Chronic Periodontitis This presentation will probably involve audience discussion, which will create action items. Use PowerPoint to keep track of these action items during your presentation In Slide Show, click on the right mouse button Select “Meeting Minder” Select the “Action Items” tab Type in action items as they come up Click OK to dismiss this box This will automatically create an Action Item slide at the end of your presentation with your points entered. Chronic Periodontitis Localized Generalized Algonquin College

Learning Outcomes Describe the development of a periodontal pocket. Relate clinical characteristics to the histopathologic changes for chronic periodontitis. Compare the gingival pocket with the periodontal pocket. Determine the severity of PD activity using clinical data.

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

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

Clinical Characteristics Deep red to bluish-red tissues Thickened marginal gingiva Blunted/cratered papilla Bleeding and/or suppuration Plaque/calculus deposits

Clinical Characteristics Variable pocket depths Horizontal/vertical bone loss Tooth mobility

Pathogenesis – Pocket Formation Bacterial challenge initiates initial lesion of gingivitis With disease progression & change in microorganisms  development of periodontitis

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

Pocket Formation Continued extension of JE requires healthy epithelial cells! Necrotic JE slows down pocket formation Pocket base degeneration less severe than lateral

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

Development of Periodontal Pocket

Continuous Cycle! Plaque  gingival inflammation  pocket formation  more plaque

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

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

Clinical & Histopathologic Features Pocket wall bluish-red Smooth, shiny surface Pitting on pressure Histopathology: Vasodilation & vasostagnation Epithelial proliferation, edema Edema & degeneration of epithelium

Clinical & Histopathologic Features 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

Clinical & Histopathologic Features Exudate Flaccid tissues Histopathology: Accumulation of inflammatory products Destruction of gingival fibers

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

Root Surface Wall Necrotic areas of cementum form; clinically soft Act as reservoir for bacteria Root planing may remove necrotic areas  firmer surface

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

Periodontal Pocket Suprabony pocket

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

Inflammatory Pathway Interproximal: Loose CT  periodontal ligament  bone  infrabony pockets & vertical bone loss  transseptal fibers transverse in oblique direction

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

Inflammatory Pathway Facial & Lingual: Loose CT  periodontal ligament  destruction of periodontal ligament fibers  infrabony pockets & vertical or angular bone loss

Stages of Periodontal Disease

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

Periodontal Pathogens Pathogens include: Nonmotile rods: Facultative: A.a., E.c. Anaerobic: P. g., P. i., B.f., F.n. Motile rods: C.r. Spirochetes: Anaerobic, motile: Treponema denticola

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

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

Overall Prognosis Dependent on: Client compliance Systemic involvement Severity of condition # of remaining teeth

Prognosis of Individual Teeth Dependent on: Attachment levels, bone height Status of adjacent teeth Type of pockets: suprabony, infrabony Furcation involvement Root resorption

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  Advanced > 7 mm  5 mm Mod-severe vertical