Chronic Periodontitis

Localized
Generalized

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 condition
Subgingival calculus common
finding
Slow-mod progression; periods of
rapid progression possible
Modified 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
4

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

Pathogenesis Pocket
Formation

Bacterial
challenge initiates
initial lesion of
gingivitis
With disease
progression &
change in
microorganisms
development of
periodontitis

Pocket Formation
Cellular & fluid inflammatory
exudate degenerates CT
Gingival fibers destroyed
Collagen fibers apical to JE
destroyed infiltration of
inflammatory cells & edema
Apical migration of junctional
epithelium along root
Coronal portion of JE detaches
8

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

12

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

13

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
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
18

Root Surface Wall

Necrotic areas of cementum form;
clinically soft
Act as reservoir for bacteria
Root 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

24

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

27

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 specific

PD 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

31

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
Periodontitis

Severity

Pocket
Depths

CAL

Bone
Loss

Tooth
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

Modsevere
horizontal
vertical

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