Chronic periodontitis

Periodontal disease comprises of a group of inflammatory conditions of the supportive tissues of the teeth that are caused by bacteria.

1. SEMINAR ON CHRONIC PERIODONTITIS Presented by: Shivani Yadav BDS 4 th Year (12083)

2. CONTENT Periodontal disease Classification Introduction Definition Major clinical and etiologic factor Prevalence Clinical features Symptoms Types D isease severity Disease progression Clinical diagnosis Radiographic features Risk factors for disease Treatment Prognosis

3. Periodontal disease Definition: Periodontal disease comprises of a group of inflammatory condtions of the supportive tissues of the teeth that are caused by bacteria. -Carranza

4. The Periodontal Disease Classification System of the American Academy of Periodontology (AAP), 1999 I . Gingival Diseases A. Dental plaque-induced gingival diseases B. Non-plaque-induced gingival lesions II. Chronic Periodontitis (slight: 1-2 mm CAL; moderate: 3-4 mm CAL; severe: > 5 mm CAL) A. Localized ( < 30% of sites are involved) B. Generalized (> 30% of sites are involved) III. Aggressive Periodontitis A. Localized ( < 30% of sites are involved) B. Generalized (> 30% of sites are involved) IV. Periodontitis as a Manifestation of Systemic Diseases A. Associated with hematological disorders B. Associated with genetic disorders C. Not otherwise specified

5. . V. Necrotizing Periodontal Diseases A. Necrotizing ulcerative gingivitis B. Necrotizing ulcerative periodontitis VI. Abscesses of the Periodontium A. Gingival abscess B. Periodontal abscess C. Pericoronal abscess VII. Periodontitis Associated With Endodontic Lesions A. Combined periodontic-endodontic lesions VIII. Developmental or Acquired Deformities and Conditions A. Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis B. Mucogingival deformities and conditions around teeth C .Mucogingival deformities and conditions on edentulous ridges D. Occlusal trauma

6. INTRODUCTION Chronic periodontitis, formerly known as adult periodontitis or chronic adult periodontitis , is the most prevalent form of periodontitis. I t is generally considered to be a slowly progressing disease . Although chronic periodontitis is most frequently observed in adults, it can occur in children and adolescents in response to chronic plaque and calculus accumulation.

7. DEFINITION Chronic periodontitis has been defined as “ an infectious disease resulting in inflammation with in supporting tissues of the teeth, progressive attachment loss and bone loss ”.

8. Major clinical and etiologic characteristics of the disease : Microbial plaque formation. Periodontal inflammation, and Loss of attachment and alveolar bone .

9. PREVALENCE Effects both sexes equally. Increases with age . Age associated disease not age related and occurs depending on disease duration.

10. CLINICAL FEATURES Most prevalent in adults but can occur in children and adolescents.(age‐35+yrs ) Supragingival and subgingival plaque accumulation (frequently associated with calculus) Gingival inflammation Pocket formation Loss of periodontal attachment Occasional suppuration Poor oral hygiene – gingiva is typically may be slightly to moderately swollen

11. . Color- pale red to magenta Consistency – soft or firm Surface topography – loss of stippling Blunted or rolled gingival margin Flattened or cratered papillae. Tooth mobility. Furcation involvement. Spontaneous gingival bleeding . Pocket depths are variable and both suprabony and intrabony pockets can be found.

12. Attachment loss with and without deep periodontal pocket. Pocket depths are variable, and both horizontal and vertical bone loss can be found.

13. Furcation involvement in the molars are common in advance cases of chronic periodontitis. Tooth mobility often appears in advanced cases when bone loss has been considerable.

14. SYMPTOMS

15. TYPES DISEASE DISTRIBUTION Chronic periodontitis is considered to be as “site specific disease” Inflammation, pockets, attachment loss and bone loss are due to direct site-specific effects of sub-gingival plaque accumulation as a result of this local effect, attachment loss and pockets may occur. It may occur on one surface of the tooth while the other surface remain normal.

16. In addition to being site specific, chronic periodontitis may be described as: Localized: Periodontitis is considered localized when <30% of the sites assessed in oral cavity demonstrate attachment loss and bone loss. Generalized : Periodontitis is considered generalized when >30% of the sites assessed demonstrate attachment loss and bone loss. The pattern of bone loss in chronic periodontitis can be vertical or horizontal.

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18. • Localized ≤ 30% of the sites are affected

19. Generalized > 30% of the sites are affected

20. MILD PERIODONTITIS 1 to 2 mm CAL MODERATE PERIODONTITIS 3 to 4 mm CAL SEVERE PERIODONTITIS ≥ 5 mm CAL DISEASE SEVERITY Severity can be categorized on the basis of the amount of Clinical attachment loss (CAL) as follows :

21. EARLY PERIODONTITIS

22. MODERATE PERIODONTITIS

23. SEVERE PERIODONTITIS

24. DISEASE PROGRESSION The rate of disease progression is usually slow but may be modified by systemic and/or environmental and behavioral factors. Chronic periodontitis does not progress at an equal rate in all affected sites throughout the mouth. More rapidly progressive lesions occur : Interproximal areas Areas of greater plaque accumulation Inaccessibility to plaque control measures (e.g., furcation areas, overhanging margins, sites of malposed teeth, or areas of food impaction)

25. Clinical Diagnosis Inflammation of the marginal gingiva extent to the attached gingiva. Clinical attachment loss. Radiographs(in case of bone loss).

