Chronic Periodontitis is most prevalent form of periodontitis. Chronic periodontitis occurs as result of extension of inflammation from the gums into the deeper supporting tissues of teeth. Inflammation of supporting tissues of teeth occurs in chronic periodontitis and along with that, attachment loss and bone loss is present. It was earlier known as adult periodontitis or slowly progressive periodontitis. Although, it is frequently observed in adults but can also occur in children and adolescents in response to chronic plaque and calculus deposits. That is why name of adult periodontitis was changed to chronic periodontitis.
Causes of Chronic Periodontitis
1. Plaque and calculus deposits in relation to teeth are the main cause of chronic periodontitis. Poor oral hygiene, tooth malpositioning, faulty tooth restoration are some of the plaque retentive factors which further increase incidence of chronic periodontitis.
2. Systemic diseases like diabetes increases incidence of chronic periodontitis and influence the host response.
3. Behavioral habit like smoking when combined with plaque induces periodontitis. Smoking can cause greater attachment loss, bone loss, furcation involvement and deeper pockets.
4. Emotional stress may influence extent and severity of chronic periodontitis. A study was conducted on individuals with life events such as divorce and bereavement and it was found that stressful events led to greater prevalence of periodontal diseases. Effect of stress may be mediated by alterations in immune response and inflammatory processes. Stress may increase level of circulating corticosteroids and may have effect on periodontium.
5. Genetic basis for periodontitis is based on recent studies that have demonstrated periodontal destruction among the family members and different generations within a family.
Microbiology in Chronic Periodontitis
Various causative organisms of chronic periodontitis are: Porphyromonas gingivalis, Prevotella intermedia, Capnocytophaga, A. actinomycetem comitans, Eikenella corrodens, Campylobacter rectus.
Clinical Features of Chronic Periodontitis
Age of onset in case of chronic periodontitis is usually 30-35 years. No consistent pattern of distribution is seen in case of chronic periodontitis.
Symptoms of Chronic Periodontitis
Chronic periodontitis is usually painless. Pain if occurs is usually localized and is dull and sometimes it is radiating deep into jaws. Sensitivity to hot and cold food stuffs is present in case of root exposure which may be associated with chronic periodontitis.
Areas of food impaction can lead to patient discomfort.
Gingival itching and tenderness may occur in case of chronic periodontitis.
Signs of Chronic Periodontitis
In case of chronic periodontitis, supragingival and subgingival plaque and calculus deposits are present. Amount of microbial deposits are consistent with severity of disease.
Slight to moderate swelling of gums is present and color of gingiva may range from pale red to magenta. Loss of stippling, blunt or rolled gingival margins and flattened or cratered papillae may also be seen.
In case of chronic periodontitis, true pocket formation is seen. Pocket depths are variable and both suprabony and infrabony periodontal pockets may be found. Spontaneous bleeding and inflammation related exudate from periodontal pockets may also be found. Loss of periodontal attachment occurs in case of periodontitis.
Lone of alveolar bone may also occur in case of chronic periodontitis. Horizontal or vertical bone loss may be seen.
In chronic periodontitis, plaque retentive factors like open interdental contacts, defective restorations, malposed teeth may also be seen.
Tooth mobility occurs in advanced cases of chronic periodontitis. Pathologic migration, furcation involvement may also occur.
Prevalence of Chronic Periodontitis
Chronic periodontitis is age associated and not age related disease. It is not the age of person which increases the prevalence of chronic periodontitis but it is the length of time that the supporting tissues of teeth that are the periodontal tissues are challenged by chronic plaque accumulation. Chronic periodontitis affects both sexes equally.
X-ray features in Chronic Periodontitis
Horizontal or vertical bone loss occurs in case of chronic periodontitis. Horizontal bone loss is usually associated with suprabony periodontal pocket and vertical bone loss usually occurs with infrabony periodontal pocket. Horizontal bone loss is commonly seen in X-rays in chronic periodontitis.
Horizontal Bone loss
Stages of Chronic Periodontitis
According to severity of disease, periodontitis can be classified as mild, moderate or severe periodontitis. 1-2 millimeters of attachment loss occurs in case of mild or slight periodontitis and 3-4 millimeters of periodontal attachment loss occurs in moderate periodontitis. Condition is severe when periodontal attachment loss is 5milimeters or more than 5 millimeters. Excessive tooth mobility and more than 40% bone loss occurs in severe periodontitis.
When bone loss and periodontal attachment loss occurs in less than 30 percent of sites, then it is known as localized periodontitis and when attachment loss and bone loss occurs in more than 30percent of site, then it is known as generalized periodontitis.
Treatment of Chronic Periodontitis
In case of chronic periodontitis, removal of irritant is done by scaling and root planning (SCRP). Scaling is done to remove plaque and calculus deposits from teeth and to remove pathogenic bacteria present in relation to teeth. In root planning, root of the tooth is smoothened to avoid any tartar accumulation. Scaling can be done with sonic or ultrasonic instruments or can be done with hand instruments. Scaling and root planning will reduce the depth of periodontal pocket and will improve the clinical attachment. Scaling and root planning will disturb the biofilm layer which is present. Debridement of pocket depths is also done by this.
To reduce the bacterial content in oral cavity, antibiotics may be given to the patient. Systemic antibiotics like metronidazole or amoxicillin can be given to the patient. To reduce bacteria in mouth, mouth washes can also be given to patient.
Gingival contouring or gingivectomy procedure may also be required for periodontal pocket elimination. Gingivectomy refers to excision of soft tissue wall of periodontal pocket. Gingivectomy procedure can be performed by surgical procedure or by electrosurgery. Gingivectomy can also be done by chemosurgery or by use of lasers.
In severe cases of chronic periodontitis, flap surgery along with bone grafting can be tried. Patient’s tissues or synthetic material can be used as graft.
Lasers can also be used to treat chronic periodontitis. Diode lasers, Nd:YAG, Er:YAG, Cr:YSGG and CO2 lasers can be used. Lasers can be used for pocket decontamination process.
Local and systemic factors are corrected. If patient is a smoker, then he should stop smoking and if patient has high blood sugar levels, then they should be reduced.
Plaque retentive factors such as defective restorations or tooth malpositioning should be corrected.
Prognosis of Chronic Periodontitis
Prognosis of chronic periodontitis is good provided inflammation can be controlled through good oral hygiene and removal of plaque retentive factors.
In patients with severe disease as evidenced by furcation involvement and increased clinical mobility or in patients who are non-compliant with oral hygiene practices, prognosis may be fair or poor.
Prevention of Chronic Periodontitis
Best method to avoid development of chronic periodontitis is maintenance of good oral hygiene. Patient should brush and floss regularly to avoid any deposits around teeth and should get regular dental cleaning done from a dentist.
Cost of Treatment of Chronic Periodontitis
Dental scaling and root planning (SCRP) is done by quadrants and can cost $100-$400 per quadrant. Cost varies from place to place and dentist to dentist. If scaling and root planning is done by a periodontist who is a gum specialist, then cost of treatment is more. Dental insurances usually cover the cost of scaling and root planning. Cost of x-rays and debridement if done will be additional. Gingivectomy costs around $190-$300 per tooth and is $500-$850 per quadrant. Tissue grafts if done will cost around $500-$900 in one specific area.
Dental Scaling with Hand Instruments