Copyright 1995 by Ahmed Khocht

All rights reserved.

Chronic Periodon,,s

AHMED KHOCHT
BChD, DDS, MSD
Diplomate, American Board of Periodontology

Plaque Related
Disease

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Gingivitis Periodontitis

Periodon,,s

Gingival Inflammation

Pocket Formation

Alveolar Bone Loss

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 Periodon,,s

Chronic Periodontitis

Aggressive Periodontitis

Necrotizing Periodontal Disease

Manifestation Systemic Disease

Probing Evalua,on

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Radiographic Evalua,on

CHRONIC
PERIODONTITIS

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 Chronic Periodon,,s
E,ology
Clinical Features
Radiographic Features
Risk Factors
Therapeu,c Concepts

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 Chronic Periodon,,s
Features
Most prevalent in adults but can occur in children
and adolescents.
Amount of destruc,on is consistent with the
presence of local factors.
Subgingival calculus is a frequent nding.
Associated with a variable microbial paKern.
Slow to moderate rate of progression, but may
have periods of rapid progression.
Can be further classied on the basis of extent
and severity.

Chronic Periodon,,s
Extent and Severity

Extent
Localized if 30% of sites are affected
Generalized if >30% of sites are affected

Severity
Slight = 1 to 2 mm CAL
Moderate = 3 to 4 mm CAL
Severe = 5 mm CAL

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Localized and generalized chronic
periodontitis patients share
numerous clinical, epidemiological
and etiological features

are considered slightly different
manifestations of the same disease

Chronic Periodon,,s
Features
Can be associated with local predisposing
factors (e.g. tooth related or iatrogenic
factors).
May be modied by and/or associated with
systemic diseases (e.g. diabetes mellitus, HIV
infec,on).
Can be modied by factors other than
systemic disease such as cigareKe smoking
and emo,onal stress.

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Chronic Periodon,,s

EXAMPLE
CASES

Anterior View

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Anterior Palatal

Anterior Lingual

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Right Buccal

Right Palatal

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Right Lingual

Right Lingual

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LeS Buccal

LeS Palatal

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 LeS Lingual

Anterior Composite

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Right Composite

LeS Composite

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 BW Composite

Maxillary Char,ng

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 Mandibular Char,ng

Clinical Features

supragingival plaque growth

subgingival plaque growth
calculus formation
gingival tissue inflammation
pocket formation
loss of periodontal attachment
loss of alveolar bone

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Gingival pocket - formed by gingival enlargement
(increased bulk of gingiva) without periodontal
attachment loss
Periodontal pocket - a pathologically
deepened gingival sulcus with
destruction of supporting periodontal
tissues

Clinical Features

Increased probing depths

(periodontal pocketing)
usually occurs as chronic
periodontitis progresses.

Periodontal probe used to

measure size of periodontal
pockets and amount of
periodontal attachment loss.

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Clinical Features pocket formation

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Suprabony pocket - bottom of
pocket is coronal to alveolar
bone crest

Infrabony pocket - bottom of

pocket is apical to alveolar
bone crest, lateral wall of
periodontal pocket is between
tooth root surface & alveolar
bone

Suprabony pocket
v bottom of pocket is coronal to alveolar
bone crest
v horizontal bone loss seen
radiographically
v transeptal fibers interproximally are
arranged horizontally
v periodontal ligament fibers on facial &
lingual surfaces follow a normal
horizontal-oblique direction between
tooth & bone

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 Infrabony pocket
v bottom of pocket is apical to crest of
alveolar bone (bone is adjacent to soft
tissue wall of periodontal pocket)
v vertical bone loss seen
radiographically
v transeptal fibers interproximally are
arranged in oblique pattern rather than
horizontally
v periodontal ligament fibers on facial &
lingual surfaces follow angular pattern of
adjacent bone

Clinical features of periodontal

pockets
Subjective clinical features
thickened bluish red marginal
gingiva
tooth mobility, localized pain
Objective clinical features
deepened periodontal probing
depths
gingival bleeding, suppuration

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Clinical Features

If gingival recession accompanies

periodontal attachment loss probing
depths may remain shallow, even with
ongoing severe periodontal attachment
loss and bone loss

Clinical Features recession and

periodontal
attachment loss

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Clinical Features

supragingival plaque growth

subgingival plaque growth
calculus formation
gingival tissue inflammation
pocket formation
loss of periodontal attachment
loss of alveolar bone
(radiographic)
occasionally suppuration

