Chronic Periodontitis
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Transcript Chronic Periodontitis
Chronic Periodontitis
Localized
Generalized
1
Learning Outcomes
1. Describe the development of a
periodontal pocket.
2. Relate clinical characteristics to the
histopathologic changes for chronic
periodontitis.
3. Compare the gingival pocket with the
periodontal pocket.
4. Determine the severity of PD activity
using clinical data.
2
Common Characteristics
Onset - any age; most common in
adults
Plaque initiates condition
Subgingival calculus common
finding
Slow-mod progression; periods of
rapid progression possible
Modified 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 individual
teeth/site
– Slight = 1-2 mm CAL
– Moderate = 3-4 mm CAL
– Severe = 5 mm CAL
4
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 inflammatory
exudate degenerates CT
Gingival fibers destroyed
Collagen fibers apical to JE
destroyed infiltration of
inflammatory cells & edema
Apical migration of junctional
epithelium 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 base
degeneration 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 wall shows most severe
degeneration
– Epithelial proliferation & degeneration
– Rete pegs protrude deep within CT
– Dense infiltrate of leukocytes & fluid
found in rete pegs & epithelium
– Degeneration & necrosis of epithelium
leads to ulceration of lateral wall,
exposure of CT, 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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Clinical & Histopathologic
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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Clinical & Histopathologic
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
Periodontal disease affects root
surface:
– Perpetuates disease
– Decay, sensitivity
– Complicates treatment
Embedded collagen fibers
degenerate cementum exposed
to environment
Bacteria penetrate unprotected root
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Root Surface Wall
Necrotic areas of cementum form;
clinically soft
Act as reservoir for bacteria
Root planing may remove necrotic
areas firmer surface
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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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Periodontal Pocket
Suprabony pocket
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Inflammatory Pathway
Stages I-III – inflammation degrades
gingival fibers
– Spreads via blood vessels:
Interproximal:
Loose CT transseptal fibers
marrow spaces of cancellous bone
periodontal ligament
suprabony pockets & horizontal
bone loss transseptal fibers
transverse horizontally
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Inflammatory Pathway
Interproximal:
– Loose CT periodontal ligament
bone infrabony pockets & vertical
bone loss transseptal fibers
transverse in oblique direction
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Inflammatory Pathway
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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Inflammatory Pathway
Facial & Lingual:
– Loose CT periodontal ligament
destruction of periodontal ligament
fibers infrabony pockets & vertical or
angular 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 by periods 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
Period 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
Dependent on:
– Client compliance
– Systemic involvement
– Severity of condition
– # of remaining teeth
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Prognosis of Individual Teeth
Dependent on:
– Attachment levels, bone height
– Status of adjacent teeth
– Type of pockets: suprabony, infrabony
– Furcation involvement
– Root resorption
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Subclassification of Chronic
Periodontitis
Severity
Pocket
Depths
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
5 mm
Modsevere
horizontal
vertical
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