Periodontitis: Causes, Diagnosis, Treatment

Periodontitis is a common inflammatory disease in the periapical tissues. According to statistics, over 40% of the diseases of the dentoalveolar system are periodontal inflammations, only caries and pulpitis outpace them.

Periodontal diseases concern literally all age groups - from young to old age. Percentage indicators, based on the calculation of 100 cases of treatment to the dentist for pain in the teeth:

• 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 - 45% (with the loss of 1-2 teeth).
• 25-35 years old - 42%.
• Persons older than 65 years - 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 leading. All diseases of periodontal disease as a whole, one way or another, affect the state of human health and significantly reduce the quality of life.

ICD Code 10

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

However, ICD-10 is still officially recognized and used in documentation, periodontitis is described in this way:

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

It should be recognized that in the classification of periodontal diseases there is still some confusion, this is due to the fact that in addition to the internal systematization of MMIS, adopted by dentists in the countries of the former CIS, except ICD-10, there are WHO classification recommendations. There are no great differences between these documents that deserve respect and attention, however, the section "chronic periodontitis" can be interpreted variably. In Russia and Ukraine there is a clinically valid definition of "fibrous, granulating, granulomatous periodontitis", whereas in ICD-10 it is described as an apical granuloma, in addition, in the international classification of diseases of the 10th revision there is no nosological form "chronic periodontitis in the stage of exacerbation ", Which is used by almost all domestic doctors. This definition, adopted in our educational and medical institutions, in ICD-10 replaces the code - K04.7 "periapical abscess without fistula formation", which completely coincides in the clinical picture and pathomorphological substantiation. Nevertheless, in the sense of documenting the periapical tissues, ICD-10 is generally accepted.

Causes of periodontitis

Etiology, causes of periodontitis are divided into three categories:

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

The pathogenetic therapy depends on the etiological factors, its effectiveness is directly determined by the presence or absence of infection, the degree of changes 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 "lead" hemolytic streptococci (62-65%), as well as saprophyte streptococci and staphylococci, nonhemolytic (12-15%) and other microorganisms. Epidermal streptococci are normally present in the oral cavity, without causing inflammation, but there is a subspecies - the so-called "greening" streptococcus, which contains a surface protein element. This protein is able to bind salivary glycoproteins, bind to other pathogenic microorganisms (yeast-like fungi, veyeillas, fusobacteria) and form specific plaques on the teeth. Bacterial compounds destroy the tooth enamel, in parallel through the gingival pockets and root canals, throwing out toxins directly into the periodontium. Caries and pulpitis are among the main causes of infectious periodontitis. Other factors may be viral and bacterial infections that penetrate the periodontum through blood or lymph, for example, such as influenza, sinusitis, and osteomyelitis. In this regard, infectious inflammatory processes in periodontium are grouped into the following groups:

• Intradental periodontitis.
• Extradental periodontitis.

2. Periodontitis caused by traumatic injury. Such a trauma can be a blow, a bruise, a hit when chewing a solid element (pebble, bone). In addition to single injuries, there is also chronic trauma caused by incorrect dental treatment (improperly applied seal), as well as malocclusion, pressure on a row of teeth in the course of professional activity (wind instrument mouthpiece), bad habits (snapping hard objects - nuts, , pencils). With chronic tissue damage at first, there is a forced adaptation to overload, a recurring injury gradually translates the process of compensation into inflammation.
3. Periodontitis, caused by a drug factor, is usually the result of incorrect therapy in the care of pulpitis or periodontitis itself. Strong chemicals penetrate the tissue, provoking inflammation. It can be tricresolfor, arsenic, formalin, phenol, resorcinol, phosphate cement, paracine, filling materials and so on. In addition, all allergic reactions that develop in response to the use of antibiotics in dentistry, also belong to the category of medical periodontitis.

The most common causes of periodontitis can 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 inflammation of the periodontal disease can be caused by non-compliance with the rules of oral hygiene, beriberi, micronutrients deficiency. It should be noted that there are also somatic diseases that contribute to the development of periodontitis:

• Diabetes.
• Chronic pathology of the endocrine system.
• Cardiovascular diseases, which can also provoke a chronic focus of infection in the oral cavity.
• Chronic pathology of the broncho-pulmonary system.
• Diseases of the digestive tract.

