Periodontitis: causes, diagnosis, treatment

Periodontitis is a common inflammatory disease in the periapical tissues. According to statistics, more than 40% of dental diseases are periodontal inflammations, surpassed only by caries and pulpitis.

Periodontal diseases affect literally all age groups – from young to old. Percentage indicators, based on 100 cases of visiting a dentist for toothache:

• Age from 8 to 12 years – 35% of cases.
• Age 12-14 years – 35-40% (loss of 3-4 teeth).
• From 14 to 18 years old – 45% (with loss of 1-2 teeth).
• 25-35 years old – 42%.
• People over 65 years old – 75% (loss of 2 to 5 teeth).

If periodontitis is not treated, chronic foci of infection in the oral cavity lead to pathologies of internal organs, among which endocarditis is the leader. All periodontal diseases in general, one way or another, affect a person's health and significantly reduce his quality of life.

ICD 10 code

In dental practice, it is customary to classify diseases of periapical tissues according to ICD-10. In addition, there is an internal classification compiled by specialists from the Moscow Medical Dental Institute (MMSI), it is accepted in many medical institutions of the post-Soviet space.

However, ICD-10 remains officially recognized and used in documentation, periodontitis is described in it as follows:

Code	Name
K04	Diseases of periapical tissues
K04.4	Acute apical periodontitis of pulpal origin
	Acute apical periodontitis NEC
K04.5	Chronic apical periodontitis
	Apical granuloma
K04.6	Periapical abscess with fistula: Dental Dentoalveolar Periodontal abscess of pulpal etiology
K04.60	Fistula communicating with the maxillary sinus
K04.61	Fistula communicating with the nasal cavity
K04.62	Fistula communicating with the oral cavity
K04.63	Fistula communicating with the skin
K04.69	Periapical abscess, unspecified, with fistula
K04.7	Periapical abscess without fistula: Dental abscess Dentoalveolar abscess Periodontal abscess of pulpal etiology Periapical abscess without fistula
K04.8	Root cyst (radicular cyst): Apical (periodontal) Periapical
K04.80	Apical, lateral cyst
K04.81	Residual cyst
K04.82	Inflammatory paradental cyst
K04.89	Root cyst, unspecified
K04.9	Other unspecified disorders of periapical tissues

It should be recognized that there is still some confusion in the classification of periodontal diseases, this is due to the fact that in addition to the internal systematization of the MMIS, adopted by practicing dentists of the former CIS countries, in addition to ICD-10, there are also WHO classification recommendations. These documents, deserving respect and attention, do not have major differences, however, the section "chronic periodontitis" can be interpreted variably. In Russia and Ukraine, there is a clinically substantiated definition of "fibrous, granulating, granulomatous periodontitis", while in ICD-10 it is described as apical granuloma, in addition, in the international classification of diseases of the 10th revision there is no nosological form "chronic periodontitis in the acute stage", which is used by almost all domestic doctors. This definition, accepted in our educational and medical institutions, in ICD-10 replaces the code - K04.7 "periapical abscess without fistula formation", which completely coincides in clinical picture and pathomorphological justification. Nevertheless, in terms of documenting diseases of periapical tissues, ICD-10 is considered generally accepted.

Causes of periodontitis

The etiology, causes of periodontitis are divided into three categories:

1. Infectious periodontitis.
2. Periodontitis caused by trauma.
3. Periodontitis caused by taking medications.

Pathogenetic therapy depends on etiological factors; its effectiveness is directly determined by the presence or absence of infection, the degree of change in the trophism of periodontal tissues, the severity of injury or exposure to chemical aggressive agents.

