Periodontitis

Periodontitis is bacterial infection that affects of all parts of the periodontium including including the gingiva, periodontal ligament, bone, and cementum. It is the result of complex interaction between the plaque biofilm that accumulates on the tooth surfaces and the bodys efforts to fight this infection. Periodontitis is the number one cause of tooth loss in adults and is particularly prevalent in smokers and those with modifying fctors such as diabetes mellitus.

The warning signs of periodontitis are red or swollen gingiva, bleeding during brushing, a bad taste in the mouth, persistent bad breath, sensitive teeth, loose teeth, and pus around the teeth and gingiva. Periodontitis have been subdivided into major categories: 1. Chronic periodontitis 2. Aggressive periodontitis

3. Several less common types of periodontitis, including periodontitis as a manifestation of systemic disease, necrotizing periodontal diseases, abscesses of the periodontium, periodontitis associated with endodontic lesions, and developmental or acquired deformities/ conditions.

Chronic periodontitis
is a bacterial infection resulting in inflammation within the supporting tissues of the teeth, progressive destruction of the periodontal ligament, and loss of supporting alveolar bone. It is characterized by a pocket formation and or gingiva recession. It is the most frequent occurring form of periodontitis. This type of periodontitis is previously known as adult periodontitis.

Characteristics of chronic periodontitis

clinical appearance of chronic periodontitis The gingival tissue may appear bright red or purplish. In such cases, the clinical signs of chronic periodontitis are very evident the initial examination of the oral cavity. The gingival tissue may be pale pink almost normal-looking appearance.

 The onset of the disease may be at any age; it is most commonly detected in adults older than age 35 but can occur in children and adolescents. Chronic periodontitis is initiated and continued by bacterial plaque that accumulates subgingivally where the patient cannot clean. The host response to the bacterial plaque plays an essential role in the pathogenesis of chronic periodontitis The prevalence and severity of chronic periodontitis increases with age. The inflammation may affect a variable number of teeth. Chronic periodontitis may be localized, involving one area of a tooths attachment, or more generalized, involving several teeth of the entire dentation. The disease progresses at a slow to moderate rate but may have bursts of rapid progression(destruction).

Feature of chronic periodontitis

 Signs and symptoms include swelling, redness, gingival bleeding upon probing, periodontal pocket, bone loss, tooth mobility, and or pus/suppuration. Subgingival calculus is usually present. Radiographic evidence of bone may be evident. Chronic periodontitis may be modified and associated with systemic disease such as diabetes mellitus. It can be modified by other factors, especially smoking. Peri-implatitis is the term for chronic periodontitis in tissue surrounding the dental implant.

Etiology of chronic periodontitis

Periodontitis has a multifactorial etiology. The nature and severity of periodontitis are determined by complex interactions between the plaque biofilm and the host. Although pathologic bacteria are necessary for periodontitis, they alone are not sufficient for the progression to chronic periodontitis. Research studies indicate that the hosts own immune response to the bacteria is a major determinant of the severity of the periodontal disease. If the subgingival plaque biofilm is not removed, periodontitis can be the interaction between the bacteria and the host, resulting in tissue destruction and bone loss.

Chronic periodontitis can be further subdivided on the basis of

extent, severity, and disease progression.

Extent is the degree or amount of periodontal destruction and can be characterized based on the number or sites that have experienced tissue destruction. Localized chronic periodontitis is chronic periodontitis in which 30% or less of the sites in the mouth has experience attachment loss and bone loss. Generalized chronic periodontitis is chronic periodontitis in which more than 30% of the sites of the mouth have experience loss and bone loss.

Severity or seriousness of the disease is determined by the rate of disease progression over time and the response of the tissues to treatment. Slight to moderate tissue destruction is characterized by a loss of up to one-third of the supporting periodontal tissues; probing depths of 4-6mm. Advance tissue destruction is characterized by loss of greater than one-third of the supporting periodontal tissues; probing depths of 7mm or greater with clinical attachment loos of 5mm or more.

 Recurrent and refractory chronic periodontitis

Sometimes new signs and symptoms of periodontitis reappear after periodontal therapy because the disease was not adequately treated and the patient did not practice and adequate self-care.

 Disease progression in chronic progression The rate of disease progression in chronic periodontitis appears to be slow. The current views is that tissue destruction may not be continuous but rather occurs in short bursts during which there is breakdown of the periodontal ligament and alveolar bone destruction. This episode of disease progression occurs randomly over time and at random sites in the mouth. In some instances, tissue destruction will continue to progress despite excellent patient self-care and professional periodontal therapy that would have succeeded in controlling the disease in mot patient.

