Granulomatous periodontitis microbial 10. Periodontitis: causes, diagnosis, treatment

The inflammatory process in the area of ​​the connective tissues surrounding the root of the tooth is called periodontitis.

The classification of the disease is great importance, because the various forms of this pathology require an individual approach when choosing therapy.

Features of symptoms are determined using three schemes: classification by origin, according to ICD-10 (WHO) and according to Lukomsky.

Origin

The classification of periodontitis by origin is as follows:

Medicamentous and traumatic types of the disease may first manifest as aseptic periodontitis, but under the influence of pathogenic flora, they gradually become infectious.

According to ICD-10

This classification was proposed by the World Health Organization in order to take into account not only the main forms of periodontitis, but also the peculiarities of the complications that arise. This approach helps to more accurately select the methods of therapy and unite the efforts of specialists in the process of diagnosis and treatment.

The following forms of periodontitis are recognized:

1. acute apical- a classic version of the disease, in which it is necessary to remove the severity of the process and remove the source of infection:
2. chronic apical- an outdated focus with education. not excluded surgical methods impact;
3. periapical abscess without fistula;
4. periapical abscess with- describes the etiology of the disease, taking into account the location of the gingival fistulas. When the infection passes into the maxillary sinus, you will need to consult an ENT doctor;
5. - requires either long-term conservative therapy with drainage of the cystic cavity, or rapid surgical intervention.

The success and duration of periodontal treatment depends on the timely visit to the doctor. An advanced form of the disease can lead to tooth loss and the development of dangerous complications.

According to Lukomsky

This type of diagnosis in modern dentistry is most in demand, since it describes all types of periodontitis, taking into account their specific differences.

Acute periodontitis is of two types:

Chronic apical periodontitis

Most often, the chronic stage is the result of acute periodontitis, although with weak immunity it sometimes develops on its own. Inflammation causes mild discomfort only when chewing food. However, a sluggish chronic process makes itself felt under the influence of cold or after suffering colds.

Orthopantomogram for periodontitis

Three forms of this pathology are known:

• fibrous. There is an expansion of the periodontium, in which the bone tissue has no signs of pathology. If such a process is detected after filling or endodontic treatment, additional therapy can be dispensed with. It is possible to determine the disease only with the help of an x-ray, where a noticeable increase in the periodontal gap will be recorded;
• granulating. In the region of the upper part of the root, a granular (granulation) red tissue is formed, which increases in size very quickly. This leads to the destruction of the bone and the periodic appearance of mild aching pain. In parallel, a fistula often forms on the gum, from which a small amount of pus can periodically come out. On x-ray, the inflammatory process looks like a darkening of an irregular shape;
• granulomatous. Looks like destruction bone tissue near the upper or in the region of the lower third of the tooth root. Without timely therapy, the pathology gradually develops into a periradicular cyst. These formations come in different shapes, but are filled with pus and have the same structure. Symptoms of granulomatous periodontitis appear as an intermediate state between the mild fibrous form and the active stage of granulomatous periodontitis. At first, the disease does not actually manifest itself, but over time, it more and more actively reminds of itself with increasing pain.

Chronic periodontitis, as a rule, passes without a pronounced etiology. There is either a slight pain, or a certain discomfort when chewing and tapping on the tooth.

Exacerbation of the chronic form

Sluggish infectious processes in the periodontal area are periodically exacerbated, causing swelling of the gums, swelling of the cheeks, pronounced pain.

The following factors provoke changes in symptoms:

An exacerbation of chronic periodontitis on an x-ray looks like a chronic form, but all the symptoms of an acute stage are observed. Until the focus of infection is completely eliminated, sluggish inflammatory processes will periodically worsen.

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Periodontitis of teeth and its treatment:

An extensive classification of periodontitis, taking into account the characteristics of different forms of the course of the disease, is needed in order to select more effective method therapy. The picture of changes in the area of ​​the tops of the dental roots is so different that it requires an individual approach to the choice medicines and methods of treatment. The duration of therapy also has its own characteristics. Let's say fibrous form periodontitis requires several visits to the doctor during the week, and granulating and granulomatous is treated for at least two months with the use of special preparations. The sooner the patient seeks help from a dentist, the greater the chance of saving a bad tooth.

One of the most insidious dental diseases is periodontitis. Its symptoms are not always pronounced, so patients often seek medical help at the wrong time. This complicates treatment, leads to complications and even tooth loss. The article clearly reveals the questions of what periodontitis is, its symptoms, treatment and prevention measures.

In medicine, such a definition of this disease is given: periodontitis is an inflammation of the periodontium, that is, the connective tissue between the cortical plate of the tooth socket (alveoli) and the cementum of the tooth root. The thickness of the periodontium is different for everyone, on average it is 0.19-0.26 mm.

Simply put, with the development of periodontitis, an area of ​​\u200b\u200bthe tissue that surrounds the root of the tooth and is responsible for its stability becomes inflamed. The periodontium is closely connected with the surrounding tissues: along its entire length - with the jaw bone, through the apical opening - with the pulp, at the edges of the tooth hole - with the periosteum and gums.

