Periodontitis Chronic

1
Definition
Chronic Periodontitis can be defined
as an infectious disease resulting in
inflammation within the supporting
tissues of the teeth, progressive
attachment loss, and bone loss.
- Previously known as adult periodontitis
or chronic adult periodontitis.
- Occur as a result of extension of
inflammation from the gingiva into
deeper periodontal tissue.
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
Gingiva
moderately swollen
Deep red to bluishred tissues
Blunted and rolled
gingival margin
Cratered papilla
Bleeding and/or
suppuration
5
Clinical Characteristics
Plaque/calculus
deposits
Variable pocket
depths
Loss of periodontal
attachment
Horizontal/vertical
bone loss
Tooth mobility
6
CLASSIFICATION
A) Based on Disease Distribution:
Localized:
Periodontitis is considered localized when <30% of

the sites assessed in mouth demonstrate attachment
loss and bone loss.
Generalized:
Periodontitis is considered generalized when >30% of

the sites assessed demonstrate attachment loss and
bone loss.
The pattern of bone loss in chronic periodontitis can
be vertical or horizontal.
Sub classification of Chronic

Periodontitis
Severity
Pocket
Depths
CAL
Bone
Loss
Furcation
Early
4-5 mm
1-2 mm
Slight
horizontal
Moderate
5-7 mm
3-4 mm
Sl mod
horizontal
Involved
Advanced
> 7 mm
5 mm
Modsevere
horizontal
vertical
Involved
DISEASE DISTRIBUTION : It is a site-specific

disease
CLINICAL SIGNS - Inflammation ,pocket formation ,attachment loss ,bone

loss - All caused by site specific effects of a sub-gingival
plaque
accumulation
- That is why the effect are on one side only other
surface may maintain normal attachment level.
- E.g..-proximal surface with plaque may have C.A.L.
- And plaque free surface FACIAL surface of same
tooth
may be without disease.
SYMPTOMS
1.
2.
3.
4.
5.
6.
7.
8.
Patient notices gum bleed

space appear between teeth due to tooth movement
May be painless (sleeping disease )goes unnoticed
Some time pain due to caries , root hypersensitivity
To cold /hot or both
PAIN-may be-- dulldeep radiating in the jaw
Area of food impaction can cause more discomfort
May be gingival tenderness or itchiness found
Periodontal Pathogens
Gram negative organism dominate

P.g., P.i., A.a. may infiltrate:
- Intercellular spaces of the epithelium
- Between deeper epithelial cells
- Basement lamina
11
Periodontal Pathogens
Contn
Pathogens include:
Nonmotile rods:
Facultative:
Actinobacillus a. E.c
Anaerobic:
P. g., P. i., T.f., F.n.
Motile rods:
Facultative:
C.r.
Spirochetes:
Anaerobic, motile:
Treponema denticola
12
Pathogenesis Pocket
Formation
Bacterial challenge
initiates initial
lesion of gingivitis
With disease
progression &
change in
microorganisms
development of
periodontitis
13
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
14
Pocket Formation
Continued
extension of JE
requires healthy
epithelial cells!
Necrotic JE slows
down pocket
formation
Pocket base
degeneration less
severe than lateral
15
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
16
Development of Periodontal
Pocket
17
Continuous Cycle!
Plaque gingival inflammation

pocket formation more plaque
18
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
19
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.
20
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
21
Clinical & Histopathologic

Features
Clinical :
1. Pocket wall bluishred
2. Smooth, shiny
surface
3. Pitting on pressure
Histopathology:
1. Vasodilation &
vasostagnation
2. Epithelial
proliferation, edema
3. Edema &
degeneration of
epithelium
22

Features
Contn
Clinical:
Histopathology:
Pocket wall may be
1. Fibrotic changes
pink & firm
dominate
2. Bleeding with probing blood flow,
degenerated, thin
3. Pain with
epithelium
instrumentation
3. Ulceration of pocket
epithelium
1.
23

Features
Contn
Histopathology:
Clinical :
Exudate
2. Flaccid tissues
1.
Accumulation of
inflammatory products
2. Destruction of gingival
fibers
1.
24
Stages of Periodontal
Disease
25
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
26
Root Surface Wall

Contn
Necrotic areas of cementum form;

clinically soft
Act as reservoir for bacteria
Root planing may remove necrotic areas
firmer surface
27
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
28
Contn
Interproximal:
Loose CT periodontal ligament bone
infrabony pockets & vertical bone loss

transseptal fibers transverse in oblique
direction
29
Contn
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
30
Contn
Facial & Lingual:

