periodontitis

DR.NAEL ALMASRI
PERIODONTIST
DIFINITION

It is inflammatory disease of supporting tissues of teeth

caused by specific micro-organism or group of specific
micro-organisms resulting in progressive destruction of
periodontal ligament and alveolar bone with pocket
.formation, recession or both

As an infectious disease resulting in inflammation within the “

supporting tissues of the teeth , progressive attachment
loss and bone loss” (Flemmig TF 1999)
DEFINITION
periodontitis manifested as: progressive
destruction of PDL & alveolar bone with
pocket formation
gingival recession
or both

Alterations of host immune response

Irreversible attachment loss and bone loss
HISTOLOGICALLY

Relocation of junctional epithelium to the

root
Destructions of the fibers of gingiva
Destructions of periodontal ligament
fibers
Alveolar bone resorption
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 (Michalowicz 1994; Shapiraet al. 2005)
Chronic periodontitis previously called adult periodontitis
Age-dependent nature of the adult periodontitis designation was
felt to be somewhat arbitrary as similar bone loss patterns can
also be seen in adolescents and even in the primary dentition of
.children
Another difficulty lay in the fact that the age at which a patient
presents for treatment does not necessarily reflect the age at
.which the disease began

Chronic” periodontitis refers to progression of the disease over“

time without treatment and does not suggest that the disease is
“untreatable
CLINICAL FEATURES OF
CHRONIC PERIODONTITIS

Gingival inflammation
color, texture and volume alterations of the marginal
gingiva
bleeding on probing (BoP) from the gingival pocket area
Loss of clinical attachment level
Periodontal pocket
Recession
Both
Loss of alveolar bone(even or angular pattern)
Root furcation exposure
Increased tooth mobility
exfoliation of teeth Drifting and eventually
.
Clinical appearance of the tissue is not a
reliable indicator of the presence or
severity of chronic periodontitis
The amount of tissue distruction
:depends on
Plaque biofilm
Host response
Local risk factors
Systemic risk factors
OVERALL CHARACTERISTICS OF
CHRONIC PERIODONTITIS

Chronic periodontitis is prevalent in adults >35 but

.may occur in children and adolecent
The rate of progression is slow to moderate; periods of
rapid tissue destruction may, however, occur
Dental plaque and calculus and plaque retentive factors are
evident
Subgingival calculus is commonly present at diseased
.site

The composition of the biofilm may vary between

.subjects and sites
site specific
Some sites healthy gingiva ,others with chronic periodontitis
.It can be modified by other factors such smoking
SYMPTOMS OF CHRONIC PERIODONTITIS

Usually painless
Bleeding
Spacing between teeth
Loosening teeth
Food impaction
Sensitivity to cold or hot
Rarely dull pain
ATTACHMENT LOSS WITH AND WITHOUT DEEP PD

Pocket depths are variable, and both horizontal

and vertical bone loss can be found
15
PREVALENCE OF CHRONIC PERIODONTITIS

Is the most commonly occurring form of

periodontitis
increased prevalence of disease in older
.people
GINGIVITIS AS A RISK FOR
CHRONIC PERIODONTITIS

Gingivitis lesions may remain stable for

many years, and may never progress to
become periodontitis lesions that
include features such as attachment
.and bone loss
PROGRESSION OF CHRONIC PERIODONTITIS

Chronic periodontitis is generally a slowly

progressing form of periodontal disease that
at any stage may undergo exacerbation
resulting in additional loss of attachment
and bone

Site specific
.
RISK FACTORS FOR CHRONIC PERIODONTITIS

Bacterial plaque
Age
Age associated but not age related
Systemic disease
Dysfunction )PMNs(
Diabetes
Smoking
Local factors
Systemic factors
Environmental and behavioral factors
Genetic predisposition
stress
SYSTEMIC AND ENVIRONMENTAL
RISK FACTORS
Uncontrolled
Uncontrolled diabetes
diabetes mellitus
mellitus (types
(types II and
and II)
II)

Smoking
Smoking

Emotional
Emotional stress
stress

Oral
Oral hygiene
hygiene habit
habit

Environmental
Environmental factor
factor and
and Nutrition
Nutrition

Osteoporosis
Osteoporosis

HIV
HIV

21
DISEASE DISTRIBUTION

Localized: if < 30% of examined sites

possess attachment loss and bone loss
Generalized: if > 30% of examined sites
possess attachment loss and bone loss
 DISEASE SEVERITY

Based on attachment loss

Slight (mild): 1-2 mm of clinical
attachment loss has occurred
Moderate: 3-4 mm of clinical attachment
loss has occurred
Severe: 5 mm or more clinical attachment
loss has occurred
RADIO GRAPHICAL DIAGNOSIS

Widening
Widening of
of PDL
PDL space
space

Loss
Loss of
of corticated
corticated interdental
interdental crestal
crestal margin
margin

Localised
Localised or
or generalized
generalized loss
loss of
of alveolar
alveolar supporting
supporting bone.
bone.

