and permanent future for Project Gutenberg™ and future
generations. To learn more about the Project Gutenberg Literary
Archive Foundation and how your efforts and donations can help,
see Sections 3 and 4 and the Foundation information page at
www.gutenberg.org.

Section 3. Information about the Project

Gutenberg Literary Archive Foundation
The Project Gutenberg Literary Archive Foundation is a non-profit
501(c)(3) educational corporation organized under the laws of the
state of Mississippi and granted tax exempt status by the Internal
Revenue Service. The Foundation’s EIN or federal tax identification
number is 64-6221541. Contributions to the Project Gutenberg
Literary Archive Foundation are tax deductible to the full extent
permitted by U.S. federal laws and your state’s laws.

The Foundation’s business office is located at 809 North 1500 West,

Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up
to date contact information can be found at the Foundation’s website
and official page at www.gutenberg.org/contact

Section 4. Information about Donations to

the Project Gutenberg Literary Archive
Foundation
Project Gutenberg™ depends upon and cannot survive without
widespread public support and donations to carry out its mission of
increasing the number of public domain and licensed works that can
be freely distributed in machine-readable form accessible by the
widest array of equipment including outdated equipment. Many
small donations ($1 to $5,000) are particularly important to
maintaining tax exempt status with the IRS.

The Foundation is committed to complying with the laws regulating

charities and charitable donations in all 50 states of the United
States. Compliance requirements are not uniform and it takes a
considerable effort, much paperwork and many fees to meet and
keep up with these requirements. We do not solicit donations in
locations where we have not received written confirmation of
compliance. To SEND DONATIONS or determine the status of
compliance for any particular state visit www.gutenberg.org/donate.

While we cannot and do not solicit contributions from states where

we have not met the solicitation requirements, we know of no
prohibition against accepting unsolicited donations from donors in
such states who approach us with offers to donate.

International donations are gratefully accepted, but we cannot make

any statements concerning tax treatment of donations received from
outside the United States. U.S. laws alone swamp our small staff.

Please check the Project Gutenberg web pages for current donation
methods and addresses. Donations are accepted in a number of
other ways including checks, online payments and credit card
donations. To donate, please visit: www.gutenberg.org/donate.

Section 5. General Information About

Project Gutenberg™ electronic works
Professor Michael S. Hart was the originator of the Project
Gutenberg™ concept of a library of electronic works that could be
freely shared with anyone. For forty years, he produced and
distributed Project Gutenberg™ eBooks with only a loose network of
volunteer support.
Project Gutenberg™ eBooks are often created from several printed
editions, all of which are confirmed as not protected by copyright in
the U.S. unless a copyright notice is included. Thus, we do not
necessarily keep eBooks in compliance with any particular paper
edition.

Most people start at our website which has the main PG search
facility: www.gutenberg.org.

This website includes information about Project Gutenberg™,

including how to make donations to the Project Gutenberg Literary
Archive Foundation, how to help produce our new eBooks, and how
to subscribe to our email newsletter to hear about new eBooks.
Welcome to Our Bookstore - The Ultimate Destination for Book Lovers
Are you passionate about books and eager to explore new worlds of
knowledge? At our website, we offer a vast collection of books that
cater to every interest and age group. From classic literature to
specialized publications, self-help books, and children’s stories, we
have it all! Each book is a gateway to new adventures, helping you
expand your knowledge and nourish your soul
Experience Convenient and Enjoyable Book Shopping Our website is more
than just an online bookstore—it’s a bridge connecting readers to the
timeless values of culture and wisdom. With a sleek and user-friendly
interface and a smart search system, you can find your favorite books
quickly and easily. Enjoy special promotions, fast home delivery, and
a seamless shopping experience that saves you time and enhances your
love for reading.
Let us accompany you on the journey of exploring knowledge and
personal growth!

ebookgate.com