Clinical Features - suppuration

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Clinical Features - suppuration

Clinical Features

gingiva typically slightly edematous

with poor oral hygiene
gingival tissue color ranging from
pale red to magenta
loss of gingival stippling
changed gingival tissue surface
topography get blunted or rolled
gingival margins & flattened or
cratered papillae

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Clinical Features - rolled gingival
margins

Knife-edge in health Rolled with disease

Clinical Features - flattened or

cratered papillae

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Clinical Features

gingiva bleeding on probing

commonly found
thickened, fibrotic marginal tissues
from long-standing chronic
inflammation may visually obscure
underlying inflammatory lesions
pronounced tooth mobility often
occurs in advanced cases
furcation involvement

Periodontal Examina/on
Furca/on Assessment
Grade 1 Grade 2 Grade 3

5/3/16

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Chronic periodontitis
Chronic periodontitis usually painless,
patient first notices gingival bleeding when
brushing or eating, or spacing between their
teeth as a result of tooth movement, or teeth
that have become loose (mobile). Areas of
localized dull pain, sometimes radiating deep
into the jaw, and gingival tenderness or
itchiness, may occur.
Patients are frequently totally unaware that
they have the disease.

Site Specificity of Chronic Periodontitis

Is a site-specific disease
phenomena the local
effects of pathogenic
dental plaque growth
dominates disease
distribution get
disease where pathogenic
dental plaque grows

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Site Specificity of Chronic Periodontitis

Site specificity of periodontitis -

periodontal destruction does not occur in all
parts of the mouth at the same time - but rather
on a few teeth at a time, or even only some
surfaces of a tooth at any given time.
Sites of periodontal destruction are often found
next to tooth surfaces with little or no
periodontal breakdown.

Diagnosing Chronic Periodontitis

Clinically diagnosed by the detection of

chronic inflammatory changes in the
marginal gingiva, presence of periodontal
pockets, and loss of clinical periodontal
attachment.
Radiographically diagnosed by evidence
of crestal alveolar bone loss.

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 Chronic Periodon,,s
E,ology

BACTERIAL INFECTIONS

Host Response

Subgingival Microbial
Complexes
185 subjects; 13,261 samples; cluster analysis
Socransky et al. 1998

Orange
complex
Red
Periodontal health

complex

Most severe
periodontitis

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 Porphyromonas gingivalis
- gram-negative, non-motile anaerobic rod

- 12.3 higher odds of detection in

periodontitis patients vs. age-matched
controls (van Winkelhoff et al. 2002)

Porphyromonas gingivalis
Potential virulence factors:
tissue invasive (epithelial cells)
collagenase enzyme production
trypsin-like proteolytic enzyme
fibrinolysin
endotoxin
hydrogen sulfide
keratinase

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 Microbial Species in Progressive
Chronic Periodontitis
81 of 134 Chinese adults exhibiting 10 sites with
3 mm AL loss over a 10-year untreated period
Papapanou et al. Species Odds ratio
J Perio 68:651, 1997
Porphyromonas gingivalis 7.0
(all at 105 organisms/site) Treponema denticola 5.7
Campylobacter rectus 4.4
Tannerella forsythia 4.0
Prevotella intermedia 3.6
Prevotella nigrescens 3.1
Peptostreptococcus micros 2.5
Fusobacterium nucleatum 2.1

Kamma et al.
J Clin Perio 28: 879, 2001

CMV, Epstein Barr virus-1, herpes simplex

virus with P. gingivalis & Dialister
pneumosintes associated with disease-active
periodontitis.
Herpesviruses are immunosuppressive and
may set the stage for overgrowth of
subgingival P. gingivalis, D. pneumosintes
and other periodontopathic bacteria.

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 Host Response

Progression of Chronic periodontitis

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, whereas others may
progress more rapidly.
More rapidly progressive lesions occur most
frequently at interproximal sites, areas with greater
plaque growth, and where plaque control is impaired
(e.g., furcation areas, overhanging margins, sites of
malposed teeth, areas of food impaction).