Loose CT periodontal ligament
destruction of periodontal ligament fibers

infrabony pockets & vertical or angular bone
loss
31
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, exudates
May last days, weeks, months
32
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
33
Prevalence:
Chronic
Periodontitis
increases
prevalence & severity with age.
in
Affect both the sexes equally.
It is an age-associated, not age related

disease.
RISK FACTORS FOR DISEASE:

1) PRIOR HISTORY OF PERIODONTITIS predictor-more risk for
developing damage to periodontium.
2) LOCAL FACTORS:
Plaque Accumulation
Oral Hygiene
Tooth Malposition
Restoration
Preserve & Quantity of certain bacteria

Host defenses
Subgingival Restoration
Environment
Calculus, smoking
Connective Tissue destruction

Genetic influence
Inflammation
Periodontopathic bacteria
Smoking, Calculus
Loss of Attachment
M
O
D
I
F
Y
I
N
G
F
A
C
T
O
R
S
3) SYSTEMIC FACTORS:
Type II or Non Insulin dependent Diabetes
mellitus (NIIDDM)
4) ENVIRONMENTAL & BEHAVIORAL
FACTORS:
Smoking
Emotional Stress
5) GENETIC FACTORS:
Frequent among family members and across
different generations.
MANAGEMENT
1.
The treatment consists of

Non-surgical procedures
Scaling
Root planing
Curettage
2.
Surgical procedure
Pocket reduction surgery
Resective
Regenerative
Correction of morphological / anatomic defects
Overall Prognosis
Dependent on:
Client compliance
Systemic involvement
Severity of condition
# of remaining teeth
38
Prognosis of Individual
Teeth
Dependent on:
Attachment levels, bone height

Status of adjacent teeth
Type of pockets: suprabony, infrabony
Furcation involvement
Root resorption
39
MCQs on Chronic
Periodontitis
1.Bacteria considered to be pathogenic

in chronic periodontitis is/are:
a) P. gingivalis
b) P. intermedia
c) A. actinomycetemcomitans
d) Both (a) and (b)
40
MCQs on Chronic
Periodontitis
2. The clinical attachment loss in

Moderate periodontitis is
a) 1 to 2 mm
b) 2 to 3 mm
c) 3 to 4 mm
d) 5 mm or more
41
MCQs on Chronic
Periodontitis
3.Following histopathological changes occur in
periodontium while pocket formation
except:
a)
Cellular & fluid inflammatory exudate

degenerates connective tissue.
b) Apical migration of junctional epithelium
along root.
c) Apical portion of JE detaches.
d) None of the above.
42
MCQs on Chronic
Periodontitis
4. Risk factors for chronic periodontitis

include:
1. Prior history of periodontitis.

2. Plaque accumulation on tooth and
gingival surfaces.
3. Type 2 diabetes.
4. All of the above.
43
MCQs on Chronic
Periodontitis
5.The treatment possibilities of chronic

periodontitis include
a) Nonsurgical periodontal therapy.

b) Pocket reduction surgery.
c) Correction of morphological /
anatomic defects.
d) All of the above.
44

Periodontitis Chronic

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1

Onset - any age; most common in adults

Extent & Severity

Severity: entire dentition or individual

Periodontitis is considered localized when <30% of

Periodontitis is considered generalized when >30% of

Sub classification of Chronic

DISEASE DISTRIBUTION : It is a site-specific

CLINICAL SIGNS - Inflammation ,pocket formation ,attachment loss ,bone

Patient notices gum bleed

Gram negative organism dominate

Cellular & fluid inflammatory exudate

Infiltrate lining epithelium

Plaque gingival inflammation

Blood vessels proliferate, dilate & are engorged.

newly formed capillaries, fibroblasts, collagen

Clinical & Histopathologic

Clinical & Histopathologic

Clinical & Histopathologic

Root Surface Wall

Periodontal disease affects root surface:

Embedded collagen fibers degenerate

Root Surface Wall

Necrotic areas of cementum form;

Stages I-III inflammation degrades

spaces of cancellous bone periodontal

infrabony pockets & vertical bone loss

Facial & Lingual:

spaces of cancellous bone supporting

Facial & Lingual:

destruction of periodontal ligament fibers

Bursts of activity followed by periods of

Accumulation of Gram negative organisms

Period of activity followed by period of

Periodontal destruction is site specific

Affect both the sexes equally.

It is an age-associated, not age related

RISK FACTORS FOR DISEASE:

Preserve & Quantity of certain bacteria

Connective Tissue destruction

The treatment consists of

Correction of morphological / anatomic defects

Attachment levels, bone height

1.Bacteria considered to be pathogenic

2. The clinical attachment loss in

Cellular & fluid inflammatory exudate

4. Risk factors for chronic periodontitis

1. Prior history of periodontitis.

5.The treatment possibilities of chronic

a) Nonsurgical periodontal therapy.

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