1. Periodontitis caused by infection. Most often, periodontal tissue is affected by microbes, among which hemolytic streptococci are the "leaders" (62-65%), as well as saprophytic streptococci and staphylococci, non-hemolytic (12-15%) and other microorganisms. Epidermal streptococci are normally present in the oral cavity without causing inflammatory processes, but there is a subspecies - the so-called "greening" streptococcus, which contains a surface protein element. This protein is able to bind salivary glycoproteins, combine with other pathogenic microorganisms (yeast-like fungi, veionella, fusobacteria) and form specific plaques on the teeth. Bacterial compounds destroy tooth enamel, simultaneously releasing toxins directly into the periodontium through the gingival pockets and root canals. Caries and pulpitis are among the main causes of infectious periodontitis. Other factors may be viral and bacterial infections that penetrate the periodontium through the blood or lymph, such as flu, sinusitis, osteomyelitis. In this regard, infectious inflammatory processes in the periodontium are combined into the following groups:

• Intradental periodontitis.
• Extradental periodontitis.

2. Periodontitis caused by traumatic injury. Such an injury may be a blow, a bruise, or getting a hard element (a stone, a bone) while chewing. In addition to one-time injuries, there is also chronic trauma caused by incorrect dental treatment (an incorrectly placed filling), as well as malocclusion, pressure on a row of teeth during professional activity (a mouthpiece of a wind instrument), bad habits (biting hard objects with teeth - nuts, the habit of gnawing pens, pencils). With chronic tissue damage, at first there is a forced adaptation to the overload, repeated trauma gradually converts the compensation process into inflammation.
3. Periodontitis caused by a drug factor is usually the result of incorrect therapy in the management of pulpitis or the periodontium itself. Strong chemicals penetrate the tissues, causing inflammation. This can be tricresolfor, arsenic, formalin, phenol, resorcinol, phosphate cement, paracin, filling materials, etc. In addition, all allergic reactions that develop in response to the use of antibiotics in dentistry also fall into the category of drug-induced periodontitis.

The most common causes of periodontitis may be associated with such pathologies as chronic gingivitis, periodontitis, pulpitis, when periodontal inflammation can be considered secondary. In children, periodontitis often develops against the background of caries. Factors that provoke periodontal inflammation may also be due to non-compliance with oral hygiene rules, vitamin deficiency, and lack of microelements. It should be noted that there are also somatic diseases that contribute to the development of periodontitis:

• Diabetes mellitus.
• Chronic pathologies of the endocrine system.
• Cardiovascular diseases, which can also be provoked by a chronic source of infection in the oral cavity.
• Chronic pathologies of the bronchopulmonary system.
• Diseases of the digestive tract.

To summarize, we can highlight 10 of the most common factors that provoke periodontitis:

• An inflammatory process in the pulp, acute or chronic.
• Gangrenous pulp lesion.
• Overdose of medications in pulpitis therapy (treatment period or amount of medication).
• Traumatic damage to the periodontium during pulp treatment or canal treatment. Chemical trauma during sterilization, canal sanitation.
• Traumatic damage to the periodontium during filling (pushing of filling material).
• Residual pulpitis (root).
• Penetration of infection located in the canal beyond the apex.
• An allergic reaction of periodontal tissues to medications or decay products of microorganisms that cause inflammation.
• Infection of the periodontium through blood, lymph, and less often by contact.
• Mechanical trauma to the tooth – functional, therapeutic (orthodontic manipulations), malocclusion.

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Pathogenesis of periodontitis

The pathogenetic mechanism of periodontal tissue inflammation development is caused by the spread of infection and toxins. Inflammation can be localized only within the boundaries of the affected tooth, but can also affect adjacent teeth, surrounding soft gum tissues, and sometimes even tissues of the opposite jaw. The pathogenesis of periodontitis is also characterized by the development of phlegmon, periostitis in advanced chronic processes and their subsequent exacerbation. Acute periodontitis develops very quickly, inflammation proceeds according to the anaphylactic, hyperergic type with a sharp reactive response of the body, increased sensitivity to the slightest irritant. If the immune system is weakened or the irritant is not very active (low-virulence bacteria), periodontitis becomes chronic, often asymptomatic. A constantly acting periapical inflammation site has a sensitizing effect on the body, which leads to chronic inflammatory processes in the digestive organs, heart (endocarditis), and kidneys.

