Chronic periodontitis

Chronic periodontitis is one of the forms of inflammation in the periapical tissues of the tooth. As a type of pathology of the periodontal ligaments, chronic inflammation can develop without clinically expressed exacerbation or be a consequence of an acute form of periodontitis that has not been adequately treated.

Chronic periodontal inflammation is always caused by the possibility of exudate outflow, usually into the tooth cavity. The constant influx of pathogenic microorganisms into periodontal tissues provokes the activation of other inflammatory processes in areas of the body remote from the teeth - in internal organs and systems. Depending on the cause provoking the process, chronic periodontitis can be long-term and asymptomatic, has the property of periodically worsening and subsiding on its own. Constant and progressive pathogenic effects on the periodontal gap most often lead to tooth destabilization, bone tissue destruction and serious complications, including osteomyelitis.

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Causes of chronic periodontitis

The main factors that provoke chronic inflammation of periodontal tissue are caries and its consequence – pulpitis. Depending on the localization of the inflammatory process, the causes of chronic periodontitis can be associated with both infectious contamination and traumatic damage to the tooth.

Apical, that is, apical periodontitis, is provoked by an infected pulp, and marginal or marginal inflammation of the periodontium is most often caused by mechanical microtrauma - the habit of gnawing a pen, pencil, cracking nuts, less often blows or bruises. The third most common cause in the list of causes is the drug factor, when the inflammatory process is provoked by incorrect treatment of pulpitis, as well as a local allergic reaction to the injected drug or dental material during tooth filling.

In dental practice, according to statistics, the leading position is occupied by infectious chronic periodontitis, which develops as a result of damage to periapical tissues by non-hemolytic and hemolytic streptococci. Toxic substances released by pathogenic microorganisms into the pulp enter the periodontal tissue through the root canal, less often the infection penetrates the periodontium hematogenously or through the lymph.

In addition, there are so-called secondary factors that activate the causes of chronic periodontitis:

• Violation of the balance of microflora in the oral cavity.
• Malocclusion of teeth (malocclusion).
• Metabolic disorder in the body.
• Microelement imbalance and vitamin deficiency.
• Chronic diseases of internal organs.
• A condition following an infectious or viral disease.
• Diabetes.
• Endocrine pathologies.
• Significant decrease in immune activity.

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Symptoms of chronic periodontitis

The danger of chronic periodontitis is its asymptomatic course, when the inflammation is practically not felt by a person. The erased symptoms of chronic periodontitis do not allow for timely diagnosis and treatment, which results in early tooth loss. Among the alarming signs that are worth paying attention to, one can note a slight painful sensation when biting hard foods. Mild discomfort is also possible with percussion, tapping on the tooth. A more pronounced symptom of inflammation can be considered the formation of a fistula on the gum, as a rule, this is a way of outflow of accumulated inflammatory exudate. Unfortunately, when a fistula is formed, decay products come out, all painful symptoms subside, so it is quite rare for a person to go to the dentist, triggering an inflammatory process that continues to develop for a long time, up to a serious exacerbation.

Manifestations and symptoms of chronic periodontitis depend on the types of inflammation, which can be as follows:

• Chronic fibrous periodontitis. A rather rare form of the inflammatory process, characterized by the gradual replacement of the affected periodontal tissues with denser fibrous fibers. The course of the inflammation is very sluggish, the person practically does not experience discomfort, short-term sensations of aching pain are possible, which quickly pass without a trace. As a rule, the fibrous form of inflammation is diagnosed by chance, when the patient consults a dentist for a completely different reason, for example, to treat a nearby tooth.
• Chronic granulating periodontitis is more pronounced and is expressed in the formation of fistulas under the mucous tissues of the alveoli. The inflammatory process is accompanied by the destruction of the bone plate of the alveolar process, granulation spreads through the formed bone defects, without causing pain. The absence of pain is explained by the fact that the exudate finds an outlet through the fistula opening, but if the granulation formations grow, a person may feel aching pain and discomfort when eating solid food. In addition, a large fistula is difficult not to notice on your own, this symptom should serve as a reason for immediate medical attention.
• Chronic granulomatous periodontitis is an inflammation of the periodontal tissues with the formation of a specific capsule filled with granulomas. This type of inflammatory process is most often asymptomatic and is dangerous because the enlarged cystogranuloma requires surgical treatment. Alarming signs may include a change in tooth color, a reaction to food temperature, and mild discomfort when biting into hard foods.