Summarizing, we can identify the 10 most common factors that provoke periodontitis:

• Inflammatory process in the pulp, acute or chronic.
• Gangrenous lesion of the pulp.
• Overdose of medications in pulpitis therapy (treatment period or amount of drug).
• Traumatic injury of periodontal disease in the treatment of pulp or canal treatment. Chemical traumatization during sterilization, channel sanitation.
• Traumatic damage of periodontal during filling (pushing of filling material).
• Residual pulpitis (root).
• Penetration of infection in the canal, beyond the apex.
• Allergic reaction of periodontal tissues to medicines or products of decomposition of microorganisms - pathogens of inflammation.
• Infection of periodontal blood, lymph, less often by contact.
• Mechanical trauma of the tooth - functional, therapeutic (orthodontic manipulation), broken bite.

[1]

Pathogenesis of periodontitis

Pathogenetic mechanism of inflammation of periodontal tissue is caused by the spread of infection, toxins. Inflammation can be localized only within the boundaries of the affected tooth, but it is also capable of capturing adjacent teeth, surrounding their soft gum tissue, sometimes even the tissues of the opposite jaw. The pathogenesis of periodontitis is also characterized by the development of phlegmon, periostitis with the chronic process running and its subsequent exacerbation. Acute periodontitis develops very quickly, inflammation proceeds through anaphylactic, hyperergic type with a sharp reactive response of the organism, increased sensitivity to the slightest irritant. If the immunity is weakened or the stimulus is not too active (malovirulent bacteria), periodontitis acquires a chronic form of the flow, often asymptomatic. The constantly acting periapical focus of inflammation affects the body in a sensitizing manner, which leads to chronic inflammatory processes in the digestive organs, the heart (endocarditis), the kidneys.

The path of infection in periodontium:

• Complicated pulpitis provokes the ingestion of toxic contents into the periodontium through the apical foramen. This process is activated by the ingestion of food, the masticatory function, especially with an incorrect bite. If the cavity of the affected tooth is sealed, and the products of necrotic decay have already appeared in the pulp, any chewing movement pushes the infection upward.
• Injury of the tooth (blow) provokes the destruction of the tooth and periodontal, the infection can penetrate into the tissue by contact with non-compliance with oral hygiene.
• Hematogenous or lymphogenous way of infection of periodontal tissue is possible in case of viral diseases - influenza, tuberculosis, hepatitis, with periodontitis occurring in a chronic, often asymptomatic form.

Statistics say that the most common is the downward pathway of infection with streptococci. Data for the past 10 years are as follows:

• Strains of non-hemolytic streptococci - 62-65%.
• Strains of alpha-hemolytic green streptococci (Streptococcus mutans, Streptococcus sanguis) - 23-26%.
• Hemolytic streptococci - 12%.

Periodontitis of the tooth

Periodontitis is a complex connective tissue that enters as part of the periodontal tissue complex. Periodontal tissue fills the space between the teeth, the so-called periodontal gaps (between the plate, the alveolus wall and the root of the tooth root). Inflammatory processes in this area are called periodontitis, from Greek words: about - peri, tooth - odontos and inflammation - itis, also the disease can be referred to as pericetient, as it relates directly to root dental cement. Inflammation is localized at the top - in the apical part, that is, at the apex of the root (apex in translation), or at the edge of the gum, less often the inflammation is diffuse, diffuse throughout the periodontium. Periodontitis of the tooth is considered a focal inflammatory disease, which refers to the diseases of periapical tissues as well as pulpitis. According to practical observations of dentists, periodontal inflammation is most often the result of chronic caries and pulpitis, when the products of the decay of bacterial infection, toxins, microparticles of the dead pulp come from the root hole to the hole, provoking infection of the dental ligaments, gums. The magnitude of focal lesions of bone tissue depends on the period, the duration of inflammation and the type of microorganism - pathogen. Inflamed root membrane of the tooth, adjacent tissues interfere with the normal process of food intake, the constant presence of an infectious focus provokes a pain symptom, often intolerable in the process of exacerbation. In addition, toxins enter the internal organs with blood flow and can cause many pathological processes in the body.