The disease is characterized mainly by damage to the ligaments that hold the tooth in the alveolus, degradation of bone tissue of varying severity, resorption (destruction) of the walls of the tooth socket and even root cementum.

According to statistics, this is a common disease, diagnosed in 45-50% of cases dental problems. Periodontitis never occurs in an "empty" place. As a rule, it is a consequence. The disease is quite serious, it is not so easy to cope with it, it has a negative impact on the entire human body and can cause such formidable complications as an abscess, acute sinusitis, osteomyelitis, or sepsis.

Types and classification

Periodontitis can occur for a number of reasons, its course can be different, which requires different methods of treatment. That is why the classification of this disease is necessary.

In medical practice, there are three types of classification of periodontitis:

• by origin,
• from WHO according to ICD-10,
• according to the Lukomsky system.

By origin, these types of periodontitis are distinguished:

• infectious - this form of the disease occurs most often, in 70-75% of cases of periodontitis. The development of pathology is provoked by harmful bacteria,
• traumatic - develops with injuries, bruises, unnatural loads on the teeth (for example, opening bottles with teeth or opening nut shells),
• medication - occurs in violation of medical technology or as a reaction to certain medications.

WHO (World Health Organization, works under the UN) in the late 90s of the twentieth century proposed that when classifying periodontitis, take into account its most frequent consequences. According to experts, this approach makes it possible to comprehensively cover the problem, influence not only the disease itself, but also minimize the risks of complications, and also combine the efforts of narrow specialists (for example, a dentist and a general practitioner or a surgeon, or an ENT doctor).

With this in mind, it was developed new system, which was included in the International Classification of Diseases of the tenth revision ( ICD-10). Periodontitis is presented here in the section "Diseases of the oral cavity, salivary glands and jaws" under the code K04, which combines diseases of the pulp and periapical tissues. This is due to the close relationship of periodontitis with pulpitis.

Classification of periodontitis according to ICD-10:

• acute apical (apical) periodontitis of pulpal origin (code K04.4). According to dentists, this is a classic option. this disease. There are no problems with determining the cause of the pathology and in making a diagnosis. The doctor must first of all eliminate the source of infection and remove the severity of the process,
• chronic apical (apical) (code K04.5). At the same time, a pathological formation of a rounded shape develops at the top of the tooth root - an apical granuloma. It has dimensions from 2 to 7 mm in diameter. Over time, without proper treatment, it can degenerate into a cyst,
• periapical abscess with or without a fistula (code K04.6 and K04.7, respectively). Depending on the location, dental, dentoalveolar suppuration and periodontal suppuration are distinguished. Fistulas can communicate with the maxillary sinus, with the skin, go into the nasal cavity (it is very dangerous if the fistulous canal goes into the maxillary sinus) or into the oral cavity,
• radicular cyst (code K04.8). It can be lateral, near-apical, residual, root.

All other unspecified pathological processes in pariapic tissues are collected under the code K04.9.

In practice, it is often used classification of periodontitis according to Lukomsky. The system is very simple, but at the same time covers all possible forms of periodontitis:

• spicy;
• serous - at the same time, blood capillaries expand locally, blood cells accumulate, and the volume of intercellular fluid increases at the site of inflammation. Serous filling provokes periodontal edema;
• purulent - pus accumulates at the site of inflammation, swelling of nearby tissues and slight swelling are possible lymph nodes. Purulent contents can find a way out of the periodontium through the fistula;
• chronic;
• granulating - destruction of bone structures occurs with simultaneous rapid growth of connective tissue;
• granulomatous - the inflammatory focus is limited by the walls of the connective tissue capsule, which can transform into a cyst;
• fibrous - periodontal tissues expand, thicken, scar;
• chronic in the acute stage - chronic inflammation is activated under the influence of various factors - reduced immunity, trauma, allergic reactions.

Causes

The main reason for the development of periodontitis is neglected or improperly treated caries. At the same time, an infection penetrates through the carious cavity, first the pulp of the tooth is affected, its necrosis and destruction occurs. Further, the inflammation spreads to the ligamentous apparatus, periosteum and bone, forming serous and purulent sacs, fibrous capsules and cysts.

If, during filling, the dental canal was poorly cleaned, depulped or filled with filling material not up to the root apex, then after a while the patient will begin periodontitis, as a result of poor-quality treatment of pulpitis. The same consequences occur if the dental instrument and remains in the root of the tooth, or during treatment, due to the negligence of the dentist, perforation of the tooth root occurs (that is, the doctor breaks through the root wall through).

If the crown is put on a “live” tooth, during the turning of which a thermal burn of the pulp occurred, then such a medical error will first lead to the death of the pulp, and after a while to the development of periodontitis.

The cause of periodontitis can be a periodontal (dental) pocket. Infection from such a pocket penetrates to the tops of the roots and provokes the occurrence of the so-called marginal periodontitis.

A common cause of pathology are injuries: dislocation or fracture of the tooth, rupture of the neurovascular bundle from hard hit(the tooth crown turns pink), a fracture of the tooth root.