All types of chronic periodontitis, despite the asymptomatic course, are characterized by a general intoxicating effect on the body, therefore, among the secondary undifferentiated signs, it is necessary to note a periodic deterioration in health, malaise, decreased activity, some symptoms of CNS irritation. In addition, chronic inflammation of the periodontium in one way or another affects the lymphatic system, which reacts to the pathological process by increasing the regional nodes.

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Exacerbation of chronic periodontitis

The only way to detect and diagnose the chronic course of inflammatory periodontal disease in time is an exacerbation. Most often, an exacerbation of chronic periodontitis develops against the background of a concomitant general disease and has serious consequences in the form of abscesses, periostitis, phlegmon or osteomyelitis of the jaw bone tissue. Odontogenic exacerbations are also possible as an independent condition when pathogenic microorganisms penetrate the maxillofacial tissues by hematogenous or rhinogenous route, in most cases this is a staphylococcal or streptococcal infection.

Symptoms of exacerbation of chronic periodontitis:

• Deterioration of general well-being due to intoxication of the body.
• An increase in body temperature is possible.
• Headache.
• Pain in the area of the infected tooth.
• Clear localization of pain, the patient always accurately points to the sore tooth.
• Gum swelling, infiltration.
• An abscess may form when the inflammatory exudate has no outflow.
• Increased toothache when eating or percussion.
• Tooth mobility.
• The sensation of a “growing tooth”; the tooth seems to be moving out of the socket due to swollen periapical tissues.
• Enlargement of regional lymph nodes.
• Asymmetric swelling of facial tissues is possible.

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Chronic periodontitis in the acute stage

Exacerbation of chronic inflammation in the clinical sense is identical to the signs of acute purulent periodontitis. As a rule, the exacerbation stage has previous episodes of minor activation of symptoms that subsided on their own and the patient did not seek medical help.

Most often, chronic periodontitis in the acute stage is the growth of granulation formations in the periodontal tissues. Periodontitis chronika granulans exacerbata is a rather serious inflammatory process, when noticeable clinical symptoms appear in the form of pain when eating, a feeling of an enlarged tooth (typical syndrome of an overgrown tooth), swelling of the gums, and less often of the face. Objective signs are a deep carious cavity, often a gingival fistula with a closed passage, painful sensations when percussing the tooth, hyperemic mucous membrane of the oral cavity.

Chronic periodontitis in the acute stage may clinically resemble acute jaw osteomyelitis, periodontal tissue abscess, exacerbation of a deep carious process or acute sinusitis. The need to differentiate clinical manifestations in the chronic form of periodontitis can complicate diagnostics, but modern dentistry has precise methods and equipment that allow for timely clarification and confirmation of the correct diagnosis. Primary diagnostic assumptions are excluded or confirmed by radiography, or more precisely, by a picture that clearly shows an expanded periodontal gap with a characteristic “flame” pattern. If necessary, several radiographic examinations (panoramic images) are carried out to help track the dynamics of therapy effectiveness.

Most often, chronic periodontitis in the acute stage is subject to conservative treatment, which involves creating access to the canal, mechanical sanitation and treatment, including the introduction of antiseptics and necessary medications. When the main inflammatory process is stopped, the tooth is closed with a permanent filling. However, advanced inflammation, complicated by periostitis, phlegmon, which excludes the possibility of preserving the tooth, may require surgical intervention. In order to prevent the infection from spreading to nearby tissues and teeth, an incision is made in the gum, conditions are created for drainage of purulent exudate, and treatment is carried out aimed at neutralizing the intoxication of the body.

Hemisection or amputation of the root, partial resection of the apex, and the tooth may be completely removed if conservative therapy does not produce results and the inflammation does not subside within 5-7 days are also possible.

Exacerbations are possible with any type of chronic inflammation in the periodontium, but according to statistics, granulating periodontitis “leads” in this list, which is characterized by a recurrent course and a fairly rapid development of the process due to the proliferation of granulations.

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Chronic periodontitis in children

Chronic inflammation in the periodontium is more common in children than in adults, especially common is chronic granulating periodontitis of baby teeth in the molar area (bifurcation of the root system). The etiology and factors that provoke chronic periodontitis in children are not much different from the causes of the inflammatory process in older patients, however, there are some peculiarities. The specificity of the structure of periodontal tissue in childhood is such that both the gum and the periapical apparatus have a loose structure, the tissue fibers do not have sufficient density. This makes the periodontium more vulnerable to infection, injury, but also creates conditions for the constant distribution and outflow of inflammatory exudate, preventing it from accumulating and forming cysts and granulomas.

