Pathophysiology and Microbiology
- Chronic periodontitis is caused by the accumulation of dental plaque, leading to chronic inflammation of the periodontal tissues.
- The disease progresses from gingivitis to chronic periodontitis, and in some cases, aggressive periodontitis.
- Gram-negative tooth-associated microbial biofilms trigger a host response, resulting in bone and soft tissue destruction.
- Matrix metalloproteinases (MMPs), cathepsins, and other osteoclast-derived enzymes contribute to tissue destruction.
- The specific plaque hypothesis and the non-specific plaque hypothesis are two theories explaining the microbiology of periodontitis.
- The disease is associated with a variable microbial pattern.
- Anaerobic species such as Porphyromonas gingivalis, Bacteroides forsythus, and Treponema denticola are implicated in chronic periodontitis.
- Microaerophile bacteria like Actinomyces actinomycetemcomitans and Campylobacter rectus may also play a role.
Signs, Symptoms, and Diagnosis
- In the early stages, chronic periodontitis may have few symptoms, leading to delayed treatment.
- Symptoms can include redness or bleeding of gums, gum swelling, halitosis, gingival recession, and deep pockets between teeth and gums.
- Loose teeth and drifting of incisors can occur in later stages.
- Gingival inflammation and bone destruction are often painless.
- Subgingival and supragingival calculus are common findings.
- Chronic periodontitis is one of the seven destructive periodontal diseases in the 1999 classification.
- Diagnosis can be challenging due to the slow and painless progression of the disease.
- A full mouth examination is necessary, including measurements of pocket depth, clinical attachment loss, bleeding on probing, plaque index, and furcation involvement.
- Radiographs are needed to assess alveolar bone loss and differentiate it from gingival edema.
Risk Factors
- Smoking and inadequate oral hygiene are major risk factors for chronic periodontitis.
- Systemic diseases like diabetes mellitus and HIV infection can modify the disease.
- Other factors such as smoking, emotional stress, anxiety, and depression can also influence chronic periodontitis.
- Age is related to the incidence of periodontal destruction, with the highest rate occurring between 50 and 60 years.
Treatment
- Smoking cessation and good oral hygiene are key to effective treatment.
- Correct any modifiable plaque retentive factors, such as overhangs on restorations.
- Treatment can involve non-surgical and surgical therapies.
- Scaling and root planing (SRP) is the typical initial treatment.
- Subgingival debridement is effective in reducing pocket depth.
- Open flap debridement is used in deeper pocket areas and provides better visualization of the root surface.
- Guided tissue regeneration using PTFE membranes is favored by some practitioners and has a greater effect on probing measures than open flap debridement.
- Enamel matrix derivative is favored by some practitioners and significantly improves attachment levels and pocket depth reduction.
- Adjunctive systemic antibiotic treatment may be used in addition to debridement-based treatments and offers additional benefits.
- Locally delivered adjunctive antimicrobial treatment using chemical antimicrobials can reduce bacterial load in the pocket.
Systemic Factors and Other Conditions
- Chronic periodontitis is an inflammatory immune response against bacteria.
- Epithelial lining ulceration in pockets may be due to systemic bacterial dissemination.
- Diabetes mellitus and cardiovascular disease are associated with chronic periodontitis.
- Chronic periodontitis is linked to head and neck squamous cell carcinoma.
- There is little evidence linking progression of periodontal disease to low birth weight or preterm birth.
- Regular scale and polish treatment does not make a difference to gingivitis, probing depths, or other oral health-related problems in adults without severe periodontitis.
- There is no consistent evidence supporting the efficacy of laser treatment as an adjunct to non-surgical periodontal treatment in adults with chronic periodontitis.
- Costs for tooth retention through supportive periodontal therapy are relatively low compared to alternatives like implants or bridgework.
Chronic periodontitis is one of the seven categories of periodontitis as defined by the American Academy of Periodontology 1999 classification system. Chronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation of the periodontal tissues that is caused by the accumulation of profuse amounts of dental plaque. Periodontitis initially begins as gingivitis and can progress onto chronic and subsequent aggressive periodontitis according to the 1999 classification.
Diagnosing chronic periodontitis is important in its early stages to prevent severe and irreversible damage to the protective and supportive structures of the tooth. However, due to chronic periodontitis being a painless progressing disease, few patients will seek dental care in the early stages. Mild to moderate chronic periodontitis can be managed by proper mechanical removal of the biofilm and calculus subgingivally. Full and effective oral hygiene and regular 3 monthly periodontal checkups are important for maintaining the stability of the disease.
Chronic periodontitis is prevalent in adults and seniors worldwide. In the US around 35% of adults (30–90 years) are affected. The cumulative effects of alveolar bone loss, attachment loss and pocket formation is more apparent with an increase in age. Age is related to the incidence of periodontal destruction: "...in a well-maintained population who practises oral home care and has regular check-ups, the incidence of incipient periodontal destruction increases with age, the highest rate occurs between 50 and 60 years, and gingival recession is the predominant lesion before 40 years, while periodontal pocketing is the principal mode of destruction between 50 and 60 years of age."
There are a variety of periodontal risk factors which can affect the prevalence, rate, extent and severity of the disease progression. Major risk factors include smoking, lack of oral hygiene with inadequate plaque biofilm control.
There is a slow to moderate rate of disease progression but the patient may have periods of rapid progression ("bursts of destruction"). Chronic periodontitis can be associated with local predisposing factors (e.g. tooth-related or iatrogenic factors). The disease may be modified by and be associated with systemic diseases (e.g. diabetes mellitus, HIV infection) It can also be modified by factors other than systemic disease such as smoking and emotional stress, anxiety and depression. Care should be taken however, when diagnosing a patient who smokes as smoking can alter some of the results of an examination. In smokers, the gingiva are pale and fibrous and tend to bleed less while being probed due to the effect of nicotine on the vasculature by vasoconstricting them. Thus, a lowered response is produced and this explains why incorrect data can be gained. There is also an increase in supragingival calculus alongside visible nicotine staining. The anterior dentition occasionally have recession and maxillary anterior and palatal surfaces are more adversely affected.