With illiterate prosthetics or overestimation of the height of the filling, congenital malocclusion, the tooth experiences loads that exceed the physiological norm. This leads to the development of chronic traumatic periodontitis.

In dentistry, potent antiseptics and medicinal pastes. IN rare cases they can cause an allergic reaction of the patient and provoke periodontitis.

body diseases such as diabetes, gastritis, ulcers, frequent bronchitis and pneumonia, sinusitis, chronic tonsillitis and others can cause various diseases oral cavity including periodontitis.

Symptoms - what to look out for

With the development of acute periodontitis, a general clinical picture is observed: there is a feeling of “protrusion” of the tooth, sharp pain is felt when biting, pressing or tapping, and local redness of the gums is possible. In complicated cases, there is an accumulation of pus, the appearance of fistulas, a very unpleasant putrefactive odor is felt from the mouth.

A distinctive feature of periodontitis is the fact that the patient clearly indicates which tooth hurts, while in other inflammations, such as pulpitis, the pain often radiates far beyond the diseased tooth.

In the case of an advanced disease, general intoxication may begin, the temperature rises, the patient complains of weakness, nausea and poor sleep.

Chronic periodontitis is usually asymptomatic. Especially if a person has good immunity, which restrains the spread of infection beyond the damaged tissues. Only with light tapping on the aching tooth and pressing on it, discomfort or mild pain is felt.

Diagnosis of the disease

The doctor can diagnose the presence of periodontitis by visual examination of the oral cavity and facial area taking into account the clinical picture, patient complaints. An instrumental examination is also carried out, percussion (tapping) of the tooth, probing of the dental canal, bite assessment.

But the surest way is. A clear blackout will be visible on it at the site of inflammation, and in addition, an x-ray will help to identify the cause of the development of the pathology, which is very important for successful therapy. For example, an x-ray image will clearly show a fragment of an instrument stuck in the root canal or an unfilled tooth root.

When making a diagnosis, it is important to differentiate periodontitis with such diseases:

• diffuse or gangrenous pulpitis,
• acute osteomyelitis,
• periradicular cyst,
• odontogenic sinusitis,
• purulent sinusitis.

Treatment Methods

Treating periodontitis is a must! Moreover, both in acute and in chronic form, the disease requires close attention. If you do not deal with this problem, then serious complications cannot be avoided - jaw periostitis (), osteomyelitis (purulent-necrotic process) of bone tissue, abscess, acute sinusitis, and even the development of sepsis in response to a local infectious process.

We must not forget that in the immediate vicinity of the oral cavity are the eyes, the human brain, where infection and pus can spread through the bloodstream. Therefore, you should immediately consult a dentist if symptoms of periodontitis appear.

Exists folk methods treatment of this pathology, but given the nature of the lesion, they can only act as an effective adjuvant to the main therapy.

First, the doctor will definitely open the tooth to provide good access to the inflamed periapical tissues that are behind the root of the tooth. Under anesthesia, mechanical cleaning of the canals, if necessary, change their length, treat them with an antiseptic, introduce the necessary antibacterial drugs(for example), which stop inflammation, stop further destruction of tissues and will contribute to their speedy recovery. Not the fact that a single injection of the drug will help. Periodontitis usually requires several treatment sessions. All this time, the tooth remains open or under a temporary filling.

After the pain subsides and the inflammation subsides, the doctor will place a permanent filling and take a control x-ray. The processes of tissue regeneration will be completed in about 6-10 months. Then we can assume that periodontitis is defeated.

In difficult cases, for example, with the development of a cyst, the formation of a fistula, more radical method treatment is surgery. Conservative treatment of a cyst - drainage of the cystic cavity, elimination of pathogenic microflora, destruction of the inner lining of the cyst - is a long process that does not always end in success.

Physiotherapeutic procedures, warm soda 15-minute baths up to 7-10 times a day are effective.

Modern dentistry is one of the most progressive areas of medicine, therefore, in 85% of cases, a complete cure of periodontitis is observed while maintaining the anatomical integrity and functions of the tooth.

Prevention

Since in most cases periodontitis develops against the background of caries or periodontal disease, the prevention of these diseases simultaneously prevents complications. The main ways to keep your teeth healthy:

• observe ,
• use toothpastes containing fluoride,
• eat well, observe the daily routine, maintain immunity at the proper level,
• in the presence of diseases of the gastrointestinal tract, endocrine, broncho-pulmonary and cardiovascular systems, pay special attention to dental health
• visit the dentist at least once every six months,
• periodically remove (it is formed differently for everyone, so the dentist will determine how often this procedure needs to be done for a particular person),
• do not chew hard objects with your teeth, do not open bottles,
• visit a dentist with a good reputation. Do not trust your health to non-professionals.

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For many years, periodontal inflammation has not disregarded researchers, during which time they have proposed a large number of different options for systematizing the disease. However, to date, they have not been able to develop and come to a unified classification of periodontitis that fully meets the requirements of clinicians, and thus allows to achieve the determination of the resistant status of this pathology within the clinical and morphological level.