Chronic periodontal inflammation in children can be both primary and develop as a consequence of a missed and untreated exacerbation, including exacerbation of pulpitis. The leading position in the list of etiological causes is occupied by caries dentis - caries, which today, according to statistics, is diagnosed in 80% of children. As a result of carious damage to the tooth, pulpitis develops, which is also often not treated at the right time, advanced inflammation of the pulp creates all the conditions for the penetration of infection into the periodontal tissue, which often leads to premature tooth loss. In addition, the danger that chronic periodontitis in children carries is the pathogenic effect on the rudiments of nearby teeth when they shift, the root stops growing according to physiological norms, the tooth either erupts before the due date, or grows defective.

Clinical manifestations of chronic inflammation in the periodontium are not expressed, often the child may feel temporary discomfort when eating, but does not pay attention to it. Detection of periodontitis is possible only during exacerbations of the process, when severe pain appears, or during regular dispensary examinations, which should become a rule for every modern child.

Periodontitis of baby teeth can be treated both conservatively and surgically, it all depends on the condition of the tooth and the degree of neglect of the inflammation. If the periodontal tissues are totally inflamed, there is a risk of damaging the rudiment of the adjacent tooth, the causative tooth is subject to extraction. If it is possible to save the baby tooth, the canal is sanitized, the inflammation is stopped, the tooth is filled.

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Chronic forms of periodontitis

Depending on the nature of the deformation of the periapical tissues, the morphological and clinical picture, chronic forms of periodontitis can be as follows:

1. Fibrous periodontitis.
2. Granulating periodontitis.
3. Granulomatous periodontitis.

The fibrous form of chronic periodontal inflammation is characterized by a long asymptomatic course of the process, in which the tissues of the periodontal gap are replaced by coarser, denser fibrous fibers. Connective tissue is not physiologically and anatomically acceptable for the periapical apparatus, it does not create conditions for normal blood supply to the tooth, so the ligaments gradually lose their functions. Most often, a person does not feel discomfort and pain, the inflammation is practically not manifested in a clinical sense. It is possible to diagnose fibrous inflammation only with the help of an X-ray, this happens during a routine examination or during treatment of a nearby tooth.

The granulating form of periodontitis also develops without obvious clinical symptoms, but the inflammation affects the periodontium faster. In addition, the formed fistula can be detected by the patient himself, and serve as a reason for contacting a dentist. If the fistula has an open passage, the inflammatory exudate flows into the oral cavity, which helps reduce pain, and also ensures a sluggish course of the process. The danger of granulating periodontitis is the gradual destruction of the alveolar process, an advanced process often does not allow preserving the tooth, it has to be removed completely.

Granulomatous periodontitis is characterized by the gradual formation of a cyst that does not cause pain. The granuloma presses on the alveolar process, gradually displacing and destroying it, which leads to an irreversible process in the form of a tooth root fracture or osteomyelitis. In addition, cystogranulomas are a source of constant infection inside the body and create conditions for chronic inflammatory processes in the internal organs.

Poor clinical manifestations do not allow for timely detection of granulomatous inflammation, and most often it is treated surgically.

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Chronic granulating periodontitis

Chronic inflammation in granulating form is considered one of the most active types among chronic periodontitis, since the formation of granulation itself cannot but cause discomfort, therefore the patient has the opportunity to promptly contact a dentist and receive adequate help. Granulation tissue is able to spread through the wall of the alveolar process up to the skin of the face, sometimes completely replacing the bone tissue of the alveolus. Periodic acute phases of the process accompany the formation of a fistula, through which the accumulated exudate finds an outflow. As soon as the contents are able to exit, the exacerbation subsides and the process again becomes sluggish, asymptomatic. Clinical signs are also absent due to sensitization of the body, which is uniquely adapting to constant infection from the source of odontogenic inflammation. Chronic granulating periodontitis is also characterized by a toxic effect on the body due to resorption in the alveolar process and the absorption of inflammation products into the bloodstream. Paradoxically, a fistula that releases exudate into the oral cavity can reduce intoxication; as soon as the fistula is blocked, the process enters the acute stage and activates general poisoning of the body. The granulating form of inflammation is considered to be quite dynamic and easily diagnosed, unlike other types of chronic inflammation of periodontal tissue.

Symptoms of chronic granulating periodontitis depend on the phase of the process (exacerbation or remission) and can be as follows:

• During the acute phase, minor pain may occur with mechanical pressure on the inflamed tooth.
• The pain is paroxysmal in nature and intensifies when eating solid food.
• There may be slight swelling of the gums around the affected tooth.
• In the area of the tooth apex, an infiltrate is clearly palpable.
• An exacerbation most often ends with the formation of a fistula, which neutralizes the pain.
• If granulation tissue actively spreads, a person may feel the formation of an atypical seal in the oral cavity - under the mucous membrane.
• During the remission phase, pain may occur when eating hot food.
• Most often, there is a carious cavity in the tooth; when pieces of food get into it, a painful sensation may occur, which subsides after the cavity is treated and food particles are removed.

