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Dr. Wael Asiri

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• Chronic periodontitis is the most prevalent form of periodontitis, and
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• chronic periodontitis should be understood as age-associated, but not • Periodontitis is a highly prevalent progressing disease, and it affects
it generally shows the characteristics of a slowly progressing age-dependent, complex chronic inflammation of the periodontal approximately 10.5% to 12% of the world’s population.
inflammatory disease. tissues. U
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• Periodontitis belongs to the group of complex inflammatory diseases *• systemic or environmental factors (e.g., diabetes mellitus, smoking) &• The classic definition described chronic periodontitis as “an infectious
in humans. modify the host immune response to the dental biofilm so that the * disease resulting in inflammation within the supporting tissues of the
• In this context, the word complex not only describes the fact that periodontal destruction becomes more progressive. teeth, progressive attachment loss, and bone loss.”
there are multiple clinical symptoms that account for the disease, but • systemic or environmental factors (e.g., diabetes mellitus, smoking)
also explains the multiple factors that lead to and influence
periodontal inflammation. g 1 11 11 I 11
modify the host immune response to the dental biofilm so that the
periodontal destruction becomes more progressive.
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• Chronic periodontitis represents major clinical and etiologic • Besides the local immune response to the dental biofilm, Findexits
characteristics such as periodontitis may also be associated with a number of systemic
disorders and defined syndromes. If
(1) microbial biofilm formation (dental plaque). Bop as
* (2) periodontal inflammation (gingival swelling, bleeding on probing). • In most cases, patients with systemic diseases, which lead to impaired
a (3) attachment as well as alveolar bone loss. host immunity, may also show periodontal destruction.
first sign
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• Altered gingival margins (rolled, flattened, cratered papillae, recessions) bit
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• Chronic periodontitis exhibits a site-specific clinical picture, where • Localized chronic periodontitis, meaning that less than 30% of the • Severity and extent of periodontal destruction will occur over time in
attachment and bone loss are not equally distributed throughout the teeth show attachment and bone loss combination with systemic disorders impairing or enhancing host
dentition. immune responses.
www.gig difWois6ai8 W • Generalized chronic periodontitis, meaning that 30% or more of the
teeth show attachment and bone loss
• Local inflammation, pocket formation, attachment loss, and bone loss • Vertical bone loss (angular) is associated with intrabony pocket • Patients with chronic periodontitis experience a progression in
are the sequelae of the direct exposure to the subgingival plaque formation. attachment and bone loss as they become older.
(dental biofilm) and local inflammatory responses. • Horizontal bone loss is usually associated with suprabony
(supraalveolar) pockets. ageassoited but
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Disease Severity Symptoms Symptoms

• Relative to the degree of attachment and bone loss, disease severity
can be described as mild, moderate, or severe.
• Mild chronic periodontitis: clinical attachment loss of 1 to 2 mm
• Moderate chronic periodontitis: clinical attachment loss of 3 to 4 mm
• Severe chronic periodontitis: clinical attachment loss of 5 mm or more
• Chronic periodontitis is commonly a slowly progressing complex • As a result of gingival recession, patients may notice black triangles
disease without a pain experience. painless between teeth or tooth sensitivity. interproximeinone
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• Therefore most patients are unaware that they have developed a • In addition, food impaction may occur in the space of interdental
chronic disease. triangles, leading to increased discomfort and bad breath.
• Gingival bleeding during oral hygiene procedures or eating may be the • In cases with advanced attachment and bone loss, tooth mobility,
first sign of disease occurrence. tooth movement, fanned out or elongated front teeth.
• Areas with advanced periodontal inflammation may present with • In cases with advanced disease progression, areas of localized dull
purulence emanating from the periodontal pocket. 111 it pain may occur. b
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 Disease Progression Disease Progression
Models of Progression
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• In general, the progression rate of chronic periodontitis is slow, so • Interestingly, disease progression is more rapid at interproximal sites mode
that symptoms of the disease appear around the age of 40 or later in compared to oral or buccal areas of neighboring teeth.
life.
• The continuous model:
• Diabetes mellitus and the degree of blood sugar control belong to the
• Onset and the rate of disease progression, however, may be most important systemic factors that are directly correlated with • Describes slow and continuous disease progression
influenced by a number of modifiable (e.g., smoking, diet) and periodontal disease. • Suggests that sites exhibit a constant progression rate of attachment loss
throughout the duration of the disease
nonmodifiable (e.g., genetic disorders and risk issues) factors.
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Models of Progression Models of Progression
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• The random or episodic-burst model: • The asynchronous, multiple-burst model: I I
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• Describes the episodic occurrence of short progressive bursts of periodontal • Describes the occurrence of periodontal destruction (bursts) during defined
• In general, 40%
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of patients ≥50 years old and almost 50% of patients
destruction followed by periods of stagnation periods, which are asynchronously interrupted by periods of stagnation or ≥65 years old show signs of mild to moderate periodontal
• Sites, teeth, and the chronology of bursts and stagnation are subject to
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remission for individual sites and teeth destruction.
random effects CAL 1 to 4mm

