Done By : Sara Al-Shraideh & Adeeba Shamsan

Edited By : Sara Al-Shraideh & Adeeba Shamsan

Lec. Date : 29/1/ 2019

Doctor : Dr. Malik Hudieb

subject Chronic periodontitis

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#1
rice: 25
 Chronic periodontitis
This script includes slides, ch(25) & past years Qs

 Classification of periodontal disease:

These classifications (1989,1999 & 2018) are based on the host response for the infectious
disease .

1989 1999 2018

A.Adult periodontitis
B. Early-onset periodontitis:
1.Prepuberal periodontitis :
<14yr
1. Gingival disease Periodontal health, gingival
disease & conditions
2. Chronic periodontitis
(localized/generalized)
3. Aggressive periodontitis Periodontitis
(localized/generalized)

2. Juvenile periodontitis:
(15-16)yr

C. Periodontitis associated 4. Periodontitis as a

with systemic disease
D. Necrotising ulcerative
periodontitis
E. Refractory periodontitis
manifistation of systemic
disease
5. Necrotising periodontal
disease(NUG/NUP)
Other condotions affecting
6. Abscesses of the periodontitis
periodontium

7. Periodontitis associated
with endodontic lesions

8. Developmental/acquired
deforitie & condition
Chronic Periodontitis: An infectious disease resulting in inflammation within the supporting
tissues of the teeth leading to progressive attachment and bone loss.

➔infectious disease: if the disease started at one site,it can affect another site inside the oral
cavity, also it may transfer between people when they are using the same spoon & cups daily (for
this reason the same bacterial type will be dominant in the same family

Every infectious disease has a Host response.

➔supporting tissues= cementum + pdl +bone

The tooth is not fixed to the bone =there is a space between the tooth & the bone (bone is not
ankylosed to tooth as implants)

➔progressive attachment and bone loss: In average:

‫هاد الرقم ما بكون من بداية‬
▪ 0.2 mm/yr = mild-moderate inflammation ‫ ولكن المريض بوصلله‬, ‫المرض‬
▪ 0.2-2.0 mm/yr = sever inflammation )with aging( ‫مع تقدم العمر‬

Attachement loss = soft tissue part , bone loss = hard part.

In general, bone loss happens because there’s No enough capillaries to supply nutrition to the
crestal bone
For ex: if a pt has a sever inflammation→he’ll ‫واضحه بتحكيلي اذا‬clue ‫لحد اآلن مافي اي‬
loss almost 2 mm per yr →so after 10 ‫ مميزه متى بنتقل المريض من‬mark ‫في‬
years,20mm will be lost →that means nothing periodontitis ‫ الى‬gingivitis
left to support the tooth .
‫بتلعب دور كبير بالموضوع‬genetics ‫لكن ال‬
oral hygiene (‫بغض النظر عن ال‬
Healthy )measures & plaque accumulation
Gingivitis Periodontitis
gingiva

Stages of periodontal diseases

• Stage 1: The Initial Lesion.
In Advanced Lesion:
• Stage 2: The Early Lesion. Gingivitis
• Loss of connective tissue attachment and
• Stage 3: The Established Lesion alveolar bone

. • Stage 4: The Advanced Lesion. Periodontitis • Extensive damage to collagen fibers

• The pocket epithelium migrates apically from the

➔ Which immune cell is dominant in this stage??
CEJ
Chronic Periodontitis
• PgE2 • Osteoclasts • RANK- RANK ligand OPG →we’ll talk about these later on
(chemotherapeutic agent) lec.
• Attachment and bone loss is irreversible, unless the dentist will interfere (we do surgery in
severe cases only, if the case was mild (1-2 mm bone loss) it’ll not require open surgery &
bony graft).
‫عمل دراسه انو‬MICHIGAN ‫العالم‬
▪ Chronic periodontitis = It takes a long time to start acting. Oral hygiene measures ‫ال‬
▪ Chronic periodontitis ≠ cannot be cured (for this reason ‫ممكن ترجع العظم لوضعه الطبيعي‬
they change its name later on) 2017 ‫ولكن بال‬, ‫بعد ما خسرناه‬
‫تراجع عن هاي الدراسه‬
 Can occur in children and adolescents.

• Initiated by dental plaque biofilm, but host response plays an essential role in tissue
destruction.

Clinical features
1. Amount of destruction is consistent with the presence of local factors: (supragingival &
subgingival) plaque & calculus.
Plaque → destruction
2. Gingival inflammation signs:
▪ Swelling
▪ Redness
▪ Gingival bleeding
3. Periodontal pocket formation:
▪ Pocket depths are variable(usually
very deep)
▪ Suppuration from the pocket can be found.

How to detect the pus presence? You should force some pressure from the apical to the coronal
part of the tooth→if there’s pus you should treat this problem before any other Tx.