Chronic granulating periodontitis is treated for a long time, the prognosis depends on the stage of the inflammation and the duration of its course. Modern dentistry strives for tooth-preserving methods of treatment, but a completely destroyed root apex, the threat of infection spreading to surrounding tissues can give reason for the extraction of the causative tooth.

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Chronic granulomatous periodontitis

The granulomatous form of chronic periodontitis is considered one of the most sluggish in clinical manifestations. This type of inflammation can develop as an independent disease, but can also be a consequence of the granulating process in the remission stage, when a fibrous capsule is formed in the apex zone, turning into a cystogranuloma state. It is the dense fibrous tissue that prevents further penetration of infection into the body and serves as a barrier to the spread of bacterial decay products. Chronic granulomatous periodontitis is characterized by a long asymptomatic course, the only noticeable sign can be a fairly large granulomatous formation in the projection of the apical zone of the tooth root.

According to morphological features, granulomatous periodontitis is classified into 3 types of inflammation:

1. Simple granulomatous periodontitis, in which the granulomas consist of dense fibrous tissue.
2. Epithelial granulomatous periodontitis, when the structure of granulomas includes epithelium. Such formations look like radicular cysts and can be a sign of a primary oncological process in the jaw.
3. Cystogranulomatous periodontitis, in which granulomas form cysts with inflammatory exudate inside.

Granulomas tend to be localized both in the apex zone and on the side of the root (apical-lateral), as well as in the bifurcation zone of multi-rooted teeth.

Treatment of single-root teeth affected by granulomatous periodontitis is carried out in one session, provided that the canal is well-patented. The treatment regimen is standard:

• Opening and mechanical treatment of the apical root canal.
• Sanitation of the canal and treatment of the inflammatory focus until complete drainage of exudate.
• Closing the canal with filling.

Multi-rooted teeth are more difficult to treat, since access to the canals is either closed or difficult. Such periodontitis is fraught with complications in the form of exacerbations of the process, which are stopped with the help of physiotherapy, anti-inflammatory drugs and regular aseptic rinses. If the infection has spread under the periosteum, gum, dissection of the gum tissue is used to create an outlet for the accumulated decay products. If conservative therapy is not effective, the doctor performs partial or complete resection of the inflamed root apex, or performs replantation when treating a multi-rooted tooth.

In general, granulomatous periodontitis can be considered cured no earlier than after a year, when complete scarring and tissue regeneration occurs at the site of the granulomas.

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Chronic fibrous periodontitis

The mildest form of periodontal inflammation, the most asymptomatic and clinically unmanifested type, is chronic fibrous periodontitis (periodontitis chronika fibroza).

Pathogenetically, fibrous growth occurs gradually, unnoticed, and can be an independent process, but also a consequence of exacerbation of granulomatous or granulating inflammation of the periodontal tissue. In addition to coarse fibrous fibers replacing periodontal structures, small focal infiltrates containing lymphocytes are visible in the oral cavity upon examination, the apical opening of the root contains increased deposits of cement elements (hypercementosis), and areas of osteosclerosis are formed along the periphery of the periodontium. As a result of constant tissue replacement, the periodontal gap widens, and the periodontium gradually loses its functional properties.

The inflammation occurs without discomfort and almost without pain. Very rarely, patients may experience minor pain with strong pressure on the causative tooth, as a rule, this occurs with unsuccessful biting of hard food, nuts, or pits. Chronic fibrous periodontitis can only be diagnosed with the help of radiography and thermal tests. Diagnostics are carried out in a differential channel, since the fibrous form, without specific symptoms, can resemble pulpitis in the gangrenous stage, caries.

Treatment of fibrous inflammation is quite successful, this is the most favorable form of periodontitis in a therapeutic sense. Even if the tooth canal is obturated, it is not opened, since there is no need to create an outflow for non-existent exudate. The inflammatory process affects only the periodontal gap, without affecting nearby tissues. If the infectious focus is large and located in the apex, it is possible to open the canal and sanitize it, diathermocoagulation of the pulp is extremely rare. After sanitization, a temporary filling is placed, and during a second visit to the dentist's office, the patient's tooth is closed with a permanent filling.

Chronic apical periodontitis

The chronic form of inflammation in the periodontium is divided into types according to the localization of the process:

• Apical or chronic apical periodontitis.
• Marginal or gingival (marginal) chronic periodontitis.