stag I Risk Factors 1. Microbiologic Aspects

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e • The composition of the oral microflora and the amount of dental • Plaque accumulation on tooth and gingival surfaces (dental biofilm
Ivy SISI IadII Nfl biofilm (plaque) are major etiologic factors. formation) at the dentogingival junction is considered the primary
pimeJl SeNetgj.g mild If initiating agent in the etiology of gingivitis and chronic periodontitis.
• The extent of the periodontal destruction depends on the host
immune competence as well as genetic predispositions influencing • Generally, optimal plaque control leads to the complete resolution of
the individual susceptibility to disease. this early gingival inflammation.

• Systemic diseases and environmental factors interfere with the • Although not all patients with gingivitis develop periodontitis, it is
development and progression of chronic periodontitis. known that all patients with periodontitis experienced prior gingivitis.

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1. Microbiologic Aspects A 2. Local Factors joined
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• Attachment and bone loss are associated with an increase in the WH flat QQ • Plaque-retentive factors are important in the development and
proportion of gram-negative organisms in the subgingival biofilm, w 4 progression of chronic periodontitis because they retain
with specific increases in organisms known to be pathogenic and jawing
its WWI microorganisms in proximity to the periodontal tissues, providing an
virulent. Porphyromonas gingivalis, Tannerella forsythia, and
A Treponema denticola, otherwise known as the red complex bacteria, period.int ecologic niche for biofilm maturation.
Is are frequently associated with ongoing attachment and bone loss in
chronic periodontitis • Calculus is considered the most important plaque-retentive factor
because of its ability to retain and harbor plaque bacteria on its rough
• Development and progression of chronic periodontitis may not surface as well as inside.
depend on the presence of one specific bacterium or bacterial
complex alone. g8IB

2. Local Factors Local factors yi

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3. Systemic Factors

• In addition, the tooth morphology may influence plaque retention. W ID S WID j di • In several instances periodon00s is also associated with other
W systemic disorders, such Papillon–Lefèvre syndrome, Ehlers–Danlos
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syndrome, Kindler syndrome, and Cohen syndrome.
• Roots may show grooves or concavities, and in some instances,
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enamel projections on the surface or furcation entrances.
• Further, it is also known that osteoporosis, severe unbalanced diet,
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factors, interfere with periodontal inflammatory responses.

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3. Systemic Factors 3. Systemic Factors 4. Immunologic Factors

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• Periodontitis is now considered as the sixth complication of diabetes
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• It was shown that the systematic therapy of chronic periodontitis • Onset, progression, and severity of the disease depend, however, on
mellitus. f leads to an at least short-term reduction of glycated hemoglobin the individual host immune response.
(HbA1c) of approximately 0.3% up to 0.6% .
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• Patients with poor glycemic control tend to experience more severe • Proinflammatory mediators regulate synthesis and secretion of
progression of periodontitis compared to patients with good glycemic • In the context of diabetes mellitus, a number of patients exhibit an matrix-metalloproteinases (MMPs) and receptor-activator-of-NF-
control. increased body weight (obesity), which also correlates with the kappaB-ligand (RANKL).
prevalence and severity of periodontal attachment and bone loss.
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5. Genetic Factors 6. Environmental and Behavioral Factors 6. Environmental and Behavioral Factors

• Several gene*c disorders are known to show periodontal destruc*on • In addition to microbial, immunologic, and genetic factors, the • Compared to nonsmokers, the following features are found in
as one of their major symptoms. development and progression of chronic periodontitis is further influenced smokers: see
by environmental and behavioral factors such as smoking and psychological
stress.
• Increased periodontal pocket depth with more than 3 mm
• Periodontal disease has been found in different family members • Increased attachment loss
(twins, siblings) and genera*ons of one family. • Smoking
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is a major risk factor for the development and progression of • More recessions
generalized chronic periodontitis. • Increased loss of alveolar bone
• Increased tooth loss
• The data showed variable results with a likelihood for heritability of *• Fewer signs of gingivitis (less bleeding upon probing) WI
up to 50%.
• The intake of more than 10 cigarettes per day tremendously increases the gingivitis
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risk of disease progression when compared to nonsmokers and former
smokers, respectively.
• A greater incidence of furcation involvement 5bleeding
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6. Environmental and Behavioral Factors 6. Environmental and Behavioral Factors

first sign or

• Due to the consumption of tobacco, reactive oxygen (radicals) is • In addi'on, stress as an e'ologic factor was even strongly associated
released that chemically irritates periodontal tissues by DNA damage, with periodon''s when pa'ents were smokers compared to inhumation Bop
lipid peroxidation of cell membranes, damage of endothelial cells, nonsmokers.
and the induction of smooth muscle cell growth.

• Psychological factors, such as stress and depression, also negatively

influence the progression of chronic periodontitis.
Thank you
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