Periodontitis: Symptoms and Treatment

Definition and Causes

Periodontitis is an inflammatory condition caused by bacteria, trauma, or medication, resulting in inflammation of the connective tissue (periodontium) located between the tooth cementum and the alveolar bone.

In the general structure of dental diseases, periodontitis occurs in all age groups of patients and accounts for 25–30% of total visits to dental facilities.

Depending on the causes, three types of periodontitis are distinguished:

  1. Traumatic Periodontitis: Can develop from a single severe mechanical impact (bruising, blow, bone penetration) or from repeated minor mechanical damage (e.g., constant biting of sewing threads).
  2. Medicamentous Periodontitis: Arises from the release of potent drugs from the root canal into the periodontal tissues (e.g., when medication is left in the tooth, and the next appointment occurs later than indicated by the safe period of drug presence in the canal).
  3. Infectious Periodontitis: Its onset is triggered by bacteria, mainly streptococci, among which non-hemolytic streptococcus accounts for 62%, viridans – 26%, and hemolytic – 12%. Additionally, the most common coccal flora is complemented by veillonellae, lactobacilli, and yeast-like fungi.

Pathways of periodontal tissue infection:

  • Intra-tooth: Toxins and bacteria exit through the root canal system after infecting the pulp and its necrosis into the periodontal tissues.
  • Extra-tooth: Inflammation spreads from surrounding tissues (osteomyelitis, osteitis, sinusitis, periodontitis, etc.).

Infection of periodontal tissues via hematogenous (through blood) and lymphogenous routes is extremely rare.

Symptoms of Periodontitis

The manifestations of the disease depend directly on its form.

Chronic forms of periodontitis mostly progress asymptomatically and are detected during radiographic examination or during exacerbations.

Signs of acute periodontitis and exacerbation of its chronic form include:

  • Toothache (often it is possible to accurately specify which tooth is hurting) — initially, the pain is mild and dull, but later it becomes more intense, throbbing, and pulsating.
  • Pain when chewing and touching the tooth.
  • Sensation of “elongated tooth” — feeling that the tooth has become longer than others and contacts first with antagonistic teeth.
  • Presence of a large carious cavity in the affected tooth or its previous treatment for deep caries or pulpitis.
  • Sometimes swelling of the soft tissues in the area of the affected tooth occurs — associated with the release of inflammatory exudate (fluid) from the focus located in the periodontium into the subperiosteal space or soft tissues.
  • Opening of a fistula tract, often located on the gum in the projection of the root of the affected tooth (may occur during exacerbation of chronic periodontitis).
  • Lack of reaction of the affected tooth to cold, hot, sweet, or sour stimuli.
  • Possible tooth mobility associated with infiltration of the periodontium.
Opening of the fistula tract

Chronic Periodontitis

The prolonged presence of microbial irritants leads to a shift towards macrophages, lymphocytes (T-cells), and plasma cells, which become encapsulated in the collagenous connective tissue.

Proinflammatory cytokines (immune system cells) act as potent stimulators of lymphocytes. Activated T-cells produce numerous cytokines that reduce the production of proinflammatory cytokines, leading to the suppression of bone destruction processes. Conversely, cytokines derived from T-cells can simultaneously enhance the production of connective tissue growth factors, stimulating and proliferating the effects on fibroblasts and the microcirculatory bed.

The ability to suppress the destructive process explains the absence or delayed resorption of bone and the restoration of collagenous connective tissue during the chronic phase of the disease. Consequently, chronic lesions can remain asymptomatic for a long time without significant changes on X-rays.

The equilibrium existing in the periodontium can be disrupted by one or more factors, such as microorganisms “lodged” inside the root canal. They progress into the periodontium, and the lesion spontaneously becomes acute with the recurrence of symptoms.

As a result, during these acute episodes, microorganisms can be detected in the bone tissue surrounding the periodontium, with a rapid increase in radiographic manifestations. This radiographic picture is due to the destruction of the apical bone, which occurs rapidly during acute phases and is relatively inactive during the chronic period. Therefore, disease progression is not continuous but occurs intermittently after periods of “stability.”

