Symptoms of periodontitis

The clinical picture of periodontitis is characterized by a pain symptom. The pain may develop spontaneously, without the influence of external or internal factors. The pain is of a "knocking", sharp, acute nature, and during an exacerbation it may be pulsating and increasing. The localization of the pain symptom depends on the area of the infected or injured periodontium, but often the pain is limited to one or two teeth. Heat and palpation increase the painful sensations, while cold can reduce them. Patients often describe the symptoms of periodontitis as an enlargement of the diseased tooth, which is explained by the pressure of exudate and pus on the periodontal area. The tooth from which the inflammation begins is mobile and often affected by caries.

The oral mucosa in the inflammation zone is hyperemic, edematous, and infiltrates may be observed. Exacerbation of the process leads to accumulation of pus, especially if the fistula tracts are closed, scarred, the face acquires asymmetric edema typical of periodontium, with involvement of the lip, lymph nodes on the side of inflammation. In addition, periodontitis is almost always accompanied by headache, in the chronic form - transient, in the acute stage - unbearable. Body temperature rises to critical values of 39-40 degrees, causing feverish, delirious states.

The main symptoms and complaints that patients with periodontitis present:

• Constant bleeding, irritation of the gums, not associated with objective external factors - eating or injury (bruise, blow).
• Pain in the area of the affected tooth when eating, less often when brushing teeth.
• Bad breath throughout the day.
• Mobility of a tooth or several teeth.
• Painful reaction to temperature effects – intake of warm, hot food, drinks.

Symptoms of periodontal inflammation, depending on the form of the disease:

• Acute periodontitis:
  • Aching, intense pain in a specific tooth, the pain is clearly localized.
  • Palpation and percussion of the inflamed area and tooth significantly increase the pain.
  • The transition from the serous form to purulent inflammation is accompanied by pulsation, tearing, and constant pain.
  • The tooth loses stability and becomes mobile.
  • Often a gumboil develops in the projection of the affected tooth.
  • The temperature rises sharply to 38-40 degrees.
  • Lack of appetite.
  • Severe asymmetrical swelling of the face.
• Chronic, sluggish periodontitis:
  • Pain when food hits the affected tooth.
  • Mild pain during palpation and percussion of the tooth.
  • Fistulas on the gum in the projection of the affected tooth are possible.
  • It is possible that purulent exudate will be released from the fistula opening.
  • A cyst in the upper area of the tooth root is possible.
• Exacerbation of chronic periodontitis:
  • Periodic pain, reaction to temperature effects.
  • Enlargement of the fistula and discharge of purulent contents.
  • Slight swelling of the gums.
  • Slight increase in body temperature, subfebrile temperature.
  • The discharge of pus relieves the pain.
  • It is possible that the fistula will scar and a new one will form.

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Pain in periodontitis

It is impossible not to notice periodontitis, it manifests itself so painfully. Sometimes the pain with periodontitis is so sharp that a person cannot touch his face, in addition, pain is also caused by eating, since the tooth is extremely mobile and irritates the inflamed tissues. The pain symptom is often accompanied by signs of intoxication, when purulent contents penetrate the periosteum, often into the blood. The pain can intensify with temperature exposure - heat, for example, with hot rinses, eating warm food, drinking. Cold can temporarily neutralize the pain, but such independent experiments with temperature exposure to a sore jaw can lead to sad consequences. Swollen gums, swollen cheek, lip, elevated body temperature (possibly up to 39-40 degrees), unbearable headache, enlarged lymph nodes - all these are signs of periodontal inflammation.

