CHRONIC PERIODONTITIS

by Dr. Marcel Hallare

CHRONIC PERIODONTITIS
Formerly known as adult periodontitis or chronic adult periodontitis is the most prevalent form of periodontitis Generally considered to be a slowly progressing disease

The presence of systemic or environmental factors that may modify the host response to plaque accumulation, such as diabetes, smoking, or stress, disease progression may become more aggressive Recently define as an infectious disease resulting in inflammation within the supporting tissues of the teeth, progressive attachment loss, and bone loss

Clinical Features
General Characteristics Clinical findings in patients with chronic periodontitis include supragingival and subgingival plaque accumulation that is frequently associated with calculus formation, gingival inflammation, pocket formation, loss of periodontal attachment and loss of alveolar bone

Gingiva ordinarily is slightly to moderately swollen and exhibits alterations in color ranging from pale red to magenta Loss of gingival stippling and changes on the surface topography may include blunted or rolled gingival margins and flattened or cratered papillae Gingival bleeding, either spontaneous or in response to probing is frequent

Inflammation-related exudates of crevicular fluid and suppuration from the pocket also may be found Tooth mobility often appears in advance cases when bone loss has been considerable Clinically diagnosed by the detection of chromic inflammatory changes in the marginal gingiva, presence of periodontal pockets, and loss of attachment Diagnosed radiographically by evidence of bone loss

Early horizontal bone loss

Severe horizontal bone loss

Disease Distribution Considered a site-specific disease The clinical signs of chronic periodontitis namely inflammation, pocket formation, attachment loss, and bone loss are considered to be due to the direct, sitespecific effects of subgingival plaque accumulation As a result of this local effect, pocketing, attachment, and bone loss may occur on one surface of the tooth while other surfaces maintain normal attachment levels

May be described as being localized when few sites demonstrate attachment and bone loss or generalized when many sites around the mouth are affected Localized periodontitis: when <30% of the sites assessed in the mouth demonstrate attachment land bone loss Generalized periodontitis: when >30% of the sites assesses in the mouth demonstrate attachment land bone loss

The pattern of bone loss observed in chronic periodontitis may be vertical, when attachment and bone loss on one tooth surface is greater than that occurring on an adjacent surface, or horizontal, when the bone loss proceeds at a uniform rate on the majority of tooth surfaces Vertical bone loss is usually associated with angular bony defects and intrabony pocket formation Horizontal bone loss is usually associated with suprabony pockets

Disease Severity With increasing age, attachment loss and bone loss becomes more prevalent and more severe due to an accumulation of destruction Severity may be classified as:

Slight (mild) periodontitis is generally considered

slight when no more than 1 to 2 mm of clinical attachment loss has occurred Moderate periodontitis is generally considered moderate when 3 to 4 mm of clinical attachment loss has occurred Severe periodontitis - is generally considered slight when 5mm or more of clinical attachment loss has occurred

Symptoms Usually painless Patients may be less likely to seek treatment and accept treatment recommendations Areas of localized dull pain, sometimes radiating deep into the jaw, have been associated with periodontitis Gingival tenderness or itchiness can also be found

Disease Progression Patient appear to have the same susceptibility to plaque-induced chronic periodontitis throughout their lives The rate of disease progression is usually slow but may be modified by systemic and/or environmental and behavioral factors Onset of chronic periodontitis can occur at any time and the first signs may be detected during adolescence in the presence of chromic plaque and calculus formation

Because of its slow rate of progression, chronic periodontitis usually becomes clinically significant in the mid-30s or later Chronic periodontitis does not progress at an equal rate in all affected sites throughout the mouth Some involved areas may remain static for long periods of time, whereas others may progress more rapidly More rapidly progressive lesions occur most frequently in interproximal areas and are usually associated with areas of greater plaque accumulation and inaccessibility to plaque control measures

Prevalence Chronic periodontitis increases in prevalence and severity with age, generally affecting both sexes equally It is not the age of the patient of the individual that causes the increase in disease prevalence, but rather the length of time that the periodontal tissues are challenged by chronic plaque accumulation

Risk Factors for Disease

Prior History of Periodontitis A prior history of periodontal disease puts patients at greater risk for developing further loss of attachment and bone, given a challenge from bacterial plaque accumulation

This means that a patient who presents with pocketing and attachment and bone loss will continue to lose periodontal support if not successfully treated A chronic periodontitis patient that has been successfully treated will develop continuing disease if plaque is allowed to accumulate This stresses the need for continuous monitoring and maintenance of periodontitis patients to prevent a reoccurrence of the disease

Local Factors Plaque accumulation on tooth and gingival surfaces at the dentogingival junction is considered the primary initiating agent in the etiology of chronic periodontitis Attachment and bone loss are associated with an increase in the proportion of gram-negative organisms in the subgingival plaque biofilm, with specific increases in organisms known to be exceptionally pathogenic and virulent

Bacteriodes gingivalis, Bacteriodes forsythus, and Treponema denticola,

otherwise known as the red complex, are frequently associated with ongoing attachment and bone loss in chronic periodontitis The identification and characterization of these and other pathogenic microorganisms and their association with attachment and bone loss has led to the specific plaque hypothesis for the development of chronic periodontitis

This hypothesis implies that although a general increase occurs in the proportion of gramnegative microorganisms in the subgingival plaque in periodontitis, it is the presence of increased proportions of members of the red complex and perhaps other microorganisms that precipitate attachment and bone loss Because plaque accumulation is the primary initiating agent in periodontal destruction, anything that facilitates plaque accumulation or prevents plaque removal by oral hygiene procedures can be detrimental to the patient

Plaque retentive factors are important in

the development and progression of chronic periodontitis because they retain plaque microorganisms in close proximity to the periodontal tissue, providing an ecologic niche for plaque growth and maturation Calculus is considered the most important plaque retentive factor because of its ability to retain and harbor plaque bacteria on its rough surface

Other factors that are known to retain plaque or prevent its removal are subgingival and/or overhanging margins of restorations; carious lesions that extend subgingivally; furcations exposed by loss of attachment and bone; crowded and malaligned teeth; and root grooves and concavities

Systemic Factors The rate of progression of plaque-induced chronic periodontitis is generally considered slow When chronic periodontitis occurs in a patient who also suffers from a systemic disease that influences the effectiveness of the host response, the rate of periodontal destruction may be significantly increased Diabetes is a systemic condition that can increase the severity and extent of periodontal disease in an affected patient

Diabetics suffer somewhat more severe periodontal disease and slightly earlier tooth loss than healthy, control population Neutrophil defect typical of this disease is probably the main factor involved

Environmental and Behavioral Factors Smoking has been shown to increase the severity and extent of periodontal disease Emotional stress has a profound effect on immunity

Genetic Factors Periodontitis is considered to be a multifactorial disease in which the normal balance between microbial plaque and host response is disrupted Periodontal destruction is frequently seen among family members and across different generations within a family, suggesting the possibility of a genetic basis to the susceptibility to periodontal disease

Chronic Periodontitis

Clinical features Chief cause of tooth loss in later adult life Patients are unaware of the disease until teeth become loose Gingivitis persists and patients complain of gingival bleeding or an unpleasant taste Potent and common cause of foulsmelling breath (halitosis)

Loss of attachment leads to pocketing which allows a probe to be passed down between teeth and gingiva In pockets, rough surface of subgingival calculus can be felt Eventually, teeth become increasingly loose and dull to percussion

THE END