Blunting
Blunting of
of the
the alveolar
alveolar crest
crest due
due to
to beginning
beginning of
of bone
bone
resorption
resorption

Bone
Bone loss
loss may
may be
be either
either horizontal
horizontal or
or vertical.
vertical.

24
 TREATING CHRONIC PERIODONTITIS
PATIENTS

Phase I therapy
OHI
Scaling and root planing
Correction of potential local, systemic and
environmental factors

systemic antibiotics should not be routinely

used in the treatment of Chronic Periodontitis
patients
Chronic periodontitis respond well
to nonsurgical treatment
AGGRESSIVE PERIODONTITIS )AGP(
Aggressive periodontitis (AgP) comprises a group
of rare, often severe, rapidly progressive forms of
periodontitis often characterized by an early age of
clinical manifestation and a distinctive
tendency for cases to aggregate in families

rapidly progressing periodontitis

highly virulent microflora and/or a high level of

.subject susceptibility to periodontaldisease
 IMMUNOLOGIC FACTORS

Functional defects of PMN’s, monocytes

or both

Hyperresponsiveness of monocytes &

macrophages producing PGE2
PRIMARY FEATURES

Non-contributory medical history

Rapid attachment loss and bone •
destruction
.Familial aggregation of cases •
SECONDARY FEATURES
Amounts of microbial deposits inconsistent with •
the severity of periodontal tissue destruction
Elevated proportions of Actinobacillusactinomycetemcomitans •
Porphyromonas gingivalis
Phagocyte abnormalities •
Hyper-responsive macrophage phenotype, including •
elevated production of prostaglandin E2 (PGE2)
and interleukin-1β (IL-1β) in response to bacterial
endotoxins

Poor response to periodontal therapy

Progression of attachment loss and bone loss may

.be self-arresting
AgP presents early in the life of the
Individual however, can occur at any age

rate of bone loss is about three to four

times faster than in chronic
periodontitis
Diagnosis of AgP requires exclusion of the
presence of systemic diseases that may
severely impair host defenses and lead to
premature tooth loss (periodontal
.manifestations of systemic diseases)
LOCALIZED AGGRESSIVE PERIODONTITIS (LAP)

Circumpubertal onset °

Localized °
first molar/incisor presentation with
interproximal attachment loss on at least two
,permanent teeth, one of which is a first molar
and involving no more than two teeth other
than first molars and incisors

Lack of clinical signs of inflammation

usually show bilaterally symmetric, rapid severe

Robust serum antibody response to infecting °

agents
RAPID RATE OF PROGRESSION
PREVALENCE
It occurs in less than 1% of adolescents

Most reports suggest a low prevalence, about 0.1-

0.2%

Blacks were at much higher risk for LAP, and black

male teenagers were 2.9 times more likely to
have the disease than black female adolescents.
In contrast, white female teenagers were more
.likely to have LAP than white male adolescents
A STRIKING FEATURE OF LAP IS THE LACK OF CLINICAL
INFLAMMATION DESPITE THE PRESENCE OF DEEP PERIODONTAL
POCKETS AND ADVANCED BONE LOSS
year-old girl suffering from localized aggressive-15
.periodontitis
Note the proper oral hygiene conditions and the scalloped outline of
the gingival margin
the lower anterior region
.the interdental papilla between teeth 31 and 32 has been lost
Intraoral radiographs show the presence of localized
angular bony defects, associated with clinical attachment level loss,
at the mesial aspect of tooth 46, 36 and at the distal aspect of
tooth 3
No significant bone loss and/or attachment loss was detectable in
.other areas of the dentition
Diagnosis: localized
aggressive periodontitis
CLINICAL FEATURES OF LAP
distolabial migration of the maxillary incisors with concomitant
,diastema formation
increasing mobility of the maxillary and mandibular incisors and )2(
,first molars
sensitivity of denuded root surfaces to thermal and tactile )3(
stimuli, and