It should be noted that pain in periodontitis can manifest itself in the form of light, transient sensations, this is typical for the initial period of the process development, when pulpitis is just beginning. If it is not treated in a timely manner, the inflammation goes into an acute phase, spreads to the tissues surrounding the pulp, and manifests itself as acute, unbearable pain. In addition to the fact that painful symptoms of periodontitis cause unbearable suffering to the patient, acute periodontitis is dangerous due to its complications, which include osteomyelitis, a breakthrough of exudate contributes to the development of purulent processes in the tissues of the face, in 5-7% of cases, sepsis is a complication. For this reason, all doctors recommend immediately seeking dental help at the first signs of the inflammatory process, exacerbation of periapical periodontitis, which from a chronic form goes into an acute form, is extremely dangerous and quite difficult to treat.

Symptoms of acute periodontitis

Acute periodontitis can develop as an exacerbation of a chronic form of inflammation, but can also be an independent process. Acute inflammation is characterized by severe pain in the area of the affected periodontium and tooth. The pain increases if the tooth is subjected to stress or pressure. The symptom can be felt in adjacent teeth, the sensation is described as pain spreading across the gum and jaw. Exacerbation of the acute form of periodontitis is accompanied by pulsating pain, tooth mobility, hyperthermia, severe swelling of the face, lips, usually asymmetrical. Sometimes self-medication with antibiotics can neutralize the pain symptom, but not the process itself, which again transforms into a chronic one. However, most often the patient still consults a dentist, usually about severe unilateral swelling of the face and intense pain. In the absence of adequate treatment, acute periodontitis is fraught with serious complications - osteomyelitis, sepsis.

Symptoms of chronic periodontitis

The main characteristic feature and danger of chronic periodontitis is the asymptomatic course of the process. Pain may appear occasionally, but does not cause severe discomfort. The periodontium is hyperemic, slightly swollen, the tooth gradually loses its stability, involving nearby teeth in the destructive process. Visible interdental spaces can be considered a typical symptom of chronic inflammation, bleeding gums are possible, not associated with food intake. If a fistula is formed in the tissue, exudate periodically flows out through it, relieving pain. The fistula often scars, forming fibrous tissue and changing the structure of the oral mucosa. Chronic periodontitis is extremely rare, accompanied by an increase in regional lymph nodes.

Chronic periodontitis is divided into the following forms:

• Fibrous chronic periodontitis.
• Granulomatous periodontitis.
• Granulating chronic periodontitis.

The main danger of chronic periodontitis is the constant foci of infection in the body, which results in the development of pathologies of the heart, joints and kidneys.

Periodontitis of the wisdom tooth

Periodontal inflammation of the wisdom tooth often occurs without clinical manifestations, without pain. However, it is the third molar that is susceptible to caries, therefore, periodontitis can potentially develop in it.

Periodontitis of the wisdom tooth is a consequence of many neglected chronic processes, one of which is pericornitis (inflammation of the surrounding tissues), pulpitis. With pericornitis, not only food particles but also pathogenic microorganisms gradually accumulate in the gum pocket. The process develops slowly, but constant mechanical pressure when eating, less often - malocclusion, more often - caries, can provoke the onset of inflammation.

The appearance and form of periodontitis of the wisdom tooth are not much different from the characteristics of similar processes in other teeth. Clinical manifestations are noticeable only in the acute stage, when in addition to the periodontium, the gums also become inflamed. In addition, purulent exudate can accumulate in the gingival pocket, which is accompanied by severe pulsating pain, swelling of the cheek on the side of the affected tooth.

Conservative treatment of inflamed periodontium is possible only at the initial stage of the process, which, unfortunately, is very rare. Most often, the diseased wisdom tooth has to be removed, this is due to the following reasons:

• Late request for help by the patient.
• The chronic inflammatory process leads to complete destruction of bone tissue and the inability to save the tooth.
• The wisdom tooth is equipped with very complex canals, which are quite difficult to access for sanitation and treatment.

Conservative therapy is possible only when lower wisdom teeth erupt at a young age, when periodontitis is more traumatic than infectious.