Goals for treatment of chronic periodontitis

Control bacterial plaque to a level that is compatible with gingival health. Alter or eliminate any contributing risk factors for periodontitis Arrest the disease progression Prevent the recurrence of periodontitis

Treatment considerations for initial therapy

Initial therapy for chronic periodontitis Consultation with patients physician may be indicated if systemic risk factors are present. These might include smoking, uncontrolled or poorly controlled diabetes, systemic diseases, stress, and medications. Individualized instruction, reinforcement, and evaluation of the patients plaque control skills. Smoking cessation counseling should be offered to patients who smoke. Debridement of tooth surfaces. Antimicrobial agents may be used as an adjunct o initial therapy. Removal or control local factors contributing to inflammation. A periodontal examination and re-evaluation of the initial therapys outcomes should be performed after allowing an appropriate time interval for resolution of inflammation and tissue repair.

The desired outcome of periodontal therapy in patients with chronic periodontitis should result in: Significant reduction in gingival inflammation. Reduction of dental plaque to a level compatible with gingival health Reduction of probing depths Prevention of further attachment The long-term outcome of periodontal therapy depends on patient compliance with self-care and periodontal maintenance at appropriate intervals. Not all patients or sites will respond equally to therapy. Disease sites that have no responded successfully to treatment are characterized by: Inflammation of the gingiva Increasing clinical attachment loss Plaque levels that is not compatible with gingival health.

Outcomes assessment

Highly destructive form of periodontitis It is a bacterial infection resulting in inflammation within the supporting tissues of the teeth and is characterized by a rapid destruction of the periodontal ligament, rapid loss of supporting bone, high risk for tooth loss, and poor response to periodontal therapy.

Aggressive periodontitis

The severity of the tissue destruction seen in aggressive periodontitis is often inconsistent with the relatively small amounts of bacterial plaque exhibited by the patient. Immune deficiencies and a genetic link have been shown to be possible modifying factors for this type of periodontal disease. Aggressive periodontitis is less common than chronic periodontitis. Two forms of aggressive periodontitis are localized aggressive periodontitis and generalized periodontitis.

Characteristics of aggressive periodontitis

A. Clinical features common to both forms of aggressive periodontitis.
1. No obvious signs or symptoms of systemic disease 2. Rapid attachment loss and alveolar bone destruction. 3. Lack clinical inflammation; affected tissue may have normal clinical appearance but probing will reveal deep periodontal pockets on proximal surface of affected teeth.

4. Relatively sparse bacterial plaque; disese severity seems exaggerated given the relatively light amount of bacterial plaque. 5. Tends to run in families. B. Features of localized aggressive periodontitis 1. Onset of disease around the time of puberty 2. rapid tissue destruction around the permanent first molars and incisors. 3. Frequently associated with the periodontal pathogen (actinobcillus

actinomycetemcomitns).

4. frequently associated with abnormal neutrophil function. 5. Seems to affect more females than males. 6. Was previously known as localized juvenile periodontitis.
C. Features of generalized aggressive periodontitis 1. Onset usually occurs in persons younger than 30 years of age, but patient may be older. 2. Rapid tissue destruction around most teeth

3. Frequently associated with the periodontal pathogens (actinobacillus actinomycetecomitans and porphyyromonas

gingivalis). 4. frequently associated with abnormal neutrophils function.

5. Was previously known as generalized juvenile periodontitis or rapidly progressive periodontitis.

Goals for treatment of aggressive periodontitis

Control of aggressive periodontitis may not be possible and in such cases, a reasonable treatment goal is to slow and progression of the disease.

Treatment considerations for aggressive periodontitis

A. Initial therapy for aggressive periodontitis. 1. consultation with physician may be indicated for children and young adults who exhibits severe periodontitis determine if a systemic disease is a modifying factors. 2. Individualized instruction, reinforcement, and evaluation of the patients plaque control skills. 3. Smoking cessation counseling should be offered to patient who smoke.

4. Debridement of tooth surfaces, combined with antimicrobial therapy. 5. Removal or control of local factors contributing to inflammation. 6. Surgical debridement of the soft tissue. 7. A periodontal examination and re-evaluation of the initial therapys outcomes should be performed after allowing an appropriate time interval for resolution of inflammation and tissue repair. 8. Due to the potential genetic link in aggressive periodontitis, evaluation and counseling of other family members is indicated.

B. Outcomes assessment 1. The desired outcome of periodontal therapy in patients with aggressive periodontitis is: a. significant reduction in gingival inflammation. b. reduction of dental plaque to a level compatible with gingival health. c. reduction probing depths. d. prevention of further attachment loss.

2. The best long-term outcomes of periodontal therapy of aggressive periodontitis will be achieved when there is good patient compliance with self care and periodontal maintenance at appropriate intervals. 3. Disease sites that do not respond successfully to treatment may occur and are characterized by: a. inflammation of the gingiva. b. increasing attachment loss. c. plaque levels that are not compatible with gingival health. d. increasing tooth mobility.