deep, dull, radiating pain during mastication, probably caused by )4(

irritation of the supporting structures by mobile teeth and impacted
.food
,Periodontal abscesses may form at this stage
regional
.lymph node enlargement may occur
RADIOGRAPHIC FINDINGS
Vertical loss of alveolar bone around the first molars
,and incisors
beginning around puberty
Radiographic findings may include an “arc-shaped loss
of alveolar bone extending from the distal surface of
the second premolar to the mesial surface of the
second molar
 RADIOGRAPHIC FINDINGS

Vertical bone loss

Arc-shaped
defects
GENERALIZED AGGRESSIVE PERIODONTITIS (GAP)

Usually affecting persons under 30 years of °

age, but patients may be older

Generalized °
interproximal attachment loss
affecting at least three permanent teeth other
than first molars and incisors

episodic nature of the destruction °

of attachment and alveolar bone

.Poor antibody response to periodontal pathogenes °

TWO GINGIVAL TISSUE RESPONSES CAN BE FOUND IN CASES
OF GAP

. 

One is a severe, acutely inflamed tissue, Bleeding may occur

spontaneously or with slight stimulation. Suppuration may be an
important feature. This tissue response is believed to occur in the
destructive stage, in which
.attachment and bone are actively lost

In other cases the gingival tissues may appear pink, free of

,inflammation, and occasionally with some degree of stippling
,although stippling may be absent However
despite the apparently mild clinical appearance, deep pockets can
be demonstrated by probing. Page and Schroeder36 believe that this
tissue response coincides with periods of quiescence in which the
.bone level remains stationary
PREVALENCE
In a study of untreated periodontal disease
conducted in Sri Lanka
by Loe et al, 8% of the population had rapid
progression of periodontal disease,
characterized by a yearly loss of attachment of
to 1.0 mm 0.1
blacks were at much higher risk than whites for
all forms of aggressive periodontitis

.
GAP may be arrested spontaneously or
after therapy, whereas others may
continue to progress leading to tooth
loss despite intervention with
.conventional treatment
RADIOGRAPHIC FINDINGS

GAP can range from severe bone loss

associated with the minimal number of
teeth, as described previously, to
advanced bone loss affecting the
majority of teeth in the dentition
RISK FACTORS FOR AGGRESSIVE
PERIODONTITIS

Microbiologic Factors 

A. actinomycetemcomitans is found in high frequency (approximately .1

.in lesions characteristic of LAP )90%
Sites with evidence of disease progression often show elevated .2
.levels of A. actinomycetemcomitans
Many patients with LAP have significantly elevated serum antibody .3
titers to
.A.actinomycetemcomitans
Clinical studies show a correlation between reduction in the .4
subgingival load of A. actinomycetemcomitans during treatment
.and a successful clinical response
A. actinomycetemcomitans produces a number of virulence .5
.factors that may contribute to the disease process
Another study found elevated levels of
P.gingivalis, Prevotella
intermedia,Fusobacterium
nucleatum, C. rectus, and Treponema
denticola in patients with either
localized or generalized aggressive
disease
Gram-negative
anaerobes

MO invade CT

Rationale for giving

antibiotics
Because of the significance of the bacterial flora in
aggressive periodontitis, systemic antibiotic therapy in conjunction
.with scaling and root planing is recommended

.
The tetracyclines have been effective in treating both
forms of aggressive periodontitis, as has a combination of
amoxicillin and metronidazole; however, antibiotic susceptibility
testing of the subgingival bacterial flora is recommended
.if there is any uncertainty regarding which antibiotics to prescribe
,Because of the aggressive

Surgery may be considered for greater access for root débridement

complex, and advanced
,nature of both localized and generalized aggressive periodontitis
.referral to a periodontal specialist is recommended
TREATMENT PLANNING

Treatment
Treatment for
for periodontitis
periodontitis generally
generally falls
falls into
into two
two categories:
categories:

1)
1) Procedures
Procedures designed
designed to
to halt
halt the
the progression
progression of
of disease.
disease.

2)
2) Procedures
Procedures designed
designed to
to regenerate
regenerate structures
structures destroyed
destroyed by
by
disease.
disease.
Non surgical Surgical

53
Periodontitis as
manifistation of
systemic disease