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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 chronic periodontitis.

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 in adults

Plaque initiates conditionSubgingival calculus common

findingSlow-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 individual teeth/site– Slight = 1-2 mm CAL– Moderate = 3-4 mm CAL– Severe = 5 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 FormationBacterial

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 destroyedCollagen 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 bacteriaRoot 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 specificPD 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 PeriodontitisSeverity Pocket

DepthsCAL Bone

LossTooth 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 Mod-severe

horizontal

vertical