The classification of periodontitis developed by the World Health Organization, which, of course, has many advantages, does not solve this problem. The difficulty of developing and implementing such a classification can be associated with the imperfection of diagnostic methods that are used in clinical settings, when there is no correlation between the clinical manifestations of the disease and the nature of morphological changes.

When considering the classifications that are used on different continents, one can notice their obvious differences and contradictions. For example, in Russia and almost the entire post-Soviet space, classification is still in progress, where the main emphasis is on serous, purulent, acute, chronic periodontitis. And also - on the form of an aggravated course of the disease. Plus on fibrous, granulating, granulomatous, etc.

In order to better understand the essence of the issue, you should get acquainted with the classification of periodontitis closer. The classification of periodontitis is carried out due to the formation (etiology), as well as characteristics and developed methods of WHO and individual authors. In our country, the classification according to Lukomsky, WHO is used.

Based on origin (etiology)

Infectious. It develops as a result of the activation of bacteria and the toxins they secrete that have penetrated the bone tissue, after which the development of inflammatory processes in the periodontium begins.

Traumatic. This type is the result of exposure to periodontal tissues of traumatic factors. Severe one-time injuries, for example, blows or bruises of the teeth, can serve as such factors. It is possible that the influence of long-term sluggish, low-intensity microtraumas, for example, protruding fillings, the presence of a “straight” bite, overload of the dentition, as well as the impact of bad habits.

medical. The formation of this type of periodontitis is such a factor as the penetration of a strong chemical, for example, arsenic paste.

Classification

There are many of them, but in our country these days they use the development of Lukomsky.

Acute periodontitis:

1. Serous;
2. Purulent.

Chronic periodontitis:

1. Fibrous;
2. Granulating;
3. Granulomatous.

In the late nineties, the World Health Organization proposed another variation of this classification:

• acute apical periodontitis;
• chronic apical periodontitis;
• periapical abscess with fistula;
• periapical abscess without fistula;
• radicular cyst;
• unspecified diseases of the dental pulp.

The acute form of this disease is distinguished by a sharp local pain, usually constant. First, it has not pronounced aching pains, localized in the corresponding area of ​​the damaged tooth. Later they become more intense, tearing and pulsating, irradiation occurs, which speaks of purulent inflammation. initial stage. The acute phase of the apical process lasts from two to fourteen days. Two stages are considered conditional:

1. It is characterized by periodontal intoxication at the beginning of the inflammatory process. Long, aching and incessant pains are noted. It is also characterized by increased sensitivity when healthy and diseased teeth come into contact. The tissues surrounding the tooth do not have any significant changes, vertical percussion gives a high sensitivity of the periodontium.
2. It is characterized by a pronounced exudative process, continuous pain. Bite and percussion are painful, pain occurs even with a slight touch of the tongue to the affected tooth. There is a symptom of growing teeth. It is characterized by irradiation of pain sensations. Inflammatory processes affect the fixation of diseased teeth, they become mobile. swell soft tissues, and there is a reaction of the lymph nodes. The patient experiences general weakness, headache, fever associated with toothache, up to 39 degrees and other ailments. X-ray changes in the periodontal not notes.

Spicy. According to the properties of the exudate, it is classified - acute serous, as well as purulent. But it is not always possible to distinguish between these characteristics, and the serous form passes into a purulent form within a short time, and is directly dependent on certain factors.

Chronic. It is subdivided based on the nature and extent of damage to periodontal tissue and bones.

Classify:

fibrous. It is difficult to diagnose this form, since patients do not have any pain. And also for the reason that according to clinical manifestations it happens that it does not differ from gangrenous pulpitis. A distinctive feature of this form of periodontitis is a change in the color of the teeth, crowns are intact, strong carious cavities, probing is not painfully noticeable. With percussion, there is no pain, as well as a response to temperature stimuli. The cavity often has necrosis of the pulp with an odor that is present in gangrene. As a rule, diagnosis is made on the basis of X-ray images, where a change in the periodontal gap can be clearly seen, represented by an extension extending to the top of the root, without accompanying alveolar resorption. This form may be a consequence of the outcome of acute inflammation. It can occur due to overload or when a significant part of the teeth is lost by the patient.

granulating. Quite often it manifests itself as weak pain sensations, as well as heaviness in the places of damage, bursting, awkwardness. The patient may experience pain when diseased teeth come into contact with healthy ones. Similar symptoms can occur from time to time and are often accompanied by a fistula with pus, as well as the ejection of granulation tissue. Such processes will soon take place. It is characterized by hyperemia of the gums near the affected tooth, which causes its deepening from the impact of the end of the instrument, and after exposure, the deepening disappears only after a while. The patient feels pain from touch. On percussion, an untreated tooth is sensitive and, at times, painful. Regional lymph nodes often enlarge and become painful. X-rays show areas of rarefaction of bone tissue in the region of the root apex.

granulomatous. This type of periodontitis in most cases proceeds without symptoms, sometimes the patient still cannot avoid an unpleasant feeling and mild pain when the jaws are closed. The anamnesis may also indicate past periodontal pathologies or pains that are associated with the onset of pulpitis. At the moment of localization of the granuloma in the region of the buccal root of the upper molar and premolar, which is characterized by protrusion of the bone, according to the parameters of the root apex.

