Chronic Period on Tit Is Impt

8/9/2019 Chronic Period on Tit Is Impt

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Chronic Periodontitis

Localized

Generalized


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Learning Outcomes

1. Describe the development of a

periodontal pocket.

2. Relate clinical characteristics to the

histopathologic changes for chronicperiodontitis.

3. Compare the gingival pocket with the

periodontal pocket.

4. Determine the severity of PD activity

using clinical data.


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Common Characteristics

Onset - any age; most common inadults

Plaque initiates condition

Subgingival calculus commonfinding

Slow-mod progression; periods of

rapid progression possibleModified by local factors/systemic

factors/stress/smoking


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Extent & Severity

Extent:

Localized: 30% of sites affected

Generalized > 30% of sites affected

Severity: entire dentition or individualteeth/site

Slight = 1-2 mm CAL Moderate = 3-4 mm CAL

Severe = mm CAL


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Clinical Characteristics

Deep red to

bluish-red tissues

Thickened

marginal gingiva

Blunted/cratered

papilla

Bleeding and/or

suppuration

Plaque/calculus

deposits


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Clinical Characteristics

Variable pocket

depths

Horizontal/vertical

bone loss

Tooth mobility


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Pathogenesis Pocket

Formation Bacterial

challenge initiates

initial lesion of

gingivitis With disease

progression &

change in

microorganisms development of

periodontitis


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Pocket Formation

Cellular & fluid inflammatoryexudate degenerates CT

Gingival fibers destroyed

Collagen fibers apical to JEdestroyed infiltration ofinflammatory cells & edema

Apical migration of junctionalepithelium along root

Coronal portion of JE detaches


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Pocket Formation

Continued

extension of JE

requires healthy

epithelial cells! Necrotic JE slows

down pocket

formation

Pocket basedegeneration less

severe than lateral


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Pocket Formation

Continue inflammation:

Coronal extension of gingival margin

JE migrates apically & separates from

root Lateral pocket wall proliferates &

extends into CT

Leukocytes & edema

Infiltrate lining epithelium Varying degrees of degeneration &

necrosis


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Development of Periodontal

Pocket


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Continuous Cycle!

Plaque gingival inflammation

pocket formation more plaque


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Histopathology

Connective Tissue:

Edematous

Dense infiltrate:

Plasma cells (80%) Lymphocytes, PMNs

Blood vessels proliferate, dilate & are

engorged

Varying degrees of degeneration in addition

to newly formed capillaries, fibroblasts,

collagen fibers in some areas


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Histopathology

Periodontal pocket:

Lateral wallshows most severedegeneration

Epithelial proliferation & degeneration Rete pegs protrude deep within CT

Dense infiltrate of leukocytes & fluidfound in rete pegs & epithelium

Degeneration & necrosis of epitheliumleads to ulceration of lateral wall,exposure ofCT, suppuration


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Clinical & Histopathologic

Features Clinical :

1. Pocket wall

bluish-red

2. Smooth, shiny

surface

3. Pitting on

pressure

Histopathology:

1. Vasodilation &

vasostagnation

2. Epithelial

proliferation,

edema

3. Edema &

degeneration of

epithelium


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Features Clinical:

1. Pocket wall may

be pink & firm

2. Bleeding with

probing

3. Pain with

instrumentation

Histopathology:

1. Fibrotic changes

dominate

2. blood flow,

degenerated,

thin epithelium

3. Ulceration of

pocket

epithelium


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Features Clinical :

1. Exudate

2. Flaccid tissues

Histopathology:

1. Accumulation of

inflammatory

products

2. Destruction of

gingival fibers


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Root Surface Wall

Periodontaldisease affects rootsurface:

Perpetuates disease

Decay, sensitivity Complicates treatment

Embedded collagen fibersdegenerate cementum exposedto environment

Bacteria penetrate unprotected root


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Root Surface Wall

Necrotic areas of cementum form;

clinically soft

A

ct as reservoir for bacteriaRoot planing may remove necrotic

areas firmer surface


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0

Classification of Pockets

Gingival:

Coronal migration of gingival margin

Periodontal: Apical migration of epithelial

attachment

Suprabony:

Base of pocket coronal to height of alveolar crest Infrabony:

Base of pocket apical to height of alveolar crest

Characterized by angular bony defects


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1

Periodontal Pocket

Suprabony pocket


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Inflammatory Pathway

Stages I-III inflammation degradesgingival fibers

Spreads via blood vessels:

Interproximal: Loose CT transseptal fibers

marrow spaces of cancellous bone periodontal ligament

suprabony pockets & horizontalbone loss transseptal fiberstransverse horizontally


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Interproximal:

Loose CT periodontal ligament

bone infrabony pockets & vertical

bone loss transseptal fiberstransverse in oblique direction


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Facial & Lingual:

Loose CT along periosteum

marrow spaces of cancellous bone

supporting bone destroyed first alvoelar bone proper periodontal

ligament suprabony pocket &

horizontal bone loss


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Facial & Lingual:

Loose CT periodontal ligament

destruction of periodontal ligament

fibers infrabony pockets & verticalorangular bone loss


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Stages of Periodontal Disease


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Periodontal Pathogens

Gram negative organisms dominate

P.g.,P.i., A.a.may infiltrate:

Intercellular spaces of the epithelium Between deeper epithelial cells

Basement lamina


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Periodontal Pathogens

Pathogens include:

Nonmotile rods:

Facultative:

A.a., E.c.

Anaerobic:

P.g.,P. i., B.f.,F.n.

Motile rods:

Facultative:

C.r. Spirochetes:

Anaerobic, motile:

Treponema denticola


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Periodontal Disease Activity

Bursts of activity followed byperiods of

quiescence characterized by:

Reduced inflammatory response

Little to no bone loss & CT loss

Accumulation of Gram negative

organisms leads to:

Bone & attachment loss

Bleeding, exudate

May last days, weeks, months


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Periodontal Disease Activity

eriod of activity followed by period of

remission:

Accumulation of Gram positive bacteria

Condition somewhat stabilized

Periodontal destruction is site specific

PD affects few teeth at one time, or

some surfaces of given teeth


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Overall Prognosis

Dependenton:

Client compliance

Systemic involvement

Severity of condition

# of remaining teeth


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Prognosis ofIndividual Teeth

Dependenton:

Attachment levels, bone height

Status of adjacent teeth

Type of pockets: suprabony,

infrabony

Furcation involvement

Root resorption


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Subclassification of Chronic

PeriodontitisSeverity PocketDepths

CAL Bone

Loss

Tooth

Mobility

Furcation

Early 4-5 mm 1-2 mm Slight

horizontal

Moderate 5-7 mm 3-4 mm Sl mod

horizontal

Advanced > 7 mm u 5 mm Mod-

severe

horizontal

vertical

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Chronic Period on Tit Is Impt