The most common form of chronic inflammation is the apical form; gingival (marginal) periodontitis is most often a consequence of constant microtrauma.

Apical inflammation owes its name to the localization of inflammation – in the apex (top) of the root. Chronic destruction of periodontal tissues, as a rule, begins precisely in this zone, which is explained by the vertical path of infection spread.

Chronic periodontitis in the root apex zone is an inflammation of the periapical structure, localized directly near the apical opening, less often affecting the mouths of the lateral parts of the ligaments. The inflammatory process can acquire a chronic form only under the condition of sensitization of the body, its adaptive reaction to the constant impact of pathogenic microorganisms. Such a conditional balance between infection and local protective reaction can last for years, aggravating the process and creating an environment for gradual infection of internal organs and systems.

Apical periodontitis can have fibrous, granulating and granulomatous forms; all three types of inflammation are characterized by an asymptomatic course and are diagnosed only in the acute stage or accidentally during routine dental examinations.

The etiology of chronic apical periodontitis, especially in children, is associated with an infection that can develop in the oral cavity as a result of advanced caries, and then pulpitis. Any type of chronic apical inflammation is prone to exacerbations, transition to a purulent process, and also to relapses.

The most favorable course is fibrous apical periodontitis, it refers to stabilization, adaptive processes. Granulating and granulomatous periodontitis are destructive inflammations, often difficult to diagnose, fraught with complications and difficult to respond to conservative tooth-preserving therapy.

Chronic apical periodontitis

Before understanding the causes that provoke Periodontitis chronika apicalis – chronic apical periodontitis, it is necessary to clarify how the apical opening of the tooth root and periodontal tissue are anatomically connected.

The pulp has a direct connection with the apex, its tissues are connected to the top of the periodontium by means of lateral openings and canals. If the pulp becomes inflamed and is not treated in a timely manner, the products of the inflammatory process gradually spread through the apex to all periodontal tissues, but the apical opening is affected first. This is how chronic apical periodontitis develops, which is most often a consequence of long-term caries damage, and then pulpitis. Since the periodontium is much more active in its protective properties than the pulp tissue, the inflammatory process rarely manifests itself with pronounced symptoms, the pathological balance and constant "fight" against infection in the periodontium can last for years, without being accompanied by noticeable discomfort or pain. The only sign after a certain period may be the formation of a granuloma or cyst large enough for the patient to begin to feel it in the oral cavity.

Such a latent course of the process is associated with many difficulties, both diagnostic and therapeutic. Chronic apical inflammation, in its sluggish and unmanifested symptoms, can be similar to periapical osteofibrosis, sclerosing fibroma, neoplasia, and the consequences of gum trauma.

In the etiological sense, the cause of chronic apical inflammation is easier to find, most often it is caused by pulpitis, which is confirmed by an X-ray. X-ray clearly determines the pathological widening of the periodontal gap, examination allows to identify the sensitivity of the causative tooth to percussion.

Other symptoms that may accompany chronic apical process in the periodontium:

• During periods of exacerbation of inflammation, noticeable pain is possible, which intensifies with mechanical pressure on the affected tooth.
• The pain is aching in nature and can subside and recur on its own.
• There is no swelling of the gums.
• In the granulating form of apical inflammation, infiltrates filled with lymphocytes can be seen on the mucosa in the area of the causative tooth.
• The granulomatous form of apical periodontitis is characterized by the formation of fairly large cystogranulomas.
• When a fistula forms and exudate drains, the pain subsides.
• Secondary symptoms of general intoxication are possible, which are not specific and most often not diagnosed as a consequence of chronic infection of the body. Weakness, fatigue, loss of appetite, not caused by obvious factors, should be carefully examined for connection with chronic inflammation in the oral cavity.

Treatment of chronic apical inflammation in the periodontium depends on the complexity, the degree of neglect of the process and the form of periodontitis. Currently, dentists strive for tooth-preserving methods, so if possible, the tooth canal is sanitized, conditions are created for adequate removal of inflammatory exudate. After stopping the inflammation, the tooth is sealed with a filling. Tooth extraction is also possible in cases where the dental bone tissue is thoroughly destroyed, the mobility of the tooth is high and there is a risk of spreading the infection to other, healthier tissues.

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Diagnosis of chronic periodontitis

Diagnosis of the inflammatory process in the periapical structure is carried out according to a standard scheme, but diagnosis of chronic periodontitis is always quite difficult due to the sluggish and asymptomatic course of the process.

Oral examinations are carried out according to the generally accepted algorithm in dental practice - questioning and collection of anamnesis, examination of the oral cavity, analysis and evaluation of clinical and instrumental examination results. The main methods that help confirm the chronic form of periodontitis are examination and radiography.

