Chronic periodontitis

Chronic periodontitis is one of the forms of the inflammatory process in the periapical tissues of the tooth. As a kind of pathology of the peri-toothed ligaments, chronic inflammation can develop without a clinically pronounced exacerbation or be the consequence of an acute form of periodontitis that does not fall prey to adequate treatment.

Chronic period of periodontal inflammation is always due to the presence of the possibility of outflow of exudate, usually in the cavity of the tooth. The constant supply of pathogenic microorganisms in the periodontal tissues provokes the activation of other inflammatory processes in the remote zones of the body from the teeth - in internal organs and systems. Depending on the cause provoking the process, chronic periodontitis can proceed for a long time and is asymptomatic, has the property of periodically exacerbating and self-abating. The constant and progressive pathogenic effect on the periodontal gap most often leads to destabilization of the tooth, to destruction of bone tissue and serious complications, up to osteomyelitis.

[1], [2], [3]

Causes of chronic periodontitis

The main factors provoking chronic inflammation of the 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 infection and traumatic tooth injury.

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

In the dental practice, according to statistics, the leading position is occupied by infectious chronic periodontitis, which develops due to the defeat of 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 by the hematogenous route or through the lymph.

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

• Disbalance of microflora in the oral cavity.
• Disturbance of occlusion of teeth (irregular bite).
• Metabolic disorders in the body.
• Imbalance of microelements and beriberi.
• Chronic diseases of internal organs.
• The condition after an infectious, viral disease.
• Diabetes.
• Endocrine pathologies.
• Significant decrease in immunity activity.

[4], [5], [6], [7], [8]

Symptoms of chronic periodontitis

The danger of the chronic form of periodontitis lies in the asymptomatic course, when 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 loss of teeth. Among the disturbing signs, which are worth paying attention to, you can note a slight painful sensation when biting hard food. Also, slight discomfort is 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 method of outflow of accumulated inflammatory exudate. Unfortunately, when the fistula is formed, the products of decay go out, all the painful symptoms subsided, so quite often a person turns to the dentist, launching an inflammatory process that continues to develop for a long time, down to a serious aggravation.

Manifestations, 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 inflammation is very sluggish, a 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 at random, when the patient turns to the dentist for a different reason, for example, to treat a nearby tooth.
• Chronic granulating periodontitis is more evident, and is expressed in the formation of fistula under the mucous tissues of the alveoli. The inflammatory process is accompanied by destruction of the bone plate of the alveolar process, granulation spreads through the formed bone defects without causing painful sensations. 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 taking solid food. In addition, a large fistula is difficult not to notice on its own, this sign should serve as an excuse for immediate medical attention.
• Chronic granulomatous periodontitis is the inflammation of periodontal tissues with the formation of a specific capsule filled with granulomas. This kind of inflammatory process is most often asymptomatic and dangerous because the overgrown cystogranuloma requires surgical treatment. Disturbing signs can serve as a discoloration of the tooth, a reaction to food temperature, slight discomfort when biting solid foods.

All types of chronic periodontitis, despite the asymptomatic course, are characterized by a general intoxication effect on the body, therefore, among the secondary undifferentiated symptoms, periodic deterioration in health, malaise, decreased activity, and some symptoms of CNS irritation should be noted. In addition, chronic periodontal inflammation somehow acts on the lymphatic system, which reacts to the pathological process by increasing regional nodes.

[9], [10], [11], [12]

Exacerbation of chronic periodontitis

The only way to timely detect and diagnose the chronic course of the inflammatory sag in periodontium is exacerbation. Most often, exacerbation of chronic periodontitis develops against a background of concomitant general disease and has serious consequences in the form of abscesses, periostitis, phlegmon or osteomyelitis of the bone tissue of the jaw. Also, odontogenic exacerbations are possible and as an independent state, when pathogenic microorganisms enter the maxillofacial tissues by hematogenous or rhinogenic pathway, in most cases it is a staphylococcal or streptococcal infection.

Symptoms of exacerbation of chronic periodontitis:

• Deterioration of general state of health due to intoxication of the body.
• A fever may occur.
• Headache.
• Pain in the area affected by infection of the tooth.
• Clear localization of pain, the patient always points to the wrong tooth.
• Swelling of the gums, infiltration.
• Perhaps the formation of an abscess, when the inflammatory exudate has no outflow.
• Strengthening of toothache while eating or percussion.
• Mobility of the tooth.
• The feeling of a "grown tooth", the tooth seems to come out of the hole due to swollen periapical tissues.
• Increased regional lymph nodes.
• An asymmetric swelling of the facial tissues is possible.