The route of infection into the periodontium:

• Complicated pulpitis provokes the entry of toxic contents into the periodontium through the apical opening. This process is activated by food intake, chewing function, especially with malocclusion. If the cavity of the affected tooth is sealed, and necrotic decay products have already appeared in the pulp, any chewing movement pushes the infection upward.
• Tooth trauma (impact) provokes destruction of the dental bed and periodontium; infection can penetrate the tissue by contact if oral hygiene is not observed.
• Hematogenous or lymphogenous infection of periodontal tissue is possible with viral diseases - influenza, tuberculosis, hepatitis, while periodontitis occurs in a chronic, often asymptomatic form.

Statistics show that the most common route of infection with streptococci is the descending route. The data for the last 10 years are as follows:

• Non-hemolytic streptococci strains – 62-65%.
• Strains of alpha-hemolytic viridans streptococci (Streptococcus mutans, Streptococcus sanguis) – 23-26%.
• Hemolytic streptococci – 12%.

Periodontitis of the tooth

The periodontium is a complex connective tissue structure that is part of the periodontal tissue complex. The periodontal tissue fills the space between the teeth, the so-called periodontal gaps (between the plate, the alveolar wall and the tooth root cementum). Inflammatory processes in this area are called periodontitis, from the Greek words: around - peri, tooth - odontos and inflammation - itis, the disease can also be called pericementitis, since it directly affects the dental root cementum. Inflammation is localized at the top - in the apical part, that is, at the top of the root (apex means top) or along the edge of the gum, less often the inflammation is diffuse, spread throughout the periodontium. Periodontitis of the tooth is considered a focal inflammatory disease, which is related to diseases of the periapical tissues in the same way as pulpitis. According to practical observations of dentists, periodontal inflammation is most often a consequence of chronic caries and pulpitis, when the decay products of bacterial infection, toxins, microparticles of dead pulp get from the root opening into the socket, causing infection of the dental ligaments and gums. The extent of focal bone tissue damage depends on the period, duration of inflammation and the type of microorganism - the causative agent. The inflamed root membrane of the tooth, the tissues adjacent to it interfere with the normal process of food intake, the constant presence of an infectious focus provokes a pain symptom, often unbearable during an exacerbation of the process. In addition, toxins enter the internal organs with the bloodstream and can be the cause of many pathological processes in the body.

Periodontitis and pulpitis

Periodontitis is a consequence of pulpitis, therefore these two diseases of the dental system are pathogenetically related, but are considered different nosological forms. How to distinguish periodontitis and pulpitis? Most often, it is difficult to differentiate the acute course of periodontitis or pulpitis, therefore we offer the following criteria for distinction, presented in this version:

Serous periodontitis, acute form	Acute pulpitis (localized)
Growing pain symptom Pain does not depend on stimuli Probing does not cause pain The mucous membrane is changed	The pain is paroxysmal and spontaneous. Probing causes pain. The mucous membrane is unchanged.
Acute purulent process in the periodontium	Acute diffuse pulpitis
Constant pain, spontaneous pain Pain is clearly localized in the causative tooth Probing – no pain Mucous membrane is changed Deterioration of the general condition X-ray shows changes in the structure of the periodontium	The pain is paroxysmal. The pain radiates into the trigeminal nerve canal. The mucous membrane is unchanged. The general condition is within normal limits.
Chronic periodontitis, fibrous form	Caries, beginning of pulpitis
Change in the color of the tooth crown Probing - without pain No reaction to temperature exposure	The color of the tooth crown is preserved. Probing is painful. Pronounced temperature tests
Chronic granulating periodontitis	Gangrenous pulpitis (partial)
Transient spontaneous pain Probing – no pain Mucous membrane is changed General condition suffers	The pain increases from hot, warm food, drinks. Probing causes pain. The mucous membrane is unchanged. The general condition is within normal limits.
Chronic granulomatous periodontitis	Simple pulpitis in chronic form
The pain is minor and tolerable. Change in tooth color. Probing without pain. No reaction to temperature stimuli.	Pain with temperature irritation Color of the tooth crown unchanged Probing is painful Elevated temperature tests

It is imperative to differentiate periodontitis and pulpitis, as this helps to develop the correct therapeutic strategy and reduces the risk of exacerbations and complications.