It is perfectly acceptable:

• when a diseased tooth has no cavity affected by caries;
• crown color changed;
• there is a carious cavity and canals with decayed pulp;
• a filling can be inserted in the tooth, but of poor quality.

Percussion of the teeth often does not cause pain, palpation of the gums from the vestibular surface indicates painful swelling. X-ray examination shows clearly defined rarefaction of bone tissue of a roundish shape. Sometimes visible destruction of dental tissue in the area of ​​the tops and hypercementosis in the lateral parts of the roots. If the treatment is carried out correctly and on time, then a favorable outcome is possible: this form of periodontitis turns into fibrous. When such treatment is absent or incomplete filling of the root canals is carried out, a root cyst of the tooth is formed.

Chronic, having an exacerbation stage. By the nature of the course of the disease, it is similar to periodontitis in acute forms, but at the same time it has its own distinctive features, for example, the presence of a destructive change in bone tissue.

aggravated. According to the frequency of cases, the most exacerbation occurs in granulating and granulomatous periodontitis, less - fibrous. In view of the fact that destructive changes in the periodontium are a concomitant factor of exacerbation, the patient does not experience severe pain when he bites, the pain is much less than when acute purulent periodontitis occurs.

With regard to other symptoms (persistent pain, swelling, reactions and lymph nodes), they have the same sequence as is inherent in acute purulent periodontitis. There are deep carious cavities, and it does not matter whether the teeth have been treated or not, that is, they are filled or without a filling.

Probing does not cause pain, but there are sharp pains, especially when vertical percussion is performed. It is possible to change the color of the affected teeth, they become mobile. Examination reveals edema, hyperemia of the mucosa, often of the skin. It does not react to temperature stimuli, but the patient feels pain during palpation of the tissues in the area of ​​the tooth.

Chronic fibrous periodontitis in the stage of exacerbations is characterized by less clear boundaries on x-rays, new foci of rarefaction appear in osteoporosis. Granulomatous at this stage also loses its clear boundaries: the apical parts of the teeth have rarefaction of bone tissues and other pathologies. Exacerbated chronic granulating periodontitis is characterized by the severity of corroded contours of the focus.

Finally

The presence of a large number of different variations in the classifications of periodontitis, which allows us to conclude that each of them individually does not meet modern requirements and the advisability of adopting a single version. Still offered different variants classifications. The desire to make everything compact and uniform is understandable.

Why are classifications needed? Are they so important that it is impossible to do without them? The answer is very simple. To improve the quality of treatment. After all, all this, of course, affects the rapid and correct diagnosis of a disease with concomitant diseases. All this will eventually affect the adoption of a particular treatment method. So, it will improve the situation in the fight against similar diseases in the future.

Yet

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

Periodontal disease affects literally all age groups - from young to old. Percentages based on 100 visits 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 old - 45% (with the loss of 1-2 teeth).
• 25-35 years old - 42%.
• Persons over 65 years old - 75% (loss of 2 to 5 teeth).

If periodontitis is not treated, chronic foci of infection in the oral cavity lead to pathologies of the internal organs, among which endocarditis is the leader. All periodontal diseases in general, 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 diseases of the periapical tissues according to ICD-10. In addition, there is an internal classification, which was compiled by specialists from the Moscow Medical Dental Institute (MMSI), it is accepted in many medical institutions of the post-Soviet space.

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

	Name
	Diseases of the periapical tissues
	Acute apical periodontitis of pulp origin
	Acute apical periodontitis NOS
	Chronic apical periodontitis
	Apical granuloma
	Periapical abscess with fistula: Dental Dentoalveolar
	Fistula with communication with maxillary sinus
	Fistula with communication with the nasal cavity
	Fistula with communication with the oral cavity
	Fistula with communication with skin
	Periapical abscess, unspecified, with fistula
	Periapical abscess without fistula: dental abscess Dentoalveolar abscess Periodontal abscess of pulpal etiology Periapical abscess without fistula
	Root cyst (root cyst): Apical (periodontal) periapical
	Apical, lateral cyst
	Residual cyst
	Inflammatory paradental cyst
	Cyst root, unspecified
	Other unspecified disorders of periapical tissues

It should be recognized that there is still some confusion in the classification of periodontal diseases, this is due to the fact that in addition to the internal systematization of MMIS adopted by dental practitioners in the countries of the former CIS, in addition to ICD-10, there are also WHO classification recommendations. These documents that deserve respect and attention do not have big differences, however, the section "chronic periodontitis" can be interpreted variably. In Russia and Ukraine there is a clinically justified definition of "fibrous, granulating, granulomatous periodontitis", while in ICD-10 it is described as an apical granuloma, in addition to international classification diseases of the 10th revision, there is no nosological form of "chronic periodontitis in the acute stage", 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 justification. However, in the sense of documenting diseases of 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 the reception medicines.

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

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

• Intradental periodontitis.
• Extradental periodontitis.

