Chronic PeriodontitisLocalizedGeneralized

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Learning OutcomesDescribe 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 CharacteristicsOnset - any age; most common in adultsPlaque initiates conditionSubgingival calculus common findingSlow-mod progression; periods of rapid progression possibleModified by local factors/systemic factors/stress/smoking

Extent & SeverityExtent:

Localized: 30% of sites affectedGeneralized > 30% of sites affected

Severity: entire dentition or individual teeth/site

Slight = 1-2 mm CALModerate = 3-4 mm CALSevere = 5 mm CAL

Clinical CharacteristicsDeep red to bluish-red tissuesThickened marginal gingivaBlunted/cratered papillaBleeding and/or suppurationPlaque/calculus deposits

Clinical CharacteristicsVariable pocket depthsHorizontal/vertical bone lossTooth mobility

Pathogenesis Pocket FormationBacterial challenge initiates initial lesion of gingivitisWith disease progression & change in microorganisms development of periodontitis

Pocket FormationCellular & fluid inflammatory exudate degenerates CTGingival fibers destroyedCollagen fibers apical to JE destroyed infiltration of inflammatory cells & edemaApical migration of junctional epithelium along rootCoronal portion of JE detaches

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

Pocket FormationContinue inflammation:

Coronal extension of gingival marginJE migrates apically & separates from rootLateral pocket wall proliferates & extends into CTLeukocytes & edemaInfiltrate lining epitheliumVarying degrees of degeneration & necrosis

Development of Periodontal Pocket

Continuous Cycle!Plaque gingival inflammation pocket formation more plaque

HistopathologyConnective Tissue:

EdematousDense infiltrate:Plasma cells (80%)Lymphocytes, PMNsBlood vessels proliferate, dilate & are engorgedVarying degrees of degeneration in addition to newly formed capillaries, fibroblasts, collagen fibers in some areas

HistopathologyPeriodontal pocket:

Lateral wall shows most severe degenerationEpithelial proliferation & degenerationRete pegs protrude deep within CTDense infiltrate of leukocytes & fluid found in rete pegs & epitheliumDegeneration & necrosis of epithelium leads to ulceration of lateral wall, exposure of CT, suppuration

Clinical & Histopathologic FeaturesClinical :

Pocket wall bluish-redSmooth, shiny surfacePitting on pressureHistopathology:

Vasodilation & vasostagnationEpithelial proliferation, edemaEdema & degeneration of epithelium

Clinical & Histopathologic FeaturesClinical:

Pocket wall may be pink & firmBleeding with probingPain with instrumentationHistopathology:

Fibrotic changes dominate blood flow, degenerated, thin epitheliumUlceration of pocket epithelium

Clinical & Histopathologic FeaturesClinical :

ExudateFlaccid tissuesHistopathology:

Accumulation of inflammatory productsDestruction of gingival fibers

Root Surface WallPeriodontal disease affects root surface:

Perpetuates diseaseDecay, sensitivityComplicates treatmentEmbedded collagen fibers degenerate cementum exposed to environmentBacteria penetrate unprotected root

Root Surface WallNecrotic areas of cementum form; clinically softAct as reservoir for bacteriaRoot planing may remove necrotic areas firmer surface

Classification of PocketsGingival:

Coronal migration of gingival marginPeriodontal:

Apical migration of epithelial attachmentSuprabony:Base of pocket coronal to height of alveolar crestInfrabony:Base of pocket apical to height of alveolar crestCharacterized by angular bony defects

Periodontal PocketSuprabony pocket

Inflammatory PathwayStages 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 PathwayInterproximal:

Loose CT periodontal ligament bone infrabony pockets & vertical bone loss transseptal fibers transverse in oblique direction

Inflammatory PathwayFacial & 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 PathwayFacial & Lingual:

Loose CT periodontal ligament destruction of periodontal ligament fibers infrabony pockets & vertical or angular bone loss

Stages of Periodontal Disease

Periodontal PathogensGram negative organisms dominate P.g., P.i., A.a. may infiltrate:

Intercellular spaces of the epitheliumBetween deeper epithelial cellsBasement lamina

Periodontal PathogensPathogens 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

Periodontal Disease ActivityBursts of activity followed by periods of quiescence characterized by:

Reduced inflammatory responseLittle to no bone loss & CT lossAccumulation of Gram negative organisms leads to:

Bone & attachment lossBleeding, exudateMay last days, weeks, months

Periodontal Disease ActivityPeriod of activity followed by period of remission:

Accumulation of Gram positive bacteriaCondition somewhat stabilizedPeriodontal destruction is site specificPD affects few teeth at one time, or some surfaces of given teeth

Overall PrognosisDependent on:

Client complianceSystemic involvementSeverity of condition# of remaining teeth

Prognosis of Individual TeethDependent on:

Attachment levels, bone heightStatus of adjacent teethType of pockets: suprabony, infrabonyFurcation involvementRoot resorption

Subclassification of Chronic Periodontitis

SeverityPocket DepthsCALBone LossTooth MobilityFurcationEarly4-5 mm1-2 mmSlighthorizontalModerate5-7 mm3-4 mmSl modhorizontalAdvanced> 7 mm 5 mmMod-severehorizontalvertical

Chronic Periodontitis

Algonquin College