Cytological studies show that about 45% of all chronic periodontitis cases are epithelialized. When epithelial cells begin to proliferate, they may do so in all directions randomly, forming irregular epithelial masses into which vascular and infiltrated connective tissue penetrate. In some lesions, the epithelium may grow into the entrance of the root canal, forming a plug-like thickening at the apical opening.

Classification and Stages of Periodontitis

The classification of periodontitis mainly reflects the cause of inflammation and what exactly is happening in the periodontal tissues. The most common classification used in practice is I.G. Lukomsky’s classification:

  • Acute apical periodontitis:
  • Serous;
  • Purulent.
  • Chronic apical periodontitis:
  • Fibrous;
  • Granulomatous;
  • Granulomatous.
  • Exacerbation of chronic periodontitis.

Also, in diagnosis, the International Classification of Diseases 10th revision (ICD-10) classification is used:

  • K04.4 Acute apical periodontitis of pulpal origin:
  • Acute apical periodontitis of pulpal origin.
  • K04.5 Chronic apical periodontitis:
  • Apical or periapical granuloma;
  • Chronic apical periodontitis of pulpal origin.
  • K04.6 Periapical abscess with sinus:
  • Dental abscess with sinus;
  • Dentioalveolar abscess with sinus.
  • K04.7 Periapical abscess without sinus:
  • Dental abscess without sinus;
  • Dentioalveolar abscess without sinus;
  • Periapical abscess without sinus.
  • K04.8 Radicular cyst:
  • Apical (periodontal) cyst;
  • Periapical cyst;
  • Residual radicular cyst.

Complications of Periodontitis

Complications of periodontitis depend on the causative tooth, localization of the inflammatory focus, form, and stage of the disease. Conditionally, all complications can be divided into several groups:

Complications caused by the spread of infection from the periodontal focus:

  • Odontogenic periostitis — spreading of the inflammatory process to the periosteum of the alveolar process and jaw body from the periodontal (odontogenic) focus.
  • Odontogenic abscess — formation of a localized cavity of purulent inflammation resulting from the purulent melting of submucosal, subcutaneous, intermuscular, interfascial, lymph node, muscle tissue, or bone. Abscess formation predominantly occurs in the peri-alveolar soft tissues.
  • Odontogenic phlegmon — formation of diffuse purulent inflammation of the connective tissue located under the skin, mucous membrane, between muscles and fascia.
  • Odontogenic sinusitis — formation of inflammation in the maxillary sinus caused by the spread of infection from the periodontal (odontogenic) focus.
  • Odontogenic lymphadenitis — formation of inflammation in regional lymph nodes caused by the spread of infection from the periodontal (odontogenic) focus.
  • Odontogenic osteomyelitis — purulent inflammation of the jawbone (simultaneously affecting all its structural components) with the development of areas of osteonecrosis.

Complication caused by destructive changes in the periradicular bone:

  • Secondary adentia — loss of one or more teeth caused by the destruction of the bone tissue surrounding the tooth root, preventing further functioning of such a tooth.

Complication caused by the formation of a fistulous tract:

  • Cutaneous fistulas — formation of a fistulous tract opening onto the skin surface.

Diagnosis of Periodontitis

The diagnosis of periodontitis is based on the patient’s complaints, medical history, general health assessment, examination of the head, neck, and oral cavity, probing, thermal testing, electric pulp testing, and radiographic examination.

Electroodontodiagnosis

Electric pulp testing (EPT) is a dental examination method based on determining the threshold of excitation of pain and tactile receptors of the tooth pulp when passing through it an electric current.