[13], [14], [15]

Chronic periodontitis in the acute stage

The exacerbation of chronic inflammation in the clinical sense is identical to the signs of acute purulent periodontitis. As a rule, the stage of exacerbation has previous episodes of minor activation of symptoms, which subsided independently and the patient did not seek help from a doctor.

Most often chronic periodontitis in the stage of exacerbation is the proliferation of granulation formations in periodontal tissues. Periodontitis chronika granulans exacerbata is a rather serious inflammatory process when there are noticeable clinical symptoms in the form of pain in eating, a feeling of an enlarged tooth (a typical syndrome of a grown tooth), puffiness of the gum, less often the face. Objective signs - a deep cavity cavity, often gingival fistula with a closed stroke, painful sensations during percussion of the tooth, hyperemic mucosa of the oral cavity.

Chronic periodontitis in the acute stage can be clinically similar to acute jaw osteomyelitis, abscess of periodontal tissue, exacerbation of the deep caries process or acute sinusitis. The need for differentiation of clinical manifestations in the chronic form of periodontitis can make diagnosis difficult, but modern dentistry has precise methods and equipment that allow you to promptly confirm and confirm the correct diagnosis. Primary diagnostic assumptions are excluded or confirmed by radiography, more precisely, a snapshot, on which an enlarged periodontal cleft with a characteristic pattern of "flame tongues" is clearly visible. If necessary, several x-ray examinations (panoramic shots) are performed, helping to track the dynamics of the effectiveness of therapy.

Most often chronic periodontitis in the acute stage is subject to conservative treatment, in which access to the canal is created, its mechanical sanitation and treatment are carried out, including the administration of antiseptics and necessary medications. The main inflammatory process is cured, the tooth is closed with a permanent seal. However, neglected inflammation, complicated by periostitis, phlegmon, excluding the possibility of retaining the tooth, may require surgical intervention. In order that the infection does not spread to nearby tissues and teeth, an incision of the gum is made, conditions are created for draining the purulent exudate, treatment is performed aimed at neutralizing the intoxication of the body.

It is also possible hemisection or amputation of the root, partial resection of the apex, the tooth can be removed completely, if the conservative therapy does not work, the inflammation does not subside within 5-7 days.

Exacerbations are possible with any kind of chronic inflammation in the periodontium, but according to the statistics in this list "granulating periodontitis" is leading, which is characterized by a recurring course and rapid development of the process due to the growth of granulations.

[16], [17], [18]

Chronic periodontitis in children

In children, the chronic course of inflammation in the periodontium is more common than in adults, especially the chronic periodontitis that granulates the milk teeth in the molar zone (bifurcation of the root system). Etiology, factors that provoke chronic periodontitis in children, do not differ much from the causes of the inflammatory process in older patients, however, there are also specific features. Specific structure of periodontal tissue in childhood is such that both the gum and periapical apparatus has a loose structure, the tissue fibers do not have sufficient density. This makes periodontis more vulnerable to infection, trauma, but also creates the conditions for the constant distribution and outflow of inflammatory exudates, preventing it from accumulating and forming cysts, granulomas.

Chronic inflammation of periodontal disease in children can be both primary and developing as a result of a missed and unpeeled exacerbation, including exacerbation of pulpitis. The dominant position in the list of etiological causes is caries dentis - caries, which is currently diagnosed in 80% of children in statistics. Due to tooth decay, the pulpitis develops, which also often does not heal at the right time, the started inflammation of the pulp creates all the conditions for penetration of the infection in the periodontal tissue, which often leads to premature tooth loss. In addition, the danger of chronic periodontitis in children is the pathogenic effect on the rudiments of nearby teeth, when they shift, the root ceases to grow according to physiological norms, the tooth either erupts before the due date, or grows inferior.

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

Periodontitis of milk 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 completely inflamed, there is a risk of damage to the rudiment of the neighboring tooth, the causative tooth is to be removed. If it is possible to preserve the milk tooth, the channel is sanitized, the inflammation stops, the tooth is sealed.