4. Loss of attachment: (localized / generalized)

▪ In one sites of the tooth
▪ In several teeth or the entire
dentition.
▪ Apical migration of the JE.
▪ Destruction of fibers of the gingiva.
▪ Destruction of PDL fibers.
▪ Loss of alveolar bone support.
 5. Loss of alveolar bone:

▪ Vertical bone loss→ Early presentation

▪ Horizontal bone loss→ After 10yrs
without Tx.

The bone loss pattern depends on the onset of presentation:

if the pt. come to the clinic at the disease’s beginning →we may find Vertical bone loss in 1 or 2
sites, but after long time we may find:
:case ‫الدكتور ممكن يجيبلنا‬
▪ Mobility
‫ كان عنده اكتر من‬, ‫ سنه‬50 ‫ عمره‬,‫ابو عمر‬
▪ Pus
:‫شي ومن ضمنهم كان عنده‬
▪ Horizontal bone loss
apical migration of JE ➔This means
▪ Plaque & calculus accumulation
that this case is periodontitis for sure

6. Mobility: in advanced cases

▪ Remember: mobility cannot be checked by RGs.
7. Chronic Periodontitis can be related to:
Root ▪ Local factors: iatrogenic/ anatomical...
▪ modified by and/or associated with systemic
diseases (e.g. diabetes mellitus, HIV)
▪ Modified by factors other than systemic disease
such as smoking and emotional stress.
Crown 8. Slow to moderate rate of progression, but may have
periods of rapid progression also
In this pic, we can say:

▪ The root is 1/3 of the tooth

▪ The root is ½ of the root

Continuous disease model:

▪ Attachment loss is continuous &

slow
▪ Linear correlation between age &
loss of attachment
▪ Gradual destruction
 Random burst disease:

▪ Usually with aggressive periodontitis

▪ The destruction occurs during periods of
exacerbation, interjected with intervals of
remission
▪ Breakdown occurs in recurrent acute
episodes/bursts of activity over a short time
span ( for ex: through 1-2 weeks the pt may
loss about 2-3 mm of bone)

9. Pain usually is NOT a symptom, So:

▪ Patients do not seek treatment early in the disease
▪ Patients do not follow through with treatment after the disease is diagnosed

Pocket -- CAL -- Bone loss

▪ A periodontal pocket is clinical evidence of attachment loss.

In this pic: there is no any
psudopocket or gingival
enlargement, but when we
measured the probing depth
it was = (11-12) mm
‫ هون طلع‬, ‫ ع اآلخر‬probe ‫دائما الزم ما تنخدع من المظهر وحاول دخل ال‬
PPD >11 mm‫معنا ال‬
This defect can be missed if we did not measure PPD properly!
Always insert your probe as much as possible regardless
bleeding

If the Dr asks you, what is the provisional diagnosis here?

Your answer will be periodontitis.

Why? Notice the relation between cingulum & CEJ (in

most ant. Teeth the cingulum is (2-3) mm away from CEJ)
below the CEJ is recession, you can see the difference in
color (dark calculus)
Clinical appearance is NOT a reliable indicator of the presence or severity of chronic periodontitis

▪ May exhibit pronounced/minimal changes in appearance

Blunt papilla
(means
calculus
deposit
underneath)

The clinical appearance of this

tissue suggests health(stippling)
however When assessed with a
probe, a deep pocket(6 mm)
reveals bone loss on the mesial
surface of the canine

Diagnosis

Extend Severity Disease

• Localized→<30%of • Mild→(1-2)mmCAL • Chronic Periodontitis

sites are affected • Moderate→(3-
• Generalized →>30%of 4)mmCAL
sites are affected • Sever →≥ 5mmCAL

Case: pt has 1 site of severe periodontitis & other sites of mild-moderate periodontitis
In this case try to give 1 diagnosis describing the most severe case in the pt
 Treatment Considerations for Chronic Periodontitis
1. OHI→usually we start by OHI at the beginning of the clinic.
2. Scaling & polishing
3. Root planning→either at the same visit with scaling or in the next visit, it depends on the
case.
 In fact scaling & RP are inseparate procedures
 In gingivitis →I might re-evaluate the case after 2 weeks (looking for soft tissue only)
 In periodontitis→we re-evaluate the case after (4-6) weeks (then we can do surgical Tx)
 Chronic periodontitis is considered as Cross-sectional study (because we don’t have a full
history about the pt)

Questions: (past year Qs & book Qs)