Apical periodontitis

Apical periodontitis is the most common type of periodontal inflammation. The definition comes from the Latin apex - top, apex, since the beginning of the process is localized in the apex of the root. The apical periodontium is connected through an opening with lateral passages with the pulp tissue, and infection occurs vertically - from the affected pulp chamber. Most often, the process occurs in a chronic form with the growth of granulates, granulomas or the formation of fibrous tissue. In general, inflammation provokes gradual destruction of periodontal tissues, often in a purulent form, this is due to the penetration of toxic products of bacterial activity.

Apical periodontitis is characterized by an asymptomatic course, its clinical picture is extremely poor in terms of manifestations and signs. As a rule, the only initial symptom of periodontitis may be transient discomfort when eating, when the infected tooth is subjected to load, pressure, and may slightly hurt, ache. The process becomes chronic and may lead to the formation of a compensatory fistula with an open passage, through which accumulated exudate or pus periodically flows out. However, this is not a signal to start treatment, at least, statistics say that in 75% of cases the patient consults a dentist already in the acute phase of the process, when the symptoms become obvious.

The acute form of apical periodontitis is clearly manifested and it is difficult to confuse it with other nosological entities:

• Severe pain attacks.
• Swelling of the gums, cheeks, lips, and often the lymph nodes.
• The tooth loses stability and becomes mobile.
• A severe headache of a diffuse nature, the pain intensifies upon palpation of the diseased tooth and seems to “flow” to the side affected by the infection.
• Subfebrile temperature can rise sharply to critical levels of 38-40 degrees.

There are frequent cases when patients try to independently manage the exacerbation of periodontitis with the help of antibiotics; if this is successful, the process again becomes chronic and moves deeper, causing inflammation of the periosteum and periostitis.

Causes that cause apical periodontitis:

1. Complication of chronic caries
2. Complication of pulpitis, pulp necrosis
3. Tooth trauma
4. Diseases of internal organs and systems of infectious or viral nature
5. Iatrogenic factor – incorrect implementation of ontodontal therapy

Apical periodontitis can be classified variably, according to ICD-10, according to Lukomsky's classifier or according to the systematization of the Moscow Medical Dental Institute (MMSI). Today, many dentists use the shorter and more narrowly focused systematizer of the MMSI (1987), in which apical periodontitis is divided into the following forms and types:

I Acute apical periodontitis.

• Phase of infection, intoxication.
• Exudation phase:
  • Serous exudate.
  • Purulent exudate.

II Chronic apical periodontitis:

• Fibrous.
• Granulating.
• Granulomatous.

III Chronic apical periodontitis in the acute stage:

• Fibrous chronic process in the acute stage.
• Granulating chronic process in the acute stage.
• Granulomatous chronic process in the acute stage.

Fibrous periodontitis

The fibrous form of apical periodontitis may be a consequence of exacerbation or the result of therapy of the granulating, granulomatous process. Many modern dentists in principle disagree with the inclusion of this form in the classification, which, by the way, does not exist in ICD-10. This is due to the non-specific symptoms of periodontitis that fibrous periodontitis exhibits, in addition, the tissue of the apical part of the root does not change, that is, one of the most important signs of periodontal inflammation is absent. Nevertheless, the state of overgrowth of inflamed tissue into fibrous tissue exists, as well as constant penetration of bacteria from the root canal, that is, there is a risk of progression, exacerbation and relapse of granulomas. What happens in the periodontium during the fibrous process? In short, the normal quantity and quality of periodontal cells changes towards a decrease and compaction, and on the contrary, the cells of the connective, coarse fibrous tissue increase, fibrous thickenings, cicatricial infiltrates are formed.

Symptomatically, fibrous periodontitis manifests itself extremely rarely. Since most often the pulp has already died, and there is no acute inflammation, there is no pain. The mucous membrane is visually indistinguishable from normal, the affected tooth does not show signs of instability, and eating does not provoke discomfort. The only manifestation of the fibrinating process may be a change in the color of the tooth and the accumulation of softened dentin particles in the carious cavity. In addition, a visible characteristic sign of periodontitis in principle is possible - an increase in interdental, periodontal gaps.