Diagnostic Signs of Acute Periodontitis:

  • Medical history: tooth pain, previous treatment, or tooth trauma, presence of periodontal diseases.
  • General condition: rarely signs of general intoxication (fever, weakness, loss of appetite, etc.).
  • Head and neck examination: no facial or neck asymmetry, normal skin color, possible enlargement of local lymph nodes.
  • Oral cavity examination: no pathological changes, possible presence of deep periodontal pockets.
  • Tooth examination: presence of a deep carious cavity, extensive filling, or prosthetic construction, sometimes a change in tooth color towards a gray shade. Tooth mobility may occur.
  • Probing and thermal testing: painless, sometimes a painless communication point with the tooth cavity is determined during probing of the carious cavity.
  • Percussion (tapping on the tooth in different directions): sharp painful sensations.
  • Electric pulp testing: 45-80 µA.
  • Radiography: visualized deep carious cavity, connecting with the tooth cavity, extensive filling, prosthetic construction, signs of previously performed endodontic treatment, or presence of a periodontal pocket. Depending on the form of acute periodontitis, the radiographic picture may differ:
  1. Fibrous periodontitis – expansion of the periodontal gap.
  2. Granulomatous periodontitis – destruction of bone tissue in the area of the root apex with clear contours.
  3. Granulating periodontitis – destruction of bone tissue in the area of the root apex with unclear contours.

Diagnostic Signs of Chronic Periodontitis:

  • Complaints: absent, possible presence of a fistulous tract on the skin or mucous membrane in the oral cavity (characteristic only for granulating periodontitis).
  • Medical history: tooth pain, previous treatment, or tooth trauma, presence of periodontal diseases.
  • General condition: unaffected.
  • Head and neck examination: no facial or neck asymmetry, normal skin color, possible presence of cutaneous fistulous tracts.
  • Oral cavity examination: no pathological changes, possible presence of a deep periodontal pocket or fistulous tract in the oral mucosa.
  • Tooth examination: presence of a deep carious cavity, extensive filling, or prosthetic construction, sometimes a change in tooth color towards a gray shade. The tooth may be mobile.
  • Probing and thermal testing: painless, sometimes a painless communication point with the tooth cavity is determined during probing of the carious cavity.
  • Percussion: painless.
  • Electric pulp testing: 45-80 µA.
  • Radiography: Deep carious cavity, connecting with the tooth cavity, extensive filling, prosthetic construction, signs of previously performed endodontic treatment, or presence of a periodontal pocket. Depending on the form of chronic periodontitis, the radiographic picture may differ:
  1. Fibrous periodontitis – expansion of the periodontal gap.
  2. Granulomatous periodontitis – destruction of bone tissue in the area of the root apex with clear contours.
  3. Granulating periodontitis – destruction of bone tissue in the area of the root apex with unclear contours.

Diagnostic Signs of Exacerbation of Chronic Periodontitis:
The clinical picture mostly corresponds to acute periodontitis, except that changes in periodontal tissues characteristic of a specific form of periodontitis are always detected radiographically.

Treatment of Periodontitis

The treatment of periodontitis aims to eliminate the causes, mechanisms, and symptoms of the disease. Treatment methods include therapeutic, surgical, and combined approaches.

Therapeutic Treatment

This method of treatment focuses on eliminating the pathogenic microflora present in the endodontium – the complex of affected tissues, including the pulp and dentin, which are morphologically and functionally connected. Therefore, this treatment is also known as endodontic treatment.

Stages of endodontic treatment include:

  • Adequate pain relief
  • Isolation of the tooth or teeth in which manipulations will be performed from the oral cavity
  • Creation of endodontic access (removal of hard tissues of the tooth or filling material obstructing access to the root canal system)
  • Measurement and determination of the length of the root canal (the distance from the canal orifice to the apex of the root)
  • Creation of the root canal with a specific diameter and shape
  • Introduction of medicinal preparations into the root canal
  • Root canal filling
  • Restoration of the anatomy and function of the tooth using filling material or orthopedic construction.
Stages of endodontic treatment

Surgical Treatment

Surgical methods of treatment are employed only when therapeutic treatment is ineffective or not feasible.

Surgical treatment methods include:

  • Root canal resection: This procedure allows for the preservation of the tooth, even if there is a cyst present at the root apex.
  • Complete root removal.
  • Complete tooth extraction, followed by replacement of the lost tooth.
Sources
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  4. Maksimovsky Yu.M., Maksimovskaya L.N., Orekhova L.Yu. Therapeutic Dentistry. Moscow: Meditsina, 2002. 640 p.
  5. Ovrutsky G.D. Chronic Odontogenic Focus. Moscow: Meditsina, 1993. 144 p.