X-rays are taken repeatedly - during the first visit to the doctor, after therapeutic measures, and also during endodontic treatment in order to track the dynamics and effectiveness of the actions taken. In addition to X-rays, quantitative results based on a point scale are important indicators; this method is used to determine the degree of destructive damage to the root apex and the general disruption of the periapical tissues.

Clinical examination includes the following methods:

• A thorough examination of the entire oral cavity.
• Percussion of the causal tooth.
• Palpation of the oral cavity and periapical tissues.
• Probing the entrance to the tooth canal (determining obstruction and pain during passage).
• It is possible to conduct temperature tests, which are most effective for examining adult patients. Diagnosis of chronic periodontitis in children, as a rule, does not involve the temperature method due to the age characteristics of the patient and the subjectivity of the descriptions of sensations.
• Determining the degree of mobility of the causal tooth using correct pressing or translational movements.
• Radiovisiography and electroodontodiagnostics can be used. The electrodiagnostic method allows assessing the vitality of the pulp.

The most informative is an X-ray of the tooth and surrounding tissues; the interpretation of the X-ray results, in turn, depends on the experience of the dentist, since chronic periodontitis often does not have specific manifestations, but is classified as inflammation in various forms - granulating, fibrous or granulomatous.

Diagnosis of chronic periodontitis by type:

1. Chronic fibrous inflammation of the periodontium is very difficult to diagnose, which is explained by the absolute asymptomatic nature of the process. In addition, morphologically and pathogenetically fibrous inflammation is very similar to chronic gangrenous pulpitis, so the main method of differentiation is an X-ray and its interpretation. An objective examination of the oral cavity shows obvious caries (in 95% of cases), probing of the canal is painless, the dental crown is intact, the tooth does not respond to temperature stimuli, percussion is most often not accompanied by painful sensations. X-ray more clearly defines the clearly deformed periodontal gap, which is noticeably widened towards the apex.
2. Chronic granulation periodontitis is slightly easier to diagnose than other types of chronic periodontal inflammation. When examining the oral cavity, hyperemic mucous membrane is visible, the gums are slightly edematous, there is a symptom of vasoparalysis (when pressing on the gum, a pit appears, which slowly levels out). Palpation and percussion cause tolerable pain, the lymph nodes are compacted, may be enlarged. X-ray shows a characteristic picture of rarefaction of bone tissue in the apex area (flame pattern).
3. Granulomatous chronic periodontitis is also difficult to diagnose if the granuloma is located in the deep layers of the gum and is not clearly expressed. If the granuloma is localized in the cheek area, in the area of the upper molars, then the patient himself accurately indicates the place of the bulge. The carious cavity in the causative tooth may be hidden, percussion does not cause pain, with the help of palpation it is possible to detect small areas of tissue compaction in the projection of the hidden granuloma. An X-ray clearly reveals a zone of rarefaction of bone tissue, most often in a rounded shape, a destructive process is also visible in the entire tooth, especially in the apex, signs of hypercementosis are visible in the marginal areas of the root.

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Differential diagnosis of chronic periodontitis

Chronic inflammation in periapical tissues is difficult to diagnose due to the sluggish course of the process, latent clinical signs and the absence of specific symptoms. That is why differential diagnostics of chronic periodontitis is so important for choosing a therapeutic direction, which helps to distinguish periodontal inflammation from chronic pulpitis, periostitis, osteomyelitis and other diseases that are similar in the clinical sense. The main "assistant" of the dentist in this difficult process is radiography, of course, practical medical experience also affects the accuracy of the diagnosis, in addition, timely seeking help from the patient helps to establish the type of disease, which, unfortunately, does not happen so often.

Differential diagnosis of chronic periodontitis can be carried out according to the following signs:

Chronic fibrous inflammation of the periodontium	Caries
Noticeable change in tooth color	The color of the tooth remains unchanged
Probing is virtually painless	Going through a tooth canal causes pain
Temperature irritants do not cause painful sensations	The tooth reacts to temperature tests
The radiograph shows deformation, destruction of bone and periodontal tissue of the tooth	The X-ray does not show any noticeable destructive changes in the tooth tissues.
Threshold values of electrical excitability exceed 100 μA	The threshold values of electrical excitability are low - from 2 to 6 μA.