Treatment of fibrous periodontitis depends on when the patient consulted a dentist. If the fibrous form of the disease occurs after previous treatment, the canals are cleaned, sanitized and there is no sign of inflammation, then therapy is not carried out. Physiotherapy procedures, rinses and dispensary observation are prescribed. If fibrous formations appeared as an independent process, the oral cavity is subjected to symptomatic and restorative treatment. The pulp, as a rule, is already dying, so special anesthesia is not required, the tooth is cleaned, the affected dentin and enamel are removed. The root necrotic pulp is also removed. Then the root canal is correctly expanded in the form of a cone in order to securely fix the filling. Filling is necessary for obturation, closing the path of penetration of microorganisms to the periodontium. After treatment, the tooth can function normally.

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Purulent periodontitis

The purulent form of periodontitis rarely develops independently, it is usually a logical consequence of the serous course of the process. From the onset of serous inflammation to the formation of purulent periodontitis, at least 10 days pass, often this period stretches for a month.

Acute purulent periodontitis has an incomparable, specific symptom - intense pulsating pain, which often radiates in the direction of the trigeminal nerve, and can be reflected in the opposite jaw. The tooth is mobile, the face is very swollen, the lymph nodes are enlarged, the temperature rises to 38-39 degrees, the general condition significantly worsens.

Objective clinical signs upon examination by a physician:

• Most often, the purulent process is diffuse and spreads to all areas of the periodontium.
• The bolt is localized in the area of the affected tooth, although pulsation can be felt in other areas, especially during percussion.
• When measuring body temperature, a discrepancy may be revealed with the subjective complaints presented by the patient. Objectively, the temperature may be subfebrile, although the patient feels it as high.
• Asymmetric swelling of the face due to swelling on the side of the affected part of the periodontium.
• The skin of the face is not changed, but is painful upon palpation.
• The lymph nodes may be enlarged, painful to palpation, and have a loose, non-compacted structure.
• Visual examination of the tooth shows significant destruction and discoloration.
• The tooth is mobile and intact.
• The carious cavity communicates with the tooth cavity.
• Probing the tooth canal does not cause pain, since the pulp is already necrotic.
• The mucous membrane is infiltrated.

Blood analysis for purulent periodontitis shows a significant increase in ESR, moderate leukocytosis, and a shift in the blood formula to the left.

An abscess can burst in two ways:

• Through the root into the cavity of the tooth is the best option.
• Into the jaw tissue, which is a serious complication, as it provokes the development of periostitis, phlegmon or a breakthrough of pus into the oral cavity (intoxication syndrome).

Treatment is aimed at the fastest possible breakthrough and outflow of purulent exudate into the tooth cavity. Then the gangrenous pulp is removed, the necessary sanitation and restoration of the tooth structure is carried out, if possible. Often, the acute course of the purulent process requires tooth extraction or dissection, drainage of the periosteum for the outflow of pus.

Serous periodontitis

The accumulation of serous fluid is the first signal of the onset of an acute inflammatory process in the apical part of the periodontium. Serous periodontitis (Petiodontitis serosa) is always accompanied by hyperemia of the oral mucosa, edema and perivascular infiltration are possible. The cause in 75% of cases is untreated pulpitis, especially when pulpitis is acute.

Symptoms of serous periodontitis:

• The color shade of the tooth changes.
• The pain is constant and aching.
• Any touch to the tooth or consumption of hard food provokes severe pain that spreads throughout the affected periodontal area.
• The pain is clearly localized, the patient can easily point to the aching tooth.
• Body temperature rarely rises; as a rule, it is within normal limits.
• The carious cavity is usually open and visible during a dental examination.
• Since the pulp is most often already dying, probing the walls of the carious cavity does not cause much discomfort or pain.
• Percussion and palpation of the gums on the side of the diseased tooth are accompanied by painful sensations.
• The lymph nodes are not enlarged.
• The radiograph of the root apex shows no changes.