1. Female pt(21years old)with chronic periodontitis….what to do?

a. Chlorohexidine for 4-6 weeks
b. Listerine for 6 weeks
c. Antibiotics
d. OHI & motivation
2. Pic for chronic periodontitis, after we do scaling & RP, the pocket depth is reduced, the
reason is:
a. Regeneration
b. Reatrechment
c. Long JE
3. ANUG included on AA1999?
True False
4. 21 years girl, presenting to clinic with generalized, mild chronic periodontitis, what is true?
a. She should improve her oral hygiene measurement
b. Prescribe Abs for 21 days
5. To be diagnosed as localized form of chronic periodontitis, the number of sites involved
should be less than: A. 10% B. 20% C. 30% D. 40% 2.
6. In chronic periodontontitis:
a. Amount of destruction is consistent with the presence of local factors
b. Amount of destruction is inconsistent with the presence of local factors
c. It depends upon age
d. None of the above
Ch (25): Chronic periodontitis
Introduction:
 Chronic periodontitis is the most common form of destructive periodontal disease in
adults.
 It can occur in both the primary and secondary dentition.
 It usually has slow to moderate rates of progression, but may have periods of rapid
progression.
 The progressive nature of the disease can only be confirmed by repeated examinations.
 The disease will progress further if treatment is not provided.
 It is recognized as the most frequently occurring form of periodontitis.

Clinical features:
 Gingival inflammation➔
1. Slightly-moderately swollen gingiva
2. Alterations in color ranging from pale red to magenta.
3. Loss of gingival stippling
4. Changes in the surface topography may include blunted or rolled gingival margins
and flattened or cratered papillae.
5. Gingival bleeding, either spontaneous or in response to probing
6. inflammation related exudates of crevicular fluid
 Loss of alveolar bone➔there is considerable variation in the form, pattern and rate of
alveolar bone resorption.
 Mobility➔ Tooth mobility often appears in advanced cases when bone loss has been
considerable.

RADIOGRAPHIC FEATURES:
 Radiographic examination is an essential part of periodontal diagnosis
 Provides evidence of alveolar bone height, extent, form of bone destruction, and the
density of cancellous trabeculation.
 In a marginal periodontitis, bone destruction is indicated first by the loss of the dense
margin, which delineates the alveolar process in health.
 As bone density decreases the bone margins becomes radiolucent and indistinct.
 With continuing bone resorption the height of the alveolar bone is reduced.
PROGRESSION OF PERIODONTAL DISEASE:
 Chronic periodontitis does not progress at an equal rate in all affected sites throughout the
mouth.
 More rapidly progressive lesions occur most frequently in:
1. Interproximal areas
2. Areas of greater plaque accumulation
3. Inaccessible areas to plaque control measures (Furcation areas, overhanging
margins, malposed teeth)

RISK FACTORS OR SUSCEPTIBILITY:

1. Prior History of Periodontitis: Although not a true risk factor for disease but rather a
disease predictor
2. Bacterial risk factors:
 Plaque accumulation on tooth and gingival surfaces at the dentogingival junction is
considered the primary initiating agent in the etiology of chronic periodontitis
 pathogens presence may not be enough for disease activity to occur.
 Microbial plaque (biofilm) is a crucial factor in inflammation of the periodontal
tissues, but the progression of gingivitis to periodontitis is largely governed by host-
based risk factors.
 Microbial biofilm of particular compositions will initiate chronic periodontitis in
certain individuals whose host response and cumulative risk factors predispose
them to periodontal destruction rather than to gingivitis.
3. Systemic Factors:
 The rate of progression of plaque- induced chronic periodontitis is generally
considered to be slow.
 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
4. Age: the prevalence of periodontal disease increases with age
5. Smoking:
 The response to periodontal therapy is impaired in smokers.
 Gingival redness and bleeding on probing are masked by the dampening of
inflammation.
6. Stress: may have direct anti-inflammatory and/or anti-immune effects
TREATMENT:
 The goals of periodontal therapy:
1. Alter/eliminate the microbial etiology
2. contributing risk factors for periodontitis
3. Thereby arresting the progression of the disease
4. preserving the dentition in a state of health, comfort, and function with appropriate
esthetics
5. Prevent the recurrence of periodontitis.
6. regeneration of the periodontal attachment apparatus
 The following procedures may be considered:
1. Removal or reshaping of restorative overhangs and over-contoured crowns
2. Correction of ill-fitting prosthetic appliances
3. Restoration of carious lesions
4. Odontoplasty
5. Tooth movement
6. Restoration of open contacts which have resulted in food impaction
7. Treatment of occlusal trauma.
 Antimicrobial agents or devices may be used as adjuncts.
 If the results of initial therapy resolve the periodontal condition, periodontal maintenance
should be scheduled at appropriate intervals.
 Periodontal Surgery:
1. Gingival augmentation therapy.
2. Regenerative therapy: Bone replacement grafts, guided tissue regeneration and
combined regenerative techniques.
3. Resective therapy: Flaps with or without osseous surgery and Gingivectomy.
 Patient’s part:
1. Patient compliance
2. Self-care
3. Periodontal maintenance (recall appointments)

The end of this script

Good luck