26. RADIOGRAPHIC FEATURES

27. RADIOGRAPHIC FEATURES Pattern of bone loss may be : Vertical, Horizontal, Vertical bone loss is usually associated with intra bony pocket formation. Horizontal bone loss is usually associated with supra bony pockets.

28. RISK FACTORS FOR DISEASE Prior History of Periodontitis Local Factors Systemic Factors Environmental and Behavioral Factors Genetic Factors Risk factor - is a characteristic, an aspect of behavior, or an environmental exposure that is associated with destructive periodontitis

29. Prior History Of Periodontitis Although not a true risk factor for disease but rather a disease predictor , a prior history of periodontitis puts patients at greater risk for developing further loss of attachment and bone, given a challenge from bacterial plaque accumulation. Patient present with persistent gingivitis or periodontitis with pocketing, attachment loss, and bone loss ,may continue to lose periodontal support if not successfully treated.

30. LOCAL FACTORS Plaque and plaque retentive factors. Microbiological Factors Causative organisms of chronic periodontitis are: • Porphyromonas gingivalis (P. gingivalis) • Prevotella intermedia (P. intermedia) Treponema denticola • Capnocytophaga • A.actinomycetemcomitans (A.a) • Eikenella corrodens (E. corrodens) • Campylobacter rectus (C. rectus) Viruses including cytomegalo , Epstein Barr, Papilloma and herpes simplex have been proposed to play a role in the etiology of periodontal diseases, possibly by changing the host response to the local subgingival microbiota.

31. LOCAL FACTORS Plaque Accumulation Oral Hygiene Tooth Malposition Restoration Preserve & Quantity of certain bacteria Host defences Subgingival Restoration Environment Calculus, smoking Connective Tissue destruction Genetic influence Inflammation Periodontopathic bacteria Smoking, Calculus Loss of Attachment M O D I F Y I N G F A C T O R S

32. Plaque retentive factors: Calculus Overhanging restorations

33. Trauma from occlusion Micro-organisms

34. SYSTEMIC FACTORS Non Genetic -Smoking is a major risk factor - Diabetes -Conditions associated with compromised immune responses (e.g. HIV) - Nutritional defects -Osteoporosis -Medications that cause drug induced gingival overgrowth (e.g. some calcium channel blockers, phenytoin, cyclosporine) Genetic factors (as yet poorly defined)

35. SMOKING Undoubtedly one of the main and most prevalent, risk factors for chronic periodontitis, risk calculations suggesting 40% of the cases of chronic periodontitis may be attributable to smoking. It has been estimated that there are 1.1 billlion are smokers worldwide and 182 million (16.6%) of them live in India .

36. DIABETES

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38. STRESS

39. AGE Both the prevalence and severity of periodontal disease increases with age. Intake of medications, Decreased immune function, and Altered nutritional status interaction

40. NUTRITION Vitamin C or ascorbic acid is essential for the formation of collagen and intercellular material, bone and teeth. ↓ phagocytic function of neutrophils and macrophages ↓ antibody response ↓ cytotoxic T-cell activity

41. OSTEOPOROSIS It is a disease characterized by low bone mass and deterioration of bone structure that causes bone fragility and increases the risk of fracture. Both osteoporosis and periodontal diseases are bone resorptive diseases Osteoporosis could be a risk factor for the progression of chronic periodontal disease . A direct association between skeletal and periodontal disease as measured by loss of interproximal alveolar bone in postmenopausal women has been reported.

42. HIV AIDS epidemics in US suggests HIV positive patients especially those with AIDS and low count of T Lymphocytes(CD4 <200 cells/ml) were at increased risk of chronic periodontitis.

43. TREATMENT NON SURGICAL THERAPY Initial therapy ( scaling and root planing) Antimicrobial therapy – as an adjunct to routine periodontal therapy. Improvement in oral hygiene. Instruction, reinforcement, evaluation of plaque control records. Removal of all the factors contributing to plaque accumulation, e.g. correction of ill-fitting appliances, overcontoured crowns, overhanging restorations, etc.

44. 2. SURGICAL THERAPY A variety of surgical treatment modalities may be appropriate in managing the patient. 1. Pocket elimination procedures. 2. Regenerative therapy: A. Bone replacement grafts; B. Guided tissue regeneration; C. Combined regenerative techniques. 3. Resective therapy: A. Flaps with or without osseous surgery; B. Gingivectomy .

45. PROGNOSIS Slight to moderate periodontitis , the prognosis is usually good provided , the inflammation can be controlled through good oral hygiene and the removal of local plaque retentive factors. In patients with more severe disease , as evidenced by furcation involvements and increasing mobility, or in patients who are noncompliant with oral hygiene practices, the prognosis may be downgraded from fair to poor .