1 chronic periodontitis localized generalized this presentation will probably involve audience...
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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