1. Periodontitis caused by traumatic injury. Such an injury can be a blow, bruise, hit when chewing a solid element (pebble, bone). In addition to single injuries, there is also chronic traumatization provoked by incorrect dental treatment (incorrectly applied filling), as well as malocclusion, pressure on a number of teeth in the process professional activity(the mouthpiece of a wind instrument), bad habits (biting teeth with hard objects - nuts, the habit of gnawing pens, pencils). In chronic tissue damage, at first, forced adaptation to overload occurs, and repeated trauma gradually translates the compensation process into inflammation.
2. Periodontitis caused by a drug factor, as a rule, is the result of incorrect therapy in the management of pulpitis or the periodontium itself. Strong chemicals penetrate the tissues, provoking inflammation. It can be tricresolphor, arsenic, formalin, phenol, resorcinol, phosphate cement, paracin, 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 drug-induced periodontitis.

The most common causes of periodontitis can be associated with pathologies such 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 periodontium can also be due to non-compliance with the rules of oral hygiene, vitamin deficiency, and a lack of trace elements. It should be noted that there are somatic diseases that contribute to the development of periodontitis:

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

Summarizing, we can distinguish the 10 most common factors provoking periodontitis:

• Inflammatory process in the pulp, acute or chronic.
• Gangrenous lesions of the pulp.
• Overdose of medications in the treatment of pulpitis (treatment period or amount of the drug).
• Traumatic periodontal injury during pulp treatment or canal treatment. Chemical trauma during sterilization, sanitation of the canal.
• Traumatic periodontal damage during filling (pushing through the filling material).
• Residual pulpitis (root).
• Penetration of the infection located in the canal beyond the apex.
• An allergic reaction of periodontal tissues to medicines or decay products of microorganisms - causative agents of inflammation.
• Infection of the periodontium through the blood, lymph, less often by contact.
• Mechanical traumatization of the tooth - functional, therapeutic (orthodontic manipulations), malocclusion.

Pathogenesis of periodontitis

The pathogenetic mechanism of the development of periodontal tissue inflammation is due to the spread of infection and toxins. Inflammation can be localized only within the boundaries of the affected tooth, but it is also able to capture neighboring teeth, the soft tissues of the gums surrounding them, sometimes even tissues of the opposite jaw. The pathogenesis of periodontitis is also characterized by the development of phlegmon, periostitis with a running chronic process and its subsequent exacerbation. Acute periodontitis develops very quickly, inflammation proceeds according to the anaphylactic, hyperergic type with a sharp reactive response of the body, increased sensitivity to the slightest stimulus. If the immune system is weakened or the irritant is not too active (malovirulent bacteria), periodontitis becomes chronic, often asymptomatic. A permanent periapical focus of inflammation affects the body in a sensitizing way, which leads to chronic inflammatory processes in the digestive organs, heart (endocarditis), and kidneys.

The way infection enters the periodontium:

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

Statistics say that the most common is the descending route of infection with streptococci. The data for the last 10 years is 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

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

Periodontitis and pulpitis

Periodontitis is a consequence of pulpitis, therefore, pathogenetically, these two diseases of the dentition are related, 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, so we offer the following criteria for distinguishing, presented in this version:

Serous periodontitis, acute form	Acute pulpitis (localized)
Increasing pain symptom Pain is independent of stimuli Probing does not cause pain Mucous membrane changed	The pain is paroxysmal, spontaneous Probing causes pain Mucous without changes
Acute purulent process in the periodontium	Acute diffuse pulpitis
Constant pain, spontaneous pain The pain is clearly localized in the causative tooth Probing - no pain Mucous changed General deterioration X-ray shows changes in periodontal structure	The pain is paroxysmal Pain radiates into the canal trigeminal nerve Mucous without changes
Chronic periodontitis, fibrous form	Caries, the beginning of pulpitis
Changing the color of the tooth crown Probing - no pain No response to temperature	The color of the tooth crown is saved Probing is painful Pronounced temperature tests
Chronic granulating periodontitis	Gangrenous pulpitis (partial)
Transient spontaneous pain Probing - no pain Mucous changed General condition suffers	The pain is aggravated by hot, warm food, drink Probing causes pain Mucous without changes General condition within the normal range
Chronic granulomatous periodontitis	Simple pulpitis in chronic form
Pain is minor, tolerable Tooth discoloration Probing without pain No response to temperature stimuli	Pain with temperature irritation The color of the tooth crown is unchanged Probing is painful Elevated temperature tests

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

Periodontitis in children

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

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

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

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

Complications of periodontitis

Complications that provoke inflammation of the periapical tissues are conventionally divided into local and general.

Complications of periodontitis of a general nature:

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

Complications of periodontitis of a local nature:

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

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

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

Diagnosis of periodontitis

Diagnostic measures are not only important, they are, perhaps, the main criterion that determines 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 the apex and all periapical zones. In addition, diagnostics should reveal the root cause of inflammation, which is sometimes very difficult to do if the patient does not seek help in a timely manner. Acute conditions are easier to assess than to diagnose a running, chronic process.

