Chronic granulating periodontitis (periodontal gap). Symptomatology, diagnosis and course of periodontitis

The periodontal gap widens as it approaches the apical part of the root and then disappears completely. The cortical plate is visible to the point where the widening of the periodontal fissure begins. In a pathomorphological study of chronic granulating periodontitis, granulation tissue develops around the root apex. It is characterized by a large number of cellular elements, among which, in addition to young fibroblasts, there are a large number of plasma cells.

Smooth resorption of the bone beams is observed in the surrounding bone tissue. The bone marrow spaces in this area are significantly expanded. Collagen fibers in the affected area are completely absent. When impregnated with silver, a rather dense network of argyrophilic fibers is revealed. They differ from the usual pre-collagen fibers found in granulation tissue by being thicker and having a peculiar looped arrangement (in this respect they resemble reticulin fibers). Stepping back from the root apex by 3-4 mm towards the lateral areas, the usual periodontal structure is found (S. P. Repnikova).

B.I. Migunov observed, in addition to smooth, osteoclastic resorption of bone tissue of the socket and cement. According to A.V. Rusakov, bone tissue is built simultaneously with resorption. Chronic granulating periodontitis must be differentiated from medium and deep caries, chronic fibrous and gangrenous pulpitis, radiologically - from other forms of chronic periodontitis and from the zone of physiological resorption.

In the differential diagnosis of chronic granulating periodontitis with chronic gangrenous pulpitis, when the roots are curved or the canals are poorly passable, the electroodontodiagnostic method can be used in older children.

L. R. Rubin, Z. A. Bugaeva, I. N. Reinvold using this method not only judge the complete death of the pulp, but also determine whether there are pathological changes at the apex of the tooth root. They believe that with complete death of the root pulp, but in the absence of radiologically pronounced changes in the periodontium, electrical stimulation from the mouths of the canals causes a sensation of a slight push or blow, appearing with a current strength of 100 to 200 microns.

With a pathological process in the periapical tissues, confirmed by x-ray, periodontitis responds to a stronger current (over 300 microns).

“Childhood Dentistry”, A.A. Kolesov

When choosing a method of treating this disease in the area of ​​both primary and permanent molars, one must remember that each of its roots may have a different nature of the inflammatory process. It is necessary to take into account the varying degrees of formation, and in baby teeth, in addition, the stage of root resorption. In this regard, the tooth has unequal length and patency of the milk canals...

Treatment of chronic periodontitis in teeth with immature roots is associated with a number of difficulties due to the anatomical structure of such teeth. When choosing a treatment method, it must be taken into account that with a wide apical foramen, the pulp extractor and expanding instruments freely penetrate the periapical tissues and can easily injure the periodontium. In addition, there is a possibility of decomposition products being pushed beyond the apical opening, especially with careless...

Good results are observed when filling the canal of an immature tooth with eigenol, eigenol-thymol or resorcinol-formalin pastes, as well as cebanite and guaiacrylic cement. To fill such a wide canal more quickly and achieve good obturation, it is better to use canal fillers. It is recommended to fill a wide canal with paste, because if there is an error in filling the canal, this deficiency is easier to correct. It must be borne in mind that eigenol paste...

periodontitis Checking the long-term results of treatment of chronic periodontitis of single-rooted permanent teeth with a formed root showed that the overwhelming number of patients experienced bone tissue regeneration in all forms of chronic periodontitis. a - radicular cyst, b - 2 years after treatment, restoration of bone tissue is observed at the site of the former cyst. The intensity of bone tissue restoration in the peri-apical area...

Chronic periodontitis of milk and permanent teeth, when the body's defenses are weakened, can be accompanied by an exacerbation of the inflammatory process, resulting in periostitis, osteomyelitis or phlegmon. The clinical picture of chronic periodontitis in the acute stage completely repeats the clinical picture of acute periodontitis, but the disease in children is more violent than in adults. K. Anastasov explains this by the insufficiently developed neuroreflex mechanisms of children...

Periodontitis develops when the inflammatory process is localized in periodontal tissues.
There are apical periodontitis, in which inflammation is localized in the area of ​​the apex of the tooth root; marginal - in case of damage to periodontal tissue along the root of the tooth and diffuse, in case of damage to the entire ligamentous apparatus.

Etiology of periodontitis

Highlight: infectious, traumatic and drug-induced periodontitis.
Infectious periodontitis develops as a result of the introduction into periodontal tissue of microorganisms that saprophyte in the oral cavity. As a rule, infection penetrates through the root canal from the carious cavity beyond the apical foramen as a result of necrosis of the dental pulp in complicated forms of caries and pulpitis. With marginal periodontitis, the infection penetrates through the gingival margin into the area of ​​the circular ligament of the tooth, affecting the latter and the subsequent development of necrosis.
Traumatic periodontitis develops with acute or chronic tooth trauma (impact, dislocation, overbite with a filling or artificial crown). Trauma to the apical periodontium occurs when the root canal is treated with an endodontic instrument and excessive removal of the filling material beyond the root apex during filling.

Medicinal periodontitis develops when aggressive medicinal substances used in dental treatment, such as arsenic paste, resorcinol-formalin liquid, penetrate into the periodontium, or an overdose of more modern, incorrectly selected filling materials that have a toxic effect on the periodontium.
Allergic periodontitis - a special case of medication, resulting from sensitization of periodontal tissues to the administration of medicinal substances.

Classification of periodontitis

Today, the classification according to I.G. is considered the most optimal. Lukomsky, proposed by the author in 1955. Based on the clinical and pathomorphological picture, periodontitis is divided into the following types.

I. Acute:
. serous (limited and diffuse); . purulent (limited and diffuse).
II. Chronic:
- granulating;
- granulomatous;
- fibrous.
III. Chronic