Granulating periodontitis	Local gangrenous process in the pulp
The tooth does not respond to temperature stimuli	Tooth pain gets worse when eating hot food
The pain is aching, bearable, and subsides spontaneously.	The pain is of a constant, aching nature.
The mucous membranes of the oral cavity may be hyperemic	The mucous membranes of the oral cavity are unchanged.
The passage of a tooth canal does not cause pain	Probing the canal is accompanied by severe pain
X-rays show visible changes in periodontal tissues	X-ray shows changes in pulp tissue
There are symptoms of general intoxication	General health is not impaired

Granulomatous periodontitis	Chronic pulpitis
The pain symptom is not pronounced, the pain does not increase from hot food	The tooth hurts when interacting with hot food and drinks
The color of the tooth changes noticeably	Tooth color unchanged
Probing is not accompanied by pain	Passing the canal is very painful
Temperature tests do not cause a reaction	Reaction to temperature tests
X-ray shows widening of the periodontal space, destruction of bone tissue	X-rays can show changes in bone tissue in 20-25% of cases

Differentiation of clinical manifestations and results of instrumental examinations allows choosing a treatment tactic that is adequate for the disease, which in turn may determine the preservation and restoration of tooth function.

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Treatment of chronic periodontitis

Treatment of chronic forms of periodontitis, as well as treatment measures in cases of exacerbation of the inflammatory process, can be both conservative and surgical. The main task of the dentist is to quickly stop the inflammation with the help of thorough sanitation of the source of infection. Prevention of the spread of infection to nearby tissues, anti-inflammatory therapy are possible only under certain conditions: •

• Patency of the tooth canal.
• A clearly localized inflammatory process.
• Preservation of most of the bone tissue.
• Absence of symptoms of severe intoxication and pain.

The first stage of chronic periodontitis treatment usually consists of mechanical treatment of the tooth cavity and canal. They are cleaned from carious decay products, treated with special antiseptics, and if possible, the cavity is closed with a permanent filling. In the presence of sluggish inflammation and significant accumulation of exudate, an outlet is created, most often by opening the obturated canal, then a temporary filling is placed. After 2-3 days, repeated sanitation is carried out, and the tooth is closed with a permanent filling. Inflammation is completely removed with the help of antibacterial dental materials (pastes), diathermocoagulation can be used, laser methods of sanitation and canal treatment are very effective. Chemical treatment of the tooth cavity is currently used less and less due to the risk of possible complications (drug-induced periodontitis). In addition, modern dentistry is aimed at maximum preservation of the dentition, and chemical disinsection in this sense has a rather aggressive effect on bone tissue, so it is replaced by safer and more effective methods of sanitation.

Surgical treatment methods:

• Tooth root amputation.
• Hemisection is the removal of roots in a multi-rooted tooth.
• Excision of the root apex.
• Tooth extraction (removal).
• Incision and drainage of the gum.

These methods are used only in cases where there is no access to the canal, for example, when treating chronic periodontitis of a wisdom tooth or treating multi-rooted teeth. Surgical methods are also indicated when intracanal therapy does not bring the expected result and there is a risk of total spread of infection to all tissues of the oral cavity. It should be noted that surgery in dentistry is an extreme measure, especially considering the availability of modern equipment and effective drugs. However, chronic inflammation in the periodontium can lead to conditions when conservative treatment is impossible in principle. This is due to the long period of inflammation, its chronization and the extent of destructive damage to the periapical tissues.

Of course, endodontic treatment of chronic periodontitis is more favorable in terms of prognosis and tooth preservation, when the crown part of the tooth and the hard structures of the root remain intact. In such cases, provided that the periodontal apparatus is relatively healthy, aesthetic restoration of the dentition or orthopedics is possible, which allows preserving not only the appearance of the teeth, but also their normal function.

Treatment of chronic forms of periodontitis

Treatment of chronic forms of periodontitis is directly related to diagnostic results that determine the type of inflammation – granulating, fibrous or granulomatous. Conservative treatment methods are the most common, since modern dentistry is aimed at organ-preserving therapy. Surgical intervention is considered an extreme measure when endodontic methods do not give results.

Usually the first visit to the dentist begins with local anesthesia, then probing of the tooth, sanitation of the canal. In parallel, the canal is cleaned mechanically or chemically from decay products, from carious deposits. The filling stage depends on the severity of the process, if possible, the tooth is closed immediately, when the inflammation requires longer treatment, a temporary filling is placed. The most favorable treatment is fibrous periodontitis, which is most often treated with physiotherapy procedures and regular rinses. Granulating periodontitis is more difficult and takes longer to treat due to its prevalence. Granulomatous periodontitis is considered a consequence of granulation, so the method of its treatment is identical to the therapy of granulating inflammation.

Tooth extraction, its replantation, cystotomy or root apex resection are performed strictly according to indications when conservative methods are not effective.

In any case, the treatment of chronic forms of periodontitis depends on the severity of the inflammation, and the doctor selects an adequate and most gentle way to neutralize the pathological process.