In addition to the etiological reasons, assessment of the clinical manifestations of periodontitis, the following points are important in the diagnosis:

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

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

Diagnosis of periodontitis involves the determination and recording of such information according to the recommended examination protocol:

• Process stage.
• Process phase.
• Presence or absence of complications.
• Classification according to ICD-10.
• Criteria that help determine the state of the dentition - permanent or temporary teeth.
• channel patency.
• Localization of pain.
• condition of the lymph nodes.
• Tooth mobility.
• The degree of pain on percussion, palpation.
• Changes in the structure of the periapical tissue on x-ray.

It is also important to correctly assess the characteristics of the pain symptom, its duration, frequency, 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 inspection.
• Palpation.
• Percussion.
• External examination of the facial area.
• Instrumental examination of the oral cavity.
• Channel sounding.
• Thermodiagnostic test.
• Bite assessment.
• Beam imaging.
• Electrodontometric examination.
• Local radiograph.
• Orthopantomogram.
• Radiovision method.
• Evaluation of the index of oral hygiene.
• Determination of the periodontal index.

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 diagnosis helps to separate similar nosological forms and choose the right tactics and treatment strategy, this is especially important for the management of chronic processes.

1. Acute apical periodontitis is differentiated from diffuse pulpitis, gangrenous pulpitis, exacerbation of chronic periodontitis, acute osteomyelitis, periostitis.
2. The purulent form of periodontitis should be separated from periradicular cysts similar in symptoms. Periradical cysts are characterized by signs of bone resorption, which does not happen with inflammation of the periodontium. In addition, the periradicular cyst strongly bulges in the area of ​​the alveolar bone, provokes displacement of the teeth, which is not typical for periodontitis.

Treatment of periodontitis

Treatment of periodontitis is aimed at solving such problems:

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

What does 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, passage of the canal, often its unsealing.
• Channel length measurement.
• Mechanical and drug treatment of the canal.
• If necessary, remove the necrotic pulp.
• Placement of 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 whole process of treatment is accompanied by regular monitoring using X-rays, in the case when standard conservative methods do not lead to success, the treatment is carried out surgically up to amputation of the root and extraction of the tooth.

What criteria guides the doctor in choosing a method of treatment of periodontitis?

• Anatomical specificity of the tooth, the structure of the roots.
• Severe pathological conditions - tooth trauma, root fracture, and so on.
• The results of previous treatment (several years ago).
• The degree of accessibility or isolation of the tooth, its root, canal.
• The value of the tooth in terms of functional as well as aesthetic.
• Possibility or lack thereof in terms of tooth restoration (tooth crown).
• Condition of periodontal and periapical tissues.

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

1. Medical periodontitis is a conservative treatment, surgery is rarely used.
2. Traumatic periodontitis - conservative treatment, perhaps surgical intervention to excise bone particles from the gums.
3. Infectious purulent periodontitis. If the patient applied on time, the treatment is carried out conservatively, a running purulent process often requires surgical manipulations up to tooth extraction.
4. Fibrous periodontitis is treated with local preparations and physiotherapy, standard conservative treatment is ineffective and there are no indications for it. Rarely, surgery is used to excise rough fibrous formations on the gum

Ambiguous interpretations of the forms of periodontal inflammation and the main methods of treatment have given rise to many classifications proposed by the world's leading experts in this field of dentistry.

Periodontitis - inflammatory disease periodontal, i.e. connective tissues surrounding the root of the tooth.

It is necessary to classify periodontitis according to a number of features because, with different forms of the course of this disease, treatment tactics can have significant differences.

Origin Classification

Infectious

This form of periodontitis is the most common. The cause of its occurrence is the microflora, most often penetrating into the periodontium from root canal through the apex.

Other ways of infection are the marginal (marginal) periodontium (with deep periodontal and bone pockets) and the periodontium of the adjacent tooth (with the formation of a cyst of a significant size that has grown to involve the roots of neighboring teeth in the process).

Photo: Marginal and lateral periodontitis

The possibility of microflora entering the periodontal area with the blood flow is regarded by a number of doctors as unlikely and is usually allowed for periodontitis with an unexplained etiology (cause).

Traumatic

Occurs when the periodontium is exposed to a load that exceeds its physiological capabilities.

Such an overload can be acute and short-term (impact, bruise) or chronic (tooth overload with a protruding filling, non-removable or removable prosthesis, in case of malocclusion, with bad habits- hold the smoking pipe with the front teeth, etc.).

Periodontal injury depends not only on the intensity of the traumatic factor, but also on the state of the periodontium itself. If the periodontium is severely damaged or significantly lost, for example, due to periodontal disease, then even a normal, physiological load can become traumatic.

medical

Occurs when irritating effects on periodontal drugs. This may be the action of erroneously applied substances that are not intended for use in the oral cavity, or necessary preparations, but in violation of the required technology or recommended concentration.

Photo: Medicamentous (arsenic) periodontitis

Medicinal periodontitis can be caused by outdated methods of treatment (when treating canals according to Dubrovin with a solution of "aqua regia"), long-term application of arsenic pastes in the treatment of pulpitis.

If the technology of intracanal whitening is violated, undesirable complications in the form of periodontitis may also occur.