[19], [20], [21], [22], [23], [24]

Chronic forms of periodontitis

Depending on the nature of deformation of periapical tissues, morphological and clinical patterns, the chronic forms of periodontitis may be:

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. The connective tissue is not physiologically and anatomically acceptable for the periapical apparatus, it does not create conditions for a normal blood supply to the tooth, therefore the ligaments gradually lose their functions. Most often a person does not feel discomfort and pain, inflammation is almost not manifested in the clinical sense. Diagnosis of fibrotic inflammation is possible only with the help of an X-ray, this happens at a clinical examination or in the treatment of a nearby tooth.

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

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

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

[25], [26], [27],

Chronic granulating periodontitis

Chronic inflammation in the granulating form is considered one of the most active species among chronic periodontitis, since the formation of granulations in itself can not but cause discomfort, therefore the patient has the opportunity to call the dentist in a timely manner and receive adequate care. 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 alveoli. The periodic acute phases of the process accompany the formation of the fistula, through which the accumulated exudate finds its outflow. As soon as the content gets the opportunity to exit, the exacerbation subsides and the process again becomes sluggish, asymptomatic. Clinical signs are absent and due to the sensibilization of the organism, which adapts itself to constant infection from a source of odontogenic inflammation. Chronic granulating periodontitis is also characterized by toxic effects on the body due to resorption in the alveolar process and absorption of inflammation products into the bloodstream. Paradoxically, the fistula that exudates into the oral cavity can reduce the intoxication, as soon as the fistula is blocked, the process passes to the stage of exacerbation and activates the common poisoning of the organism. The granulating form of inflammation is considered to be quite dynamic and well amenable to diagnosis, unlike other types of chronic inflammation of periodontal tissue.

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

• In the phase of exacerbation, minor pain sensations may appear at mechanical pressure on the inflamed tooth.
• The pain is of a paroxysmal nature and is intensified when taking solid food.
• A slight swelling of the gum around the causative tooth is possible.
• In the apex zone of the tooth, the infiltration is clearly felt.
• The aggravation most often ends with the formation of a fistula, which neutralizes the pain.
• If the granulation tissue is actively spreading, a person can feel in the oral cavity forming an atypical compaction - under the mucous membrane.
• In the phase of remission, pain can occur when taking hot food.
• Most often in the tooth there is a carious cavity, when it hits food pieces, a painful sensation may appear, subsiding after the treatment of the cavity, the removal of food particles.

Chronic granulating periodontitis is treated for a long time, the prognosis depends on the stage in which the inflammation is and on the duration of its course. Modern dentistry tends to dental-preserving methods of treatment, however, the completely destroyed root tip, the threat of infection spreading to surrounding tissues may give rise to the extraction of the causative tooth.

[28], [29], [30], [31]

Chronic granulomatous periodontitis

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

According to morphological signs, granulomatous periodontitis is classified as 3 types of inflammation:

1. A simple granulomatous periodontitis, in which granulomas consist of a dense fibrous tissue.
2. Epithelial granulomatous periodontitis, when the structure of the granulomas is epithelium. Such formations look like radicular cysts and may be a sign of a primary oncoprocess in the jaw.
3. Cystogranulomatous periodontitis, in which granulomas form cysts with inflammatory exudate inside.

Granulomas have a property to localize both in the apex zone and on the side of the root (apical-lateral), as well as in the zone of bifurcation of multi-rooted teeth.

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

• Opening and machining of the apical root canal.
• Sanitation of the canal and treatment of the inflammatory focus to complete exudation of exudate.
• Closing the channel by filling.

Multi-rooted teeth are treated more difficultly, as access to 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 to the periosteum, the gum, a gum tissue cut is used to create a release of accumulated decay products. If conservative therapy is not effective, the doctor performs a partial or complete resection of the inflamed apex of the root, or performs a re-implantation in the treatment of a multi-root tooth.

In general, granulomatous periodontitis can be considered cured no earlier than a year later, when the granuloma is completely scarring and tissue regeneration.

[32], [33], [34], [35]

Chronic fibrous periodontitis

The easiest variant of periodontal inflammation, the most asymptomatic and undeveloped in the clinical sense, is the chronic fibrotic periodontitis (periodontitis chronika fibroza).