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Progression of Chronic Periodontitis

Continuous model of disease progression classic

model (linear breakdown occurring steadily over
time)

Loss of
periodontal
attachment

Increasing length of time

Progression of Chronic Periodontitis

Episodic model of disease progression newer model

(sporadic periods of disease activity surrounded
by extended periods of disease quiescence
inactive)

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Periods of exacerbation - increased inflammatory
response to microbial plaque leading to progressive
loss of periodontal attachment & alveolar bone
(episodic burst disease progression)

Periods of quiescence - reduced inflammatory

response & no progressive loss of
periodontal attachment or alveolar bone

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 Progression of Chronic Periodontitis

Both the continuous and the

episodic pattern of periodontitis
disease progression can appear in
different patients, or at different
sites within the same patient, or at
different times within the same
patient.

Risk Factors for Chronic Periodontitis

Older age
Subgingival infection with specific pathogenic bacteria
(i.e., Porphyromonas gingivalis), and possibly
activation of certain herpesviruses in gingival
tissues
Previous history of periodontitis
Gender
Race/ethnic group
Smoking
Certain systemic diseases
Psychosocial stress
Genetic predisposition

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 Chronic periodontitis
Chronic periodontitis is age-associated,
not age-related.

It is not the age 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.

Chronic Periodontitis Risk Factors

v Previoushistory of periodontitis - a prior

history of periodontitis confers a greater risk
for developing further loss of attachment and
bone, given a challenge from pathogenic
bacterial plaque growth (a patient presenting
with pocketing, attachment loss, and bone loss
will continue to lose periodontal support if not
successfully treated also, a high risk of
recurrent disease exists if pathogenic plaque re-
grows post-treatment).

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Periodontal Therapy

Aims
Effectiveness

Therapeu,c Aims

Control Disease

Correct Damage

Maintenance

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 Prac&ce Parameters of Care in Periodon&cs: Parameter on
Chronic Periodon//s with Slight to Moderate Loss of Periodontal
Support

Therapeutic Goals:
To alter or eliminate microbial etiology & contributing risk
factors for periodontitis
1.) arresting disease progression
2.) preserving dentition in state of health,
comfort & function with appropriate esthetics
3.) prevent periodontitis recurrence.
Regeneration of lost periodontal attachment may be
attempted, where indicated.

Prac&ce Parameters of Care in Periodon&cs: Parameter

on Chronic Periodon//s with Slight to Moderate Loss of
Periodontal Support

Treatment Considerations:
- Contributing systemic risk factors include diabetes,
smoking, certain periodontal bacteria, aging, gender,
genetic predisposition, certain systemic diseases
causing immunosuppression, stress, nutrition,
pregnancy, substance abuse, HIV infection, certain
medications.
- Patients systemic health status, age, compliance,
therapeutic preferences, ability to control plaque.
- Clinicians ability to remove subgingival plaque & calculus,
restorative & prosthetic demands.

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 Prac&ce Parameters of Care in Periodon&cs: Parameter
on Chronic Periodon//s with Slight to Moderate Loss of
Periodontal Support

Treatment Plan for Active Therapy:

1. Patient education & customized oral hygiene instruction.
2. Debridement of teeth to remove plaque & calculus.
3. Adjunctive antimicrobial therapy for patients only partially effective with
traditional mechanical oral hygiene methods.
4. Removal of local factors: overhanging or open margins, over-contoured
crowns, open contacts, caries, malpositioned teeth, narrow embrasure spaces,
occlusal trauma.
5. Re-evaluation after appropriate interval:
- Maintenance if resolution attained.
- Periodontal surgery to correct anatomical defects.

Prac&ce Parameters of Care in Periodon&cs: Parameter

on Chronic Periodon//s with Slight to Moderate Loss of
Periodontal Support

Outcomes Assessment:
- Satisfactory result with significant reduction in clinical signs of
gingival inflammation, reduction in probing depths, stabilization
or gain of clinical periodontal attachment level, reduced
clinically-detectable plaque to level compatible with gingival
health.
- Unsatisfactory: characterized by continued gingival
inflammation, persistent or increased probing depths, loss of
clinical periodontal attachment, & persistence of clinically
detectable plaque levels not compatible with gingival health. Not
all patients or sites respond equally well or acceptably to
periodontal therapy additional therapy may be warranted on
a site-specific basis.

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Therapeu,c Eec,veness

Tooth Loss Studies

Scaling/root-planing Studies

Surgical Studies

QUESTIONS ?

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