Periodontitis and pulpitis

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

Serous periodontitis, acute form	Acute pulpitis (localized)
Increasing pain symptom Pain does not depend on stimuli Sensory does not cause pain Mucous membrane is changed	The pain is paroxysmal, spontaneous character Probing causes pain Mucous without changes
Acute purulent process in periodontium	Acute diffuse pulpitis
Constant pain, spontaneous pain Pain clearly localized in the causative tooth Probe - without pain Mucous altered Deterioration of general condition X-ray shows changes in the periodontal structure	Pain paroxysmal Pain radiates into the trigeminal nerve channel Mucous without changes General condition within normal range
Chronic periodontitis, fibrous form	Caries, the beginning of pulpitis
Changing the color of the tooth crown Probing - no pain No reaction to the temperature effect	The color of the tooth crown is preserved Sensing painfully Expressed temperature tests
Chronic granulating periodontitis	Gangrenous pulpitis (partial)
Transient spontaneous pain Probing - no pain Mucous altered General condition suffers	The pain is aggravated by hot, warm food, drinking Sensing causes pain Mucous without changes General condition within the limits of the norm
Chronic granulomatous periodontitis	Simple pulpitis in chronic form
Pain is negligible, tolerable. Changing the color of the tooth. Sensing without pain. No reaction to the temperature stimuli	Pain with temperature irritation Color of the crown of the tooth unchanged Sensing painfully Elevated temperature probes

Differentiating periodontitis and pulpitis is mandatory, as it helps to build the right therapeutic strategy and reduces the risk of exacerbations, complications.

Periodontitis in children

Unfortunately, periodontitis in children is increasingly diagnosed. As a rule, inflammation of the periodontal tissue provokes caries - a disease of civilization. In addition, children rarely complain about dental problems, and parents neglect the preventive examination of a children's dentist. Therefore, children's periodontitis according to statistics is about 50% of all cases of treatment in dental institutions.

The inflammatory periodontal process can be divided into 2 categories:

1. Periodontitis of infant teeth.
2. Periodontitis of permanent teeth.

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

Complications of periodontitis

Complications, which provoke inflammation of periapical tissues, are conditionally divided into local and general.

Complications of periodontitis of a general nature:

• Persistent headache.
• The general intoxication of an organism (more often at an acute purulent periodontitis).
• Hyperthermia sometimes to critical levels of 39-40 degrees.
• The chronic course of periodontitis provokes many autoimmune diseases, among which rheumatism and endocarditis are leading, and kidney pathologies are less common.

Complications of local periodontitis:

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

The most dangerous complications are purulent process, when pus spreads in the direction of the bone tissue of the jaw and exit into the periosteum (under the periosteum). Necrotizing and melting the tissue provoke the development of an extensive phlegmon in the neck. With purulent periodontitis of the upper jaw (premolars, molars), the most common complication is submucosal abscess and odontogenic maxillary sinusitis.

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

[2], [3], [4], [5]

Diagnosis of periodontitis

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

Diagnosis of periodontitis involves the collection of anamnestic data, examination of the oral cavity, additional methods and methods of examination to assess the condition of apex and all periapical areas. In addition, the diagnosis should identify the root cause of inflammation, which can sometimes be very difficult to do with the ill-treatment of the patient from the patient. Acute status is easier to assess than diagnosing a neglected, chronic process.

In addition to etiologic reasons, assessing the clinical manifestations of periodontitis, the following are important in diagnosis:

• 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 evaluation of the red border of the lips.
• Presence of chronic or acute inflammatory diseases of internal organs and systems.
• Threatening conditions - a heart attack, a violation of cerebral circulation.

The main diagnostic load is borne by X-ray examination, which helps to make an accurate differentiation of the diagnosis of periapical system diseases.

