Periodontology - Clinical Attachment Loss

Clinical attachment loss which is also known as CAL, is the presence of periodontal disease. Periodontal disease, or gum disease, is a set of inflammatory conditions which affect the tissues that surround the teeth. In the early stage, the condition is called gingivitis. With gingivitis, the gums become swollen, red and may even bleed. In the more serious form, the condition is called periodontitis. With periodontitis, the gums detach away from the tooth, there can be bone loss, and the teeth may become loose or even fall out. Bad breath can also be a side effect of periodontitis.

Generally, periodontal disease is caused by bacteria in the mouth which infects the tissue around the teeth. The risk factors for periodontal disease include smoking, diabetes, HIV/AIDS, a family history and some medications. A diagnosis is made by inspecting the gum tissue around the teeth both visually and with a probe. X-rays may also be used to evaluate bone loss around the teeth.

Treatment for periodontal disease includes good oral hygiene practices and regularly scheduled professional teeth cleanings. Effective oral hygiene usually includes twice daily brushing and regular flossing. In some cases, dental surgery or antibiotics may be suggested as part of the treatment plan. In 2015, 538 million people were estimated to be affected with periodontal disease worldwide. In the United States, almost half of people over the age of 30 are impacted and about 70% of those who are over 65 have the condition. Males are more likely to be affected than females.

Chronic periodontitis is a prevalent disease found in the oral cavity. It involves chronic inflammation of the periodontal tissues due to the accumulation of dental plaque. Periodontitis starts as gingivitis and can progress onto chronic and aggressive periodontitis. It is important to diagnose chronic periodontitis in its early stages in order to prevent severe and irreversible damage to the tooth. Because chronic periodontitis is painless as the disease progresses, it’s not common for patients to seek dental treatment in the early stages. Mild to moderate chronic periodontitis is manageable with the proper mechanical removal of the biofilm and calculus subgingivally. Thorough and effective oral hygiene and regular periodontal checkups every three months are critical for managing the disease.

There are numerous risk factors which can affect the prevalence, rate, extent and severity of the progression of the disease. Some of the most important risk factors include smoking, poor oral hygiene and the inability to control plaque biofilm.

Anatomy of the attachment

The teeth are attached to the surrounding and supporting alveolar bone through the periodontal ligament (PDL) fibers. These PDL fibers run from the bone into the cementum, which exists naturally on the root surface of teeth. They are also attached to the gingival tissue which covers the alveolar bone via an attachment apparatus. Because the attachment exists superficial to the height of the alveolar bone, it is called the supracrestal attachment apparatus.

The supracrestal attachment apparatus is made from two layers which are the coronal junctional epithelium and the more apical gingival connective tissue fibers. Together, the two layers form the thickness of the gingival tissue and this specific dimension is called the biologic width.

Periodontal disease

Plaque-induced periodontal diseases are generally classified as being destructive or non-destructive. Clinical attachment loss is a sign of destructive and physiologically irreversible periodontal disease. Clinical attachment loss is a term which is almost exclusively used to describe to connective tissue attachment loss.

Sites with periodontitis can exhibit clinical signs of gingival inflammation and experience a loss of connective tissue attachment. Connective tissue attachment loss describes the pathological detachment of collagen fibers from the cemental surface with the concomitant apical migration of the junctional or pocket epithelium onto the root surface.