Chronic Periodontitis

1
Chronic Periodontitis

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• Localized
• Generalized

2
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.

3
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 gt 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

5
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

13
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
• Pocket wall bluish-red
• Smooth, shiny surface
• Pitting on pressure

• Histopathology
• Vasodilation vasostagnation
• Epithelial proliferation, edema
• Edema degeneration of epithelium

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Clinical Histopathologic Features

• Clinical
• Pocket wall may be pink firm
• Bleeding with probing
• Pain with instrumentation

• Histopathology
• Fibrotic changes dominate
• ? blood flow, degenerated, thin epithelium
• Ulceration of pocket epithelium

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Clinical Histopathologic Features

• Clinical
• Exudate
• Flaccid tissues

• Histopathology
• Accumulation of inflammatory products
• 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 gt 7 mm ? 5 mm Mod-severe horizontal vertical ? ?