Pathogenically fibrous growth occurs gradually, imperceptibly, can be an independent process, but also as a result of exacerbation of granulomatous or granulating inflammation of periodontal tissue. In addition to coarse fibrous fibers replacing periodontal structures, small focal infiltrates containing lymphocytes are visible in the oral cavity, the apical foramen of the root contains increased deposits of cement elements (hypercement), and osteosclerosis is formed around the periphery of the periodontium. As a result of constant replacement of tissues, the periodontal gap widens, the periodontium gradually loses its functional properties.

Inflammation occurs without discomfort and almost without pain. Very rarely patients can experience minor pain with strong pressure on the causative tooth, as a rule, this happens when unsuccessful biting of solid foods, nuts, and bones. Diagnosis of chronic fibrotic periodontitis is possible only with the help of radiography and thermal tests. Diagnosis is carried out in a differential channel, since the fibrous form, not having a specific symptomatology, can resemble pulpitis in the gangrenous stage, caries.

The treatment of fibrous inflammation is quite successful, it is the most favorable form of periodontitis in the therapeutic sense. Even with the obturation of the tooth canal, it is not opened, since there is no need to create an outflow to a non-existent exudate. The inflammatory process concerns 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 its sanation, diathermocoagulation of the pulp is rarely carried out. After the sanation, a temporary seal is placed, when the dental office is visited again, the patient's tooth is closed with a permanent seal.

Chronic apical periodontitis

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

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

The most common apical form of chronic inflammation, gingival (marginal) periodontitis is often the result of constant microtrauma.

The apical inflammation by its name is due to the localization of inflammation - in the apex (apex) of the root. Chronic destruction of periodontal tissue, as a rule, begins precisely with this zone, which can be explained by the vertical pathway of infection.

Chronic periodontitis in the apex of the root is an inflammation of the periapical structure, localized immediately near the apical foramen, less often affecting the mouth of the lateral parts of the ligaments. The inflammatory process can acquire a chronic form only under the condition of sensibilization of the organism, its adaptive reaction to the permanent effect 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 the gradual infestation of internal organs and systems.

The apical periodontitis can have a fibrous, granulating and granulomatous form, all three types of inflammation are characterized by an asymptomatic course, diagnosed only at the stage of exacerbation or at random during dispensary 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 consequence of neglected caries and then pulpitis. Any kind of chronic apical inflammation is prone to exacerbations, transition to a purulent process, and also to relapses.

The most favorable course of 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 dental preserving therapy.

Chronic apical periodontitis

Before you understand the causes of the provocation of the Reriodontitis chronika apicalis - chronic apical periodontitis, it is necessary to clarify how the apex foramen of the tooth root and periodontal tissue is anatomically related.

Direct connection with apex has a pulp, it is its tissues that connect with the tip of the periodontal with the help of side openings and tubules. If the pulp is inflamed and not treated in a timely manner, the products of the inflammatory process gradually spread through the apex in all periodontal tissues, but the apical foramen is first affected. This is how chronic apical periodontitis develops, which is most often the result of a long caries lesion, and then pulpitis. Since periodontium is much more active in protective properties than pulp tissue, inflammatory process is rarely manifested by severe symptoms, pathological balance and constant "struggle" with infection in periodontium can last for years without any tangible discomfort or pain. The only sign after a certain period may be a granuloma or cyst that is large enough to be felt by the patient in the oral cavity.

With such a hidden course of the process, many difficulties, both diagnostic and therapeutic, are associated. Chronic apical inflammation for flaccid and undeveloped symptoms may 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 on an x-ray. Radiography clearly determines the pathological expansion of the periodontal gap, inspection allows you to identify the sensitivity of the causative tooth to percussion.

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

• In the period of exacerbation of the inflammation, there is a perceptible pain that increases with mechanical pressure on the affected tooth.
• The pain is aching, it can subside and recur on its own.
• Edema of the gum is not observed.
• With the granulating form of apical inflammation on the mucosa in the area of the causative tooth, infiltrates filled with lymphocytes can be seen.
• The granulomatous form of the apical periodontitis is characterized by the formation of rather large cystogranules.
• With the formation of the fistula and the outflow of exudate, the pain subsides.
• Possible secondary symptoms of general intoxication, 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 the connection with chronic inflammation in the oral cavity.