It should be noted that the symptoms of serous periodontitis are very similar to those of acute pulpitis due to the fact that both of these diseases are pathogenetically united. Also, serous exacerbations may be similar to purulent periodontitis, but differentiation is quite clearly carried out using X-rays, in addition, pulpitis is characterized by night, pulsating pain, reaction to temperature exposure. In acute pulpitis, percussion or palpation does not cause discomfort, since the process does not affect the apex of the root. Purulent periodontitis is characterized by fever, headache, pulsation, swelling of the gums and cheeks, which the serous form does not have in the list of symptoms.

How is serous periodontitis treated?

First of all, the infectious focus located in the root canal and periodontium is neutralized. Antibacterial therapy is carried out, the carious cavity is sanitized, then it is closed, the tooth is filled. Tooth extraction in the serous process is carried out extremely rarely, since modern dentistry is aimed at preserving the dentition and is equipped with all the latest achievements in its field. If timely treatment is not carried out, serous periodontitis turns into a purulent form, the period of exacerbation and formation of pus can last from 1 to 3 weeks.

It is much easier and faster to cure serous inflammation, so at the first signs of pain, you need to see a dentist.

Toxic periodontitis

Drug-induced or toxic periodontitis is considered an iatrogenic type of inflammatory process in periapical tissues, as it is provoked by the incorrect use of potent drugs in odontotherapy. The main dangerous drugs that cause inflammation are tricresol, formalin, arsenic.

The huge range of effective, but having side effects, drugs used in dentistry is constantly being reviewed. Earlier, several decades ago, pastes made from incompatible antibiotics (penicillin and biomycin), tricresol-formalin were widely and universally used. Complications caused by potent drugs were many times greater than the predicted benefit, so today such products are withdrawn from dental practice.

Reasons why toxic periodontitis could occur:

• An error in the technology of preparing a sanitizing solution or paste.
• High toxicity of a fast-acting antibiotic (rapid absorption).
• Sensitization leading to drug allergy.
• Excessive use of antibiotics without truly acute indications.
• Prescribing unjustifiably low or, conversely, excessively high doses of drugs.
• Local toxic effect on the pulp, root apex and periodontium.
• Incompatibility (antagonism) of drugs in the manufacture of solutions and pastes.

The highest percentage of complications was associated with the use of formalin-based preparations; bone tissue destruction with the introduction of formalin paste occurred in 40% of patients. In addition to the fact that formalin preparations provoked pathological changes in periodontal tissue, they often indirectly led to an exacerbation of cardiovascular diseases and reactions from the peripheral nervous system.

Today, such phenomena are almost completely excluded; concentrated chemical preparations are not used in treatment, since the pharmaceutical industry offers more effective and safe options for treating diseases of the periapical tissues.

Drug-induced periodontitis

Today, drug-induced periodontitis is considered a rarity, due to the use of completely new, effective and at the same time safe drugs in dental practice. However, in the treatment of pulpitis, it is still necessary to use strong agents such as arsenous acid, phenolic compounds and other drugs.

Drug-induced periodontitis is almost always acute and is provoked by the penetration of arsenic, silver nitrate, phenolic preparations, pyocid, thymol, etc. into the periodontal tissue. These potent agents cause inflammation, necrosis, and often tissue burns. The inflammation develops quickly, reactively, affecting not only the root apex, but also deeper layers of bone tissue. Untimely treatment and stopping the aggressive effects of the drug can result in the extraction of the entire tooth.

Clinically, toxic inflammation is manifested by severe pain that develops during the treatment of pulpitis, less often periodontosis. In pulpitis, drug-induced periodontitis is most often localized in the apex of the root, as a complication of periodontosis therapy - localized along the edges of the periodontium (marginal periodontitis). The pain is constant, dull, aching, intensifies with forceful impact on the tooth (during food intake, palpation, percussion). The tooth can lose stability literally in a day, the gums are often hyperemic, edematous.