Periodontitis in children

Unfortunately, periodontitis is increasingly diagnosed in children. As a rule, inflammation of periodontal tissues provokes caries - a disease of civilization. In addition, children rarely complain of dental problems, and parents neglect preventive examinations by a pediatric dentist. Therefore, according to statistics, childhood periodontitis accounts for about 50% of all cases of visits to dental institutions.

The inflammatory process of the periodontium can be divided into 2 categories:

1. Periodontitis of milk teeth.
2. Periodontitis of permanent teeth.

Otherwise, the classification of periapical tissue inflammation in children is systematized in the same way as periodontal diseases in adult patients.

Complications of periodontitis

Complications caused by inflammation of periapical tissues are conventionally divided into local and general.

General complications of periodontitis:

• Persistent headache.
• General intoxication of the body (most often with acute purulent periodontitis).
• Hyperthermia sometimes reaches critical levels of 39-40 degrees.
• Chronic periodontitis provokes many autoimmune diseases, among which rheumatism and endocarditis are the leaders, and kidney pathologies are less common.

Complications of local periodontitis:

• Cysts, fistulas.
• Purulent formations in the form of abscesses.
• The development of a purulent process can lead to phlegmon of the neck.
• Osteomyelitis.
• Odontogenic sinusitis when contents break through into the maxillary sinus.

The most dangerous complications are caused by a purulent process, when pus spreads in the direction of the jaw bone tissue and exits into the periosteum (under the periosteum). Necrosis and tissue melting provoke the development of extensive phlegmon in the neck area. With purulent periodontitis of the upper jaw (premolars, molars), the most common complications are submucous abscess and odontogenic sinusitis.

The outcome of complications is very difficult to predict, since the migration of bacteria occurs quickly, they are localized in the jaw bone, spreading to nearby tissues. The reactivity of the process depends on the type and form of periodontitis, the state of the body and its protective properties. Timely diagnostics, therapy help to reduce the risk of complications, but often this depends not on the doctor, but on the patient himself, that is, on the timing of seeking dental care.

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Diagnosis of periodontitis

Diagnostic measures are not only important, they are perhaps the main criterion determining the effective treatment of periodontal inflammation.

Diagnosis of periodontitis involves collecting anamnestic data, examining the oral cavity, additional methods and methods of examination to assess the condition of the apex and all periapical zones. In addition, diagnosis should identify the root cause of inflammation, which is sometimes very difficult to do due to the untimely appeal for help from the patient. Acute conditions are easier to assess than to diagnose an advanced, chronic process.

In addition to the etiological causes and assessment of the clinical manifestations of periodontitis, the following points are important in diagnostics:

• Resistance or intolerance to drugs or dental material to avoid drug reactions.
• General condition of the patient, presence of concomitant pathological factors.
• Acute inflammation of the oral mucosa and assessment of the red border of the lips.
• The presence of chronic or acute inflammatory diseases of internal organs and systems.
• Threatening conditions – heart attack, cerebrovascular accident.

The main diagnostic burden falls on the X-ray examination, which helps to accurately differentiate the diagnosis of diseases of the periapical system.

Diagnosis of periodontitis involves determining and recording the following information according to the recommended examination protocol:

• Stage of the process.
• Phase of the process.
• Presence or absence of complications.
• Classification according to ICD-10.
• Criteria that help determine the condition of the dentition – permanent or temporary teeth.
• Channel patency.
• Localization of pain.
• Condition of the lymph nodes.
• Tooth mobility.
• Degree of pain on percussion and palpation.
• Changes in the structure of periapical tissue on an X-ray image.