Treatment of chronic apical inflammation in periodontitis depends on the complexity, degree of neglect of the process and the form of periodontitis. At present, dentists are striving for tooth-preserving methods, therefore, if possible, the tooth canal is sanitized, creating conditions for adequate removal of inflammatory exudates. After stopping the inflammation, the tooth is closed with a seal. Extraction of the tooth is also possible in cases where the tooth bone is destroyed thoroughly, the mobility of the tooth is great and there is a risk of spreading the infection to other, healthier tissues.

[36], [37], [38], [39],

Diagnosis of chronic periodontitis

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

Oral examination is carried out according to the generally accepted dental practice algorithm - interrogation 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 performed repeatedly - during the first visit to the doctor, after therapeutic measures, as well as during endodontic treatment to monitor the dynamics and effectiveness of the actions. In addition to X-ray images, quantitative results based on a scoring scale are important indicators, using this method determine the severity of destructive damage to root apex and a general disturbance of periapical tissues.

Clinical examination includes such methods:

• Thorough examination of the entire oral cavity.
• Percussion of the causative tooth.
• Palpation of the oral cavity, periapical tissues.
• Probing of the entrance to the canal of the tooth (definition of obturation and pain during passage).
• It is possible to conduct temperature tests that are most effective for examining adult patients. Diagnosis of chronic periodontitis in children, as a rule, does not involve a temperature method due to the age characteristics of the patient and the bias of the descriptions of sensations.
• Determination of the degree of mobility of the causal tooth by means of correct indentation or translational movements.
• It is possible to use radiovisiography, electrodontodiagnostics. The electrodiagnostic method makes it possible to assess the vitality of the pulp.

The most informative is the X-ray of the tooth and surrounding tissues, the interpretation of the results of radiography 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 species:

1. Chronic fibrous inflammation of the periodontium is very difficult to diagnose, which is explained by the absolute asymptotic nature of the process. In addition, morphologically and pathogenetically fibrous inflammation is very similar to chronic gangrenous pulpitis, therefore the main method of differentiation is the X-ray image and its interpretation. An objective examination of the oral cavity shows pronounced caries (in 95% of cases), the sounding of the canal passes without pain, the tooth crown is intact, the tooth does not respond to temperature stimuli, percussion is most often not accompanied by painful sensations. Radiography more clearly determines the clearly deformed periodontal gap, which is markedly enlarged towards the apex.
2. Chronic periodontitis with granulations is diagnosed a little easier than other types of chronic periodontal inflammation. When examining the oral cavity, hyperemic mucous membrane is visible, the gum is slightly swollen, there is a symptom of vasoparesis (when pressing on the gum appears a fossa that slowly aligns). Palpation and percussion cause tolerable pain, lymph nodes condensed, can be enlarged. X-ray shows a characteristic picture of the rarefaction of bone tissue in the apex region (flame pattern).
3. Granulomatous chronic periodontitis is also difficult to diagnose if the granuloma is in the deep layers of the gum and not clearly expressed. If the granuloma is located in the cheek zone, in the region of the upper molars, then the patient himself points precisely to the place of bulging. The carious cavity in the causative tooth can be hidden, the percussion does not cause pain, with the help of palpation it is possible to detect small areas of tissue tightening in the projection of the latent granuloma. The X-ray image clearly reveals the zone of rarefaction of bone tissue, most often in a rounded form, also a destructive process is seen in the entire tooth, especially in the apex, signs of hypercement in marginal areas of the root are seen.

[40], [41], [42], [43], [44], [45], [46]

Differential diagnosis of chronic periodontitis

The chronic course of inflammation in the periapical tissues is difficult to diagnose due to the sluggish course of the process, implicit clinical signs and the absence of specific symptoms. That is why, in order to choose a therapeutic direction, differential diagnostics of chronic periodontitis is so important, which helps to distinguish periodontal inflammation from chronic pulpitis, periostitis, osteomyelitis and other diseases similar in clinical sense. The main "assistant" of the dentist in this difficult process is radiography, certainly the accuracy of the diagnosis is influenced by practical medical experience, in addition it helps to establish the type of disease timely access for help from the patient, which, unfortunately, is not so common.