Traumatic and drug-induced periodontitis at first can behave as aseptic, but the easy accession of infection quickly translates these forms of inflammation into an infectious one.

Video: periodontitis

Classification of periodontitis according to ICD-10 (WHO)

The international organization approached the classification of periodontitis comprehensively. She proposed a classification that takes into account not only the acute or chronic course of the disease, but also the most common types of complications.

This approach to the examination and treatment of various forms of periodontitis helps to more fully influence all the mechanisms of the development of the pathological process, as well as to combine the actions of various specialists (for example, a dentist-therapist, a dentist-surgeon and an ENT).

In the ICD-10, periodontitis is designated in section K04 - diseases of the periapical tissues.

K04.4 Acute apical periodontitis of pulpal origin

Acute apical periodontitis is one of the classic variants, with a well-defined cause and clinical manifestations. The primary task of the doctor is to remove the severity of the process, as well as the source of infection.

K04.5 Chronic apical periodontitis

Apical granuloma - there is a long-standing focus of infection. With a large size of the granuloma, surgical methods of treatment should also be considered, for example, resection, truncation of the root tip.

K04.6 Periapical abscess with fistula:

• dental
• dentoalveolar,
• periodontal abscess of pulpal origin.

Fistulas are divided depending on what the message is with:

• K04.60 Having communication [fistula] with maxillary sinus.
• K04.61 Having a communication [fistula] with the nasal cavity.
• K04.62 Having communication [fistula] with the oral cavity.
• K04.63 Having communication [fistula] with skin.
• K04.69 Periapical abscess with fistula, unspecified

Photo: Fistula with communication with the oral cavity (left) and with the skin (right)

These diagnoses imply the possibility of close collaboration with ENT specialists. If there is a fistulous passage in the maxillary sinus, it will not do without sinusitis.

If the process is old, old, then it is quite possible that the fistula is also formed and after the elimination of the cause it will not resolve itself. Surgical excision should be considered.

K04.7 Periapical abscess without fistula

• dental abscess,
• Dentoalveolar abscess
• Periodontal abscess of pulpal origin,
• Periapical abscess without fistula.

K04.8 Root cyst

• K04.80 Apical and lateral.

Root cyst requires either long-term exposure or more drastic (surgical).

At conservative treatment the cystic cavity should be drained, as well as the microflora that supports the growth of the cyst should be eliminated. In addition, it is necessary to destroy the inner lining of the cyst, allowing the restoration of bone tissue.

According to Lukomsky

Classification according to Lukomsky is by far the most popular in practical dentistry. With a small volume, it covers and characterizes all clinically significant forms of periodontitis, in the diagnosis and treatment of which there may be fundamental differences.

Acute periodontitis

Acute periodontitis is divided into:

• serous. Complaints of discomfort or soreness, aggravated by tapping on the tooth. There may be a feeling of distension. The intensity of complaints is gradually increasing. On examination, a large filling or a significant defect in the crown of the tooth is revealed, the probing and thermal test of which are painless.
• purulent. Complaints of severe, tearing, throbbing pain, which increases significantly at the slightest touch to the tooth (when closing the mouth). Swelling of the adjacent soft tissues is possible, as well as an increase and soreness of the nearest lymph nodes. Often, acute purulent periodontitis is accompanied by general disorders of the body: weakness, fever, chills.

Chronic forms of periodontitis may be the result of acute, but may also occur as initially chronic. Complaints are usually not expressed or very insignificant, for example, in the form of mild pain when tapping on the tooth.

The tooth may have a large filling or be severely decayed, often discolored.

The main method for diagnosing chronic periodontitis is radiography, it is also a method differential diagnosis between individual forms chronic inflammation periodontal.

Granulating

Radiographically, it is manifested by an uneven expansion of the periodontal fissure in the region of the apical foramen. The expansion does not have clear contours, the dimensions range from 1–2 to 5–8 mm.

Granulomatous

In the picture it looks like a rounded focus of destruction of the bone structure with clear, contrasting edges.

It can be located both in the region of the root apex, in contact with it, and border a significant part of the lower third of the tooth root. With further progression of the process, it develops into a periradicular cyst.

Fibrous

It manifests itself in the form of a uniform expansion of the periodontium, either only in the region of the root apex, or throughout its entire length. In this case, often the bone wall of the tooth socket does not show signs of destruction.

If such a process is observed in a tooth previously subjected to endodontic treatment, if there are no complaints and the condition of the root filling is not satisfactory, then treatment is not required.

Chronic in the acute stage

Clinically manifested as acute periodontitis, but has radiological signs of chronic. Often accompanied by the appearance of swelling (periostitis) and / or the presence of fistulous passages with active purulent discharge.

Chronic periodontitis is a serious complication of untreated or untreated caries. It is a source of a very active microflora that can give both local complications (periostitis, osteomyelitis, abscesses and phlegmon of the maxillofacial region) and cause general harm to the body (sepsis).

Periodontal lesions are especially dangerous during pregnancy. Therefore, the task of each person is to prevent the appearance of any form of periodontitis and contact the dentist in a timely manner to provide qualified assistance.