In the diagnosis of drug-induced acute periodontitis, it is important to differentiate it from other diseases with similar clinical presentations – acute pulpitis, acute infectious periodontitis.

Treatment of intoxication consists of immediate removal of the drug from the tooth cavity, i.e. neutralization of the root cause. After removal of the turunda, paste, contact with the periodontal tissues is created to ensure rapid outflow of accumulated exudate. Necrotic pulp is cleaned, the canal is sanitized. Then, an adequate drug is introduced into the expanded canal, most often a broad-spectrum antibiotic. Ion galvanization with anesthetic and iodine gives a good effect, after which the tooth is closed with a filling. Physiotherapy procedures and therapeutic rinsing can be prescribed. It should be noted that toxic periodontitis is quite successfully treated with the help of physiotherapy without prescribing antibiotics. This is possible with timely detection of the inflammatory process, in addition, this method is used for periodontal inflammation in the process of curing periodontosis.

Currently, drug-induced, toxic periodontitis is considered a great rarity and is most often explained by the patient’s failure to comply with the doctor’s visit schedule.

Marginal periodontitis

Marginal periodontal inflammation is the definition of the localization of the process that can develop in the apex - the top of the tooth root, the upper part of the periodontal tissues or along the edges. Marginal periodontitis (Parodontitis marginalis) is an inflammation of the edges of the periodontium, most often provoked by trauma and then infection of the damaged tissues.

In order for an infectious agent to penetrate the periodontium through a canal, this must be preceded by a violation of the protective barriers of entry into the alveolus. This is facilitated by mechanical tissue damage, i.e. a bruise, a blow, food getting into the canal, the crown growing under the gum, and, less often, errors in odontotherapy (rough pushing of dental material into the canal). Thus, the etiology of marginal acute periodontitis is defined as infectious and traumatic.

In addition, marginal periodontitis may be a consequence of aggravated inflammation, which previously occurred in a chronic form. Marginal inflammation of the periodontium is currently classified as a "periodontal disease", such periodontitis is often called deep gingivitis, alveolar pyorrhea, since these nosologies are very similar symptomatically and pathogenetically. In addition, inflammation of the periodontal tissue is, in principle, a consequence of the pathogenetic chain in the process of developing pyorrhea, periodontitis and is provoked not only by mechanical factors, but also by tissue irritation by tartar and accumulation of detritus in the gingival pockets.

Symptoms of marginal periodontitis:

• Hyperemia and swelling of the gums.
• Swelling in the area of the affected tooth, especially along the edges of the periodontium.
• The acute form of the disease is characterized by swelling of the transitional fold between the teeth.
• Swelling of the cheek on the side of the affected tooth is possible, the lip swells. The swelling is asymmetrical.
• The gums are noticeably receding from the tooth.
• Often purulent exudate flows from their gum pocket.
• There may be an abscess (multiple abscesses) on the gum in the projection of the diseased tooth.
• The tooth is sensitive to percussion, palpation, and is mobile in the lateral direction.
• The lymph nodes are enlarged and painful upon palpation.

The clinical picture of marginal inflammation is very similar to the symptoms of typical apical periodontitis in the acute stage, but the inflammatory signs are expressed somewhat less strongly, since there is an outflow of purulent exudate through the gingival cyst.