It is also important to correctly assess the characteristics of the pain symptom, its duration, frequency, localization zone, presence or absence of irradiation, dependence on food intake and temperature irritants.

What measures are taken to examine periodontal tissue inflammation?

• Visual inspection and examination.
• Palpation.
• Percussion.
• External examination of the facial area.
• Instrumental examination of the oral cavity.
• Channel probing.
• Thermodiagnostic test.
• Evaluation of bite.
• Radiation imaging.
• Electroodontometry examination.
• Local radiograph.
• Orthopantomogram.
• Radiovision method.
• Evaluation of the oral hygiene index.
• Determination of the periodontal index.

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Differential diagnosis of periodontitis

Since periodontitis is pathogenetically associated with previous inflammatory destructive conditions, it is often similar in clinical manifestations to its predecessors. Differential diagnostics helps to separate similar nosological forms and choose the right tactics and strategy of treatment, this is especially important for the curation of chronic processes.

1. Acute apical periodontitis is differentiated from diffuse pulpitis, gangrenous pulpitis, exacerbation of chronic periodontitis, acute osteomyelitis, and periostitis.
2. The purulent form of periodontitis should be separated from periradicular cysts with similar symptoms. Periradicular cysts are characterized by signs of bone resorption, which does not happen with periodontitis. In addition, periradicular cysts bulge strongly in the alveolar bone zone, causing tooth displacement, which is not typical for periodontitis.
3. Acute periodontitis may resemble odontogenic sinusitis and sinusitis, as all these conditions are accompanied by radiating pain in the direction of the trigeminal nerve canal, pain during tooth percussion. Odontogenic sinusitis differs from periodontitis by typical nasal congestion and the presence of serous discharge from it. In addition, sinusitis and sinusitis cause severe specific pain, and the change in the transparency of the maxillary sinus is clearly defined on an X-ray.

The basic method that helps to conduct differential diagnostics of periodontitis is an X-ray examination, which puts an end to the final diagnosis.

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Treatment of periodontitis

Treatment of periodontitis is aimed at solving the following problems:

• Stopping the source of inflammation.
• Maximum preservation of the anatomical structure of the tooth and its functions.
• Improving the general condition of the patient and the quality of life in general.

What does periodontitis treatment involve?

• Local anesthesia, anaesthesia.
• Providing access to the inflamed canal by opening.
• Expansion of the tooth cavity.
• Providing access to the root.
• Probing, passing through the canal, often unsealing it.
• Measuring the length of the channel.
• Mechanical and medicinal treatment of the canal.
• If necessary, removal of necrotic pulp.
• Placement of temporary filling material.
• After a certain period of time, a permanent filling is installed.
• Restoration of the dentition, including damaged teeth, endodontic therapy.

The entire treatment process is accompanied by regular monitoring using X-rays; in cases where standard conservative methods are not successful, treatment is carried out surgically, including root amputation and tooth extraction.

What criteria does a doctor use when choosing a method for treating periodontitis?

• Anatomical specifics of the tooth, structure of the roots.
• Expressed pathological conditions – tooth trauma, root fracture, etc.
• Results of previously conducted treatment (several years ago).
• The degree of accessibility or isolation of a tooth, its root, or canal.
• The value of a tooth in a functional as well as an aesthetic sense.
• The possibility or lack thereof in terms of tooth restoration (dental crown).
• Condition of periodontal and periapical tissues.

As a rule, treatment procedures are painless, carried out under local anesthesia, and timely visit to the dentist makes the treatment effective and fast.

1. Drug-induced periodontitis – conservative treatment, surgery is rarely used.
2. Traumatic periodontitis – conservative treatment, possibly surgical intervention to remove bone particles from the gums.
3. Infectious purulent periodontitis. If the patient seeks help in time, the treatment is conservative, an advanced purulent process often requires surgical manipulations up to tooth extraction.
4. Fibrous periodontitis is treated with local medications and physiotherapy; standard conservative treatment is ineffective and there are no indications for it. Surgery to excise coarse fibrous formations on the gum is rarely used.