Other types of periodontitis

Less common forms of periodontitis. This group is composed of uncommon types of periodontitis including 1. periodontitis as a manifestation of a systemic diseases, 2. necrotizing periodontal diseases, 3. abscesses of the periodontium, 4.periodontitis associated with endodontic lesions, 5.developmental or acquired deformities and conditions, 6. occlusal trauma

Periodontitis as a manifestation of a systemic disease

A. Systemic disease a number of disease and conditions, such as immunosuppression, hematological disorders, and genetic disorders, have been documented as being capable of affecting the periodontium and/or the outcome of periodontal therapy B. Immune dysfunction in rare cases, periodontitis may be seen in young children beginning with the eruption of the primary teeth and characterized by severe bone and tooth loss. Periodontitis around primary teeth is associated with systemic conditions that interfere with the bodys resistance to bacterial infections. Rare systemic conditions that are associated with periodontitis in very young children include leukocyte adherence deficiency congenital primary immunodeficiency, hypophosphatemia, chronic neutrophil defects, and cyclic neutrophil.

Necrotizing periodontal disease

are destructive infections of the periodontal tissues that involve tissue necrosis that is limited to the gingival tissues or tissue necrosis of the gingival tissues combined with loss of attachment and alveolar bone loss.

These conditions have previously been known as trench mouth, Vincent's infection, and acute necrotizing gingivitis.

 Both necrotizing ulcerative gingivitis(ANUG) and necrotizing ulcerative periodontitis(NUP)are collectively referred to as necrotizing periodontal diseases because there is insufficient evidence that they are truly separate diseases. It is suggested that ANUG and NUP might possibly be stages of the same infection. Both of these diseases appear to be related to diminished systemic resistance to bacterial infections.

A. definitions 1.necrotizing ulcerative gingivitis(ANUG)- painful infection, primarily of the interdental and marginal gingiva, characterized by partial loss of the interdental papillae 2. necrotizing ulcerative periodontitis(NUP)- painful infection characterized by necrosis of gingival tissues, periodontal ligament, and alveolar bone. NUP is an extremely rapid and destructive form of periodontitis that can produce loss of periodontal attachment.

B. Signs and symptoms of necrotizing periodontal diseases: 1. Sudden onset 2. Gingival necrosis-tissue death resulting in partial loss of interdental papillae, giving the appearance that the papillae have been punched-out or cratered. 3. Fiery red gingiva 4. Spontaneous gingival bleeding

5. Intense oral pain that causes affected patients to seek dental treatment. This symptoms is unusual since gingivitis and periodontitis are not normally associated with pain. 6.An unmistakable, fetid oral odor, because of the pain the patient avoids brushing, allowing materia alba, plaque, sloughed tissue, blood, and stagnant saliva to collect in the oral cavity. 7. Excessive salivation.

8.pseudomembrane-a gray, layer of tissue that covers the necrotic areas of the gingiva. a. the pseudomembrane may involve the gingiva of several teeth or it may cover the entire gingiva. b. it is easily wiped off with gauze, exposing a area of fiery red shiny gingiva. c. the pseudomembrane is composed mainly of necrotic tissue cells, fibrin, leukocyte, and microorganism. 9. Fever and mailse

10. Swollen lymph nodes. 11. In the cases of NUP, additional signs include rapid gingival recession, extremely rapid and irregular bone loss, delayed wound healing, and spread of infection to the adjacent mucosa. C. Bacterial etiology. Necrotizing periodontal diseases are associated with fusiform bacteria, provotella intermedia, and spirochetes.

D. Predisposing factors of necrotizing periodontal diseases 1.Cigartte smoking-most patients who experience NUG or NUP are smoker. 2. Increased levels of personal stress. 3.Poor nutrition. 4. Fatigue 5. Immune dysfunction or suppression. Immune dysfunction can exist in patients who are otherwise systemically healthy. 6. pre-exiting gingivitis or tissue trauma.

E. Most commonly observed in: 1. NUG: persons between 15 to 25 years of age, particularly student and military recruits enduring times of increased stress. 2. NUP: individuals with systemic conditions including but not limited to human immunodeficiency virus (HIV) infection, severe malnutrition, and immunosuppression. F. Treatment 1. Treatment considerations include irrigation and debridement of the necrotic tissue and tooth surfaces, patient self-care instruction, pain control, and antibiotic therapy as appropriate for the management of systemic manifestations (fever, swollen lymph nodes).

2. An excellent and very comprehensive description of dental hygiene care of the patient with necrotizing periodontal disease can be found in Wilkins. 3. Patient counseling should include instruction on proper nutrition, intake of fluids, plaque control, and smoking cessation. A liquid dietary replacement, such as ensure or boost, can be recommended.

Occlusal trauma in patients with periodontitis

A. Characteristics 1. Occlusal trauma I patient with preexisting periodontitis is termed secondary occlusal trauma and is defined as injury as the result of occlusal forces applied to a tooth or teeth that have previously experience (1) attachment loss and/or (2) bone loss. In this type of occlusal trauma the periodontium was unhealthy before experiencing excessive occlusal forces.

2. Local environmental risk factors, excessive occlusal trauma does not initiate periodontitis. Rather, rapid bone loss and pocket formation result when excessive occlusal forces are applied to a tooth with an existing unhealthy, inflammed periodontium.

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