Treatment of marginal periodontitis does not involve opening the tooth and sanitizing the canal, as is done in standard treatment of periodontitis. First of all, therapy depends on whether the pulp and the tooth are alive. If the pulp is intact, this process cannot be considered apical and is classified as a periodontal disease, which is treated differently. If the tooth is depulped, it is necessary to differentiate the inflammatory process, for this purpose the bottom of the gingival pocket is examined. The criterion that allows confirming marginal periodontitis is a fairly large size and depth of the gingival pocket. Often this formation is so large that its bottom touches the apex of the root, which in turn again causes difficulties with diagnosis, since pus can flow out over the edge of the gum. Combined forms - apical and marginal periodontitis at the same time - are extremely rare in dental practice. As a rule, an X-ray puts an end to the differential diagnosis, after which a therapeutic strategy is developed. Treatment of confirmed marginal inflammation in 99% of cases consists of systematic washing of pockets by injection (irrigation). Various mildly aggressive antiseptic solutions are used in warm form. If the process is neglected and there is a large accumulation of pus, an incision is made in the gum along the root canal to ensure the outflow of the contents. Tooth extraction is also possible, but this happens due to the patient's own fault, when he seeks help late, and the process is so neglected that other methods of treatment are ineffective.

Periodontitis under the crown

After dental prosthetics, after some time a pathological process may develop under the crown. Periodontitis under the crown of the tooth is manifested by pain, sensitivity of the tooth to temperature effects. This is due to pulp necrosis or an insufficiently dense cementing lining. Pulp necrosis, in turn, is a consequence of the removal of too deep dentin tissue, or an existing chronic inflammatory process that was missed and not treated. Most often in practice, infectious periodontitis under the crown is encountered, which is caused by the following reasons:

• Insufficient quality of root canal filling during treatment of chronic or acute pulpitis.
• When preparing a tooth for a crown, when the pulp is not removed and the tooth remains alive, while undiagnosed, undetected pulpitis is already developing

In addition, there are iatrogenic and objective factors:

• Thermal burn and inflammation of the pulp during tooth grinding is an iatrogenic cause.
• Traumatic tooth damage is an objective reason when a tooth is bruised, hit, or damaged when biting into food that is too hard (nuts, pits).
• Malocclusion.
• An incorrectly fitted crown, incorrect crown formation from an anatomical point of view. This disrupts the normal process of chewing food, provokes trauma to the interdental papillae.

Diagnostic criteria for determining the localization of the inflammatory process may be as follows:

• When the crown is removed, the pain and sensitivity go away.
• Tooth sensitivity and its reaction to thermal stimuli indicate pulp necrosis.
• Pain when biting hard food indicates the development of inflammation in the periodontal area.

Periodontitis under the crown is most often localized at the edges, that is, it is considered marginal and is usually caused by mechanical provoking causes. In this case, constant mechanical pressure on the crown ends with its advancement and the gum tissue, the gingival pocket acquires the status of a pathological pocket, inflammation of the gum develops, it bleeds. A favorable environment for the development of bacteria, infection is created in the pocket, the process spreads to the periodontal tissue.

Generalized periodontitis

Aggressive periodontitis most often occurs in puberty. Generalized periodontitis is a rapid reactive destruction of tissues, periodontal ligament, and the entire alveolar bone (process). Such progression leads to the complete loss of many teeth.

This type of inflammation is classified as juvenile periodontitis (JP) in generalized form. The disease can be localized in the area of permanent first molars, lower incisors, then it is classified as localized juvenile periodontitis, if the process affects many permanent teeth, it is characterized as generalized.

The first detailed description of UP in a generalized form was presented at the beginning of the last century as a disease of a systemic non-inflammatory nature. Today, the pathogenetic mechanism of rapid destruction of the dentition has been studied more fully and it has been established that the localized form of periodontitis in adolescents is provoked by specific deposits - dental plaque. This gave the right direction in understanding the etiology and generalized form of inflammation, subsequently 5 types of bacteria were identified that cause reactive damage to the periodontium and destruction of collagen and a new age group was identified - children from 5 to 10 years old.

In this regard, age-related periodontitis is divided into three groups, each of which can be either localized or in an extended, generalized form:

• Prepubertal juvenile periodontitis.
• Juvenile periodontitis.
• Postjuvenile periodontitis.