Differential diagnosis of chronic periodontitis can be carried out on the following grounds:

Chronic fibrous inflammation of the periodontal disease	Caries
Noticeably discoloration of the tooth	The color of the tooth remains unchanged
Probing is practically painless	Passage of the tooth canal causes pain
Temperature stimuli do not cause painful sensations	The tooth reacts to temperature tests
X-ray shows deformation, destruction of bone and periodontal tooth tissue	X-ray picture does not show noticeable destructive changes in the tooth tissues
The 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	Pain in the tooth is worse when taking hot food
The pain is aching, tolerant, self-abating	The pain is constantly aching
Mucous membranes of the oral cavity can be hyperemic	Mucous membranes of the oral cavity without changes
Passage of the tooth canal does not cause pain	Channel sounding is accompanied by severe pain
X-ray shows visible changes in periodontal tissues	X-ray shows a change in the tissues of the pulp
There are symptoms of general intoxication	General health is not violated

Granulomatous periodontitis	Chronic pulpitis
The pain symptom is not expressed, the pain is not aggravated by hot food	The tooth hurts when interacting with hot food, drinking
The color of the tooth changes markedly	Color of tooth without changes
Sensing is not accompanied by pain	Passing the channel is very painful
Temperature probes do not cause a reaction	Reaction to temperature tests
X-rays show an extension of the periodontal gap, destruction of bone tissue	X-ray can show a change in bone tissue in 20-25% of cases

Differentiation of clinical manifestations, results of instrumental examinations allows choosing an appropriate treatment tactics, which, in turn, can depend on the preservation and restoration of tooth functions.

[47], [48], [49]

Treatment of chronic periodontitis

Treatment of chronic forms of periodontitis, as well as medical measures in cases of aggravation 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 a thorough sanation of the source of infection. Prevention of the spread of infection in nearby tissues, anti-inflammatory therapy is possible only under certain conditions: •

• Perforation of the tooth canal.
• Clearly localized inflammatory process.
• Preservation of most of the bone tissue.
• Absence of symptoms of severe intoxication and pain.

The first stage of the treatment of chronic periodontitis, as a rule, consists in the mechanical processing of the dental cavity, the canal. They are cleaned from the products of caries decomposition, treated with special antiseptics, if possible, the cavity is closed with a permanent seal. If there is a slow inflammation and a significant accumulation of exudate, an outlet is created, most often by opening the channel, then a temporary filling is inserted. After 2-3 days, a second sanation is carried out, and the tooth is closed with a permanent seal. Completely inflammation will be removed with the help of antibacterial dental materials (pastes), diathermocoagulation can be used, laser methods of sanitation and canal treatment are very effective. The chemical treatment of the tooth cavity is now used increasingly less often because of the risk of possible complications (drug periodontitis). In addition, modern dentistry is aimed at maximum preservation of the dentition, and chemical disinsection in this sense is quite aggressive on bone tissue, so it is replaced by safer and more effective methods of sanitation.

Surgical methods of treatment:

• Amputation of the root of the tooth.
• Hemisection - removal of roots in a multi-rooted tooth.
• Excision of root apex.
• Extraction of the tooth (removal).
• Gum incision and drainage.

These methods are used only in cases where there is no access to the channel, for example, in the treatment of chronic periodontitis of the wisdom tooth or the treatment of multi-rooted teeth. Surgical methods are also shown when intracanal therapy does not bring the expected result and there is a risk of total spread of infection on all tissues of the oral cavity. It should be noted that surgery in dentistry is an extreme measure, especially given the availability of modern equipment and effective drugs. Nevertheless, chronic inflammations in periodontitis can lead to such conditions, when conservative treatment is in principle impossible. This is due to a long period of inflammation, its chronicization and the vast destruction of periapical tissues.

Certainly, the endodontic treatment of chronic periodontitis is more favorable in terms of the prognosis and preservation of the tooth, when the whole remains the crown part of the tooth, the solid structure of the root. In such cases, given a relatively healthy periodontal apparatus, aesthetic restoration of the dentition or orthopedics is possible, which allows to preserve 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, fibrotic or granulomatous. The most common conservative methods of treatment, as modern dentistry is aimed at organ-preserving therapy. Surgical intervention is considered an extreme measure when endodontic methods fail.