Diagnosis of periodontitis involves the identification and recording of such information in accordance with the recommended protocol of the survey:

• Stage of the process.
• Phase of the process.
• Presence or absence of complications.
• Classification according to ICD-10.
• Criteria to help determine the condition of the dentition are permanent or temporary teeth.
• Channel passage.
• Localization of pain.
• The condition of the lymph nodes.
• Mobility of the tooth.
• Degree of pain with percussion, palpation.
• Changes in the structure of periapical tissue on the X-ray.

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

What measures are taken to examine the inflammation of periodontal tissue?

• Visual inspection and examination.
• Palpation.
• Percussion.
• External examination of the facial area.
• Instrumental examination of the oral cavity.
• Channel sounding.
• Thermodiagnostic test.
• Assessment of occlusion.
• Radial visualization.
• Electrodontometric examination.
• Local radiograph.
• Orthopantomogram.
• Radiovisual method.
• Evaluation of the index of oral hygiene.
• Definition of the periodontal index.

[6], [7], [8], [9], [10], [11]

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 treatment strategy, especially it is important for curating chronic processes.

1. Acute apical periodontitis is differentiated with diffuse pulpitis, gangrenous pulpitis, exacerbation of chronic periodontitis, with acute osteomyelitis, periostitis.
2. The purulent form of periodontitis should be separated from the similar near-root cysts. For a circumcortical cyst, signs of bone resorption are characteristic, which is not the case with periodontal inflammation. In addition, the circumcision cyst strongly swells in the area of the alveolar bone, provokes the displacement of teeth, which is not typical for periodontitis.
3. Acute periodontitis can be similar to odontogenic sinusitis and sinusitis, as all these conditions are accompanied by irradiating pain along the direction of the trigeminal nerve channel, painfulness with percussion of the tooth. Odontogenic sinusitis differs from periodontitis with a 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 the 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.

[12], [13], [14], [15], [16], [17], [18]

Treatment of periodontitis

The treatment of periodontitis is aimed at solving such problems: 

• Cupping of the focus of inflammation.
• Maximum preservation of the anatomical structure of the tooth and its functions.
• Improvement of the general condition of the patient and the quality of life in general.

What does the treatment of periodontitis include? 

• Local anesthesia, anesthesia.
• Providing access to the inflamed channel by opening.
• Expansion of the cavity of the tooth.
• Providing access to the root.
• Probing, channel passage, often its unmasking.
• Measuring the length of the channel.
• Mechanical and medicinal treatment of the canal.
• If necessary, removal of necrotic pulp.
• Setting a temporary filling material.
• After a certain period of time, the installation of a permanent seal.
• Restoration of the dentition, including a damaged tooth, endodontic therapy.

The news of the treatment process is accompanied by regular x-ray control, in the case when standard conservative methods do not lead to success, the treatment is performed surgically until the root is amputated and the tooth is extracted.

What criteria is the doctor guided in the choice of the method of treatment of periodontitis? 

• Anatomical specificity of the tooth, the structure of the roots.
• Pronounced pathological conditions - tooth trauma, fracture of roots and so on.
• Results of previous treatment (several years ago).
• The degree of accessibility or isolation of the tooth, its root, canal.
• Value of the tooth in the sense of functional, as well as aesthetic.
• The possibility or lack thereof in the sense of restoring the tooth (crown of the tooth).
• Condition of periodontal and periapical tissues.

As a rule, medical measures are painless, conducted under local anesthesia, and timely treatment to the dentist, makes treatment effective and fast. 

1. Medication periodontitis is a conservative treatment, surgery is rarely used.
2. Traumatic periodontitis - conservative treatment, possibly surgical intervention to excise bone particles from the gums.
3. Infectious purulent periodontitis. If the patient turned on time, the treatment is conservative, a running purulent process often requires surgical manipulation up to the removal of the tooth.
4. Fibrous periodontitis is treated with local medications and physiotherapy, standard conservative treatment is ineffective and there is no evidence for it. Rare surgery is used to excise the rough fibrous formations on the gum.