The generalized process is very severe, accompanied by total hyperplastic gingivitis with obvious symptoms of gum inflammation - swelling, hyperemia, bleeding. Gum recession progresses rapidly, bone tissue is destroyed. The etiology of GP is still unclear, the latest research in this area has shown that dental plaque, stones, and even caries, previously considered the fundamental causes of GP, cannot be called basic etiological factors. The clinical picture of the process is practically independent of the above phenomena, but is closely associated with other pathologies - infectious diseases of the respiratory system, otitis, systemic autoimmune diseases.

Diagnostics carried out in a timely manner helps to conduct active treatment of the generalized form of UP and even stabilize the condition of the teeth, as much as possible. Diagnostics are carried out using standard methods:

• Inspection.
• Measuring the channel depth (probing depth).
• Determining the degree of gum bleeding.
• X-ray.

Treatment of generalized periodontitis:

• Removal of all dental plaque.
• Correction of the surface of the roots of teeth (exposed, open).
• Orthopedic manipulations.
• Symptomatic conservative treatment aimed at eliminating bacterial foci.
• Recommendations for special oral hygiene performed at home.

Dynamic monitoring is then carried out with an assessment of the effectiveness of the treatment. If the clinic shows a noticeable improvement, the periodontal structures are corrected by surgical methods - the depth of the gum pockets is reduced, areas affected by inflammation are excised.

Thus, an early visit to the doctor helps to stop generalized periodontitis and arrest the pathological process of diffuse atrophy of the alveolar processes.

Necrotic periodontitis

The ulcerative-necrotic form of periodontitis is currently very rare and is a consequence of the total destruction of periodontal tissues. Necrotic periodontitis is characterized by the formation of craters in the bone tissue in the interdental space. Periodontitis purulenta necrotica always leads to the death and purulent melting of periodontal tissues.

Clinical manifestations of necrotic periodontitis:

• Hyperemic, edematous tissue of the gums and interdental ligaments.
• Visible necrotic areas of tissue of a greenish tint.
• Visible fibrinoid necrosis of microvessels.
• When examining the pulp, colonies of bacteria and basophilic parts of decaying cells are detected in it.
• In the area of the affected periodontium, merging small abscesses are observed.
• If the necrosis of soft tissues is accompanied by a putrefactive process in bone tissue, clear signs of wet gangrene develop.
• The pulp acquires a characteristic black color.
• Tissue necrosis is accompanied by total infection of nearby structures, which is manifested by severe pain.
• The necrotic process is characterized by attacks of night pain.
• The pain is not clearly localized in the causative tooth, radiates in the direction of the trigeminal nerve, and can radiate to the ear, back of the head, under the jaw, and opposite teeth.
• The pain intensifies with thermal or physical impact.
• The tooth cavity is closed by necrotic tissue, under which exudate accumulates.

Necrotic periodontitis is a favorable environment and conditions for the mass reproduction of pathogenic microorganisms, which ultimately leads to diseases of internal organs and systems. Sometimes bacterial colonies grow to astronomical levels, this is due to the following reasons:

• Bacteria live and multiply perfectly in necrotic tissue, vital tissue is not suitable for this, therefore, with granulomatous periodontitis, the process does not develop as rapidly and extensively as with total necrosis of the periodontium.
• A living tooth with a living pulp is also not suitable for bacterial seeding, whereas necrosis of the pulp tissue, the apex of the root, creates a favorable environment for this, since bacterial invasion does not meet with resistance.
• Radiographic voids formed from necrotic tissue serve as an excellent background and zone for bacterial infection.
• The constant influx of bacteria from an unsanitized oral cavity also contributes to infection of the apical part of the root, often this condition leads to periodontitis of multiple roots, that is, several teeth are affected at once.

It is for this reason that without complete and thorough removal of all necrotic tissue, it is almost impossible to stop the inflammatory process as a whole. Necrotic periodontitis is treated for a long time, in several stages and necessarily with constant dynamic observation and radiographic control. The generalized form is currently rare, but if it is diagnosed, it usually ends with the loss of the affected teeth.