Usually the first visit to the dentist begins with local anesthesia, then the tooth is probed, the channel is sanitized. In parallel, the canal is cleansed mechanically or chemically for decomposition products, from carious deposits. The stage of filling depends on the degree of severity of the process, if possible, the tooth is closed immediately, when the inflammation needs a longer treatment, a temporary seal is placed. The most favorable treatment for fibrous periodontitis, which is most often supervised with the help of physiotherapy procedures and regular rinses. It is more difficult and longer to treat the granulating form of periodontitis due to its prevalence. Granulomatous periodontitis is considered a consequence of granulations, so the method of its treatment is identical to the therapy of granulating inflammation.

Removal of the tooth, its re-implantation, cystotomy or resection of the apex of the root are carried out 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 chooses an adequate and most sparing way to neutralize the pathological process.

Treatment of chronic granulomatous periodontitis

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

Granuloma is an abscess in the periodontal tissue, most often in the apex zone, the size of the granuloma is less than 0.5 centimeter. If the formation in size exceeds 0, 5 cm 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 the granuloma is formed and the canal is well traversed, are treated in a single session, during which the canal is sanitized, processed, and the tooth is sealed with a seal.

Multi-rooted tooth, including the wisdom tooth, as a rule, does not allow sanitation of canals, therefore it is tried to be treated conservatively by impregnation methods (silvering, resorcinol, potassium iodide). If complications develop in the treatment process, most often medicamentous inflammations, physiotherapy, 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 time-consuming. The process of scarring and tissue regeneration is constantly monitored by examinations, X-rays. If a month after conservative therapy the doctor does not see positive dynamics, it is possible to use surgical methods - apex resection, tooth re-implantation.

Treatment of chronic granulating periodontitis

Chronic granulating periodontitis is treated for a long time, sometimes for half a year.

The patient needs at least 4 visits to the dentist, and in addition to them a few more preventive visits to inspect and confirm the effectiveness of the chosen method of therapy.

1. First visit:
   • Diagnostics.
   • Anesthesia.
   • Opening the channel.
   • Sanitation of the canal, removal of caries deposits.
   • Removal of necrotic pulp residues.
   • Washing the channel with antiseptics.
   • Introduction of an anti-inflammatory agent into the canal of the tooth.
   • Setting a temporary seal.
   • It is possible to prescribe antibiotics in tablet form.
2. Second visit:
   • Inspection of the oral cavity.
   • Removal of temporary filling material.
   • Channel washing, sanitation.
   • Another temporary filling of the canal with antiseptic material.
   • The seal remains for 2-3 months.
3. Third visit to the doctor:
   • X-ray monitoring.
   • Opening the channel and processing it.
   • Constant tooth filling.
4. The fourth visit to the doctor is necessary to confirm the effectiveness of treatment and the absence of complications

Treatment of granulating periodontitis can result in surgical intervention with a neglected inflammatory process.

In what cases is the surgical treatment of granulating periodontitis shown?

• Abnormal position of the apex, curvature of the apex.
• The impossibility of probing the canal, its obstruction.
• The lack of effectiveness of conservative treatment during the month.
• Progression of inflammation during treatment.

Prophylaxis of chronic periodontitis

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

1. Regular, thorough care of the oral cavity.
2. Reasonable eating and limiting sweet foods.
3. Regular visits to the dentist from childhood. Clinical examination by statistics provides a reduction in caries disease by 65-70%.
4. Timely call to the doctor at the first alarming symptoms.
5. Fulfillment of all recommendations of the dentist during the treatment of periodontitis.

Prevention of chronic periodontitis is a systemic issue and 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 dental trip should not cause rejection or fear. The use of highly effective techniques, the availability of precise equipment and the variety of methods of anesthesia make dental treatment absolutely safe. Therefore, the main thing in prevention is constant examinations of the doctor, because only a specialist is able to detect the first signs of caries and inflammation in time and only the dentist can choose the right method of treatment.

Chronic periodontitis to date is the most commonly diagnosed oral disease, second only to caries in a sad list of dental problems. The chronic form of the inflammatory process is dangerous not only in the absence of clinical manifestations, but also in that 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 going to the dentist. Even in case of an exacerbation the doctor will be able to choose the most gentle method of treatment and will try to do everything in order to preserve the tooth and its function. Visiting the doctor every six months, you not only can prevent periodontitis, but also provide yourself with no caries, tartar, and therefore a really healthy smile.