1. Chronic Periodontitis
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Chronic Periodontitis
Localized
Generalized
Algonquin College

2. Learning Outcomes Describe the development of a periodontal pocket.
Relate clinical characteristics to the histopathologic changes for chronic periodontitis.
Compare the gingival pocket with the periodontal pocket.
Determine the severity of PD activity using clinical data.

3. 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

4. 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

5. Clinical Characteristics
Deep red to bluish-red tissues
Thickened marginal gingiva
Blunted/cratered papilla
Bleeding and/or suppuration
Plaque/calculus deposits

6. Clinical Characteristics
Variable pocket depths
Horizontal/vertical bone loss
Tooth mobility

7. Pathogenesis – Pocket Formation
Bacterial challenge initiates initial lesion of gingivitis
With disease progression & change in microorganisms  development of periodontitis

8. 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

9. Pocket Formation
Continued extension of JE requires healthy epithelial cells!
Necrotic JE slows down pocket formation
Pocket base degeneration less severe than lateral

10. 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

11. Development of Periodontal Pocket

12. Continuous Cycle!
Plaque  gingival inflammation  pocket formation  more plaque

13. 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

14. 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

15. Clinical & Histopathologic Features
Pocket wall bluish-red
Smooth, shiny surface
Pitting on pressure
Histopathology:
Vasodilation & vasostagnation
Epithelial proliferation, edema
Edema & degeneration of epithelium

16. Clinical & Histopathologic Features
Pocket wall may be pink & firm
Bleeding with probing
Pain with instrumentation
Histopathology:
Fibrotic changes dominate
 blood flow, degenerated, thin epithelium
Ulceration of pocket epithelium

17. Clinical & Histopathologic Features
Exudate
Flaccid tissues
Histopathology:
Accumulation of inflammatory products
Destruction of gingival fibers

18. 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

19. Root Surface Wall Necrotic areas of cementum form; clinically soft
Act as reservoir for bacteria
Root planing may remove necrotic areas  firmer surface

20. 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

21. Periodontal Pocket
Suprabony pocket

22. 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

23. Inflammatory Pathway Interproximal:
Loose CT  periodontal ligament  bone  infrabony pockets & vertical bone loss  transseptal fibers transverse in oblique direction

24. 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

25. Inflammatory Pathway Facial & Lingual:
Loose CT  periodontal ligament  destruction of periodontal ligament fibers  infrabony pockets & vertical or angular bone loss

26. Stages of Periodontal Disease

27. 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

28. Periodontal Pathogens
Pathogens include:
Nonmotile rods:
Facultative:
A.a., E.c.
Anaerobic:
P. g., P. i., B.f., F.n.
Motile rods:
C.r.
Spirochetes:
Anaerobic, motile:
Treponema denticola

29. 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

30. 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

31. Overall Prognosis Dependent on: Client compliance Systemic involvement
Severity of condition
# of remaining teeth

32. Prognosis of Individual Teeth
Dependent on:
Attachment levels, bone height
Status of adjacent teeth
Type of pockets: suprabony, infrabony
Furcation involvement
Root resorption

33. 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 
Advanced
> 7 mm
 5 mm
Mod-severe
vertical