Treatment of chronic granulomatous periodontitis

Granulomatous periodontitis is usually a consequence of a previous granulating form of inflammation. Cystic formations and granulomas differ from each other in size, and this is what determines the choice of treatment method.

Granuloma is an abscess in the periodontal tissue, most often in the apex area, the size of the granuloma is less than 0.5 centimeters. If the formation exceeds 0.5 cm in size and reaches a centimeter, it is defined as a cystogranuloma.

Treatment of granulomatous periodontitis can be surgical or conservative, it all depends on the location of the formations and their condition.

Single-root teeth, provided that a granuloma has formed and the canal is well-patented, are treated in one session, during which the canal is sanitized, processed, apical therapy (diathermocoagulation) is performed, and the tooth is sealed with a filling.

A multi-rooted tooth, including a wisdom tooth, as a rule, does not provide the opportunity for canal sanitation, so they try to treat it conservatively with impregnation methods (silvering, resorcinol, potassium iodide). If complications develop during the treatment process, most often drug-induced inflammation, physiotherapy and antiseptic rinses are additionally prescribed.

The period of complete restoration of periodontal tissues can take 12 months, so the treatment of granulomatous periodontitis is considered quite difficult and lengthy. The process of scarring and tissue regeneration is constantly monitored by examinations and X-rays. If after a month of conservative therapy the doctor does not see positive dynamics, it is possible to use surgical methods - apex resection, tooth replantation.

Treatment of chronic granulating periodontitis

Chronic granulating periodontitis requires long-term treatment, sometimes up to six months.

The patient is required to have at least 4 visits to the dentist, and in addition to these, several more preventive visits for examination and confirmation of the effectiveness of the chosen method of therapy.

1. First visit:
   • Diagnostics.
   • Anesthesia.
   • Opening the channel.
   • Canal sanitation, removal of carious deposits.
   • Removal of remnants of necrotic pulp.
   • Flushing the canal with antiseptics.
   • Introduction of an anti-inflammatory agent into the tooth canal.
   • Placing a temporary filling.
   • Antibiotics may be prescribed in tablet form.
2. Second visit:
   • Examination of the oral cavity.
   • Removal of temporary filling material.
   • Canal flushing, sanitation.
   • Another temporary filling of the canal using an antiseptic material.
   • The filling remains for 2-3 months.
3. Third visit to the doctor:
   • X-ray control.
   • Opening the canal and its treatment.
   • Permanent tooth filling.
4. A fourth visit to the doctor is necessary to confirm the effectiveness of the treatment and the absence of complications.

Treatment of granulating periodontitis may also end with surgical intervention if the inflammatory process is advanced.

In what cases is surgical treatment of granulating periodontitis indicated?

• Abnormal position of the apex, curvature of the apex.
• Impossibility of probing the canal, its obstruction.
• Lack of effectiveness of conservative treatment within a month.
• Progression of inflammation during treatment.

Prevention of chronic periodontitis

Preventive measures to prevent chronic periodontitis are, first of all, prevention of caries, and then pulpitis. This is possible only under the following conditions:

1. Regular, thorough oral care.
2. Eat sensibly and limit sweet foods.
3. Regular visits to the dentist from childhood. According to statistics, dental check-ups reduce the incidence of caries by 65-70%.
4. Seek timely medical attention at the first alarming symptoms.
5. Compliance with all recommendations of the dentist during the treatment of periodontitis.

Prevention of chronic periodontitis is a systemic issue that requires not only a conscious attitude to one's own health on the part of the patient, but also constant educational work on the part of dentists. Fortunately, modern medicine, in particular dentistry, has ceased to be traumatic and today a visit to the dentist should not cause rejection or fear. The use of highly effective methods, the availability of precise equipment and a variety of pain relief methods make dental treatment completely safe. Therefore, the main thing in prevention is regular check-ups with a doctor, because only a specialist can detect the first signs of caries, an inflammatory process in time, and only a dentist can choose the right method of treatment.

Chronic periodontitis is currently the most frequently diagnosed oral disease, ranking second after caries in the sad list of dental problems. The chronic form of the inflammatory process is dangerous not only because of the absence of clinical manifestations, but also because it is a constant source of infection of internal organs, so the only way to protect yourself in this sense is not to be afraid of visits to the dentist. Even in the case of an exacerbation, the doctor will be able to choose the most gentle method of treatment and will try to do everything to preserve the tooth and its function. By visiting the doctor once every six months, you will not only be able to prevent periodontitis, but also ensure the absence of caries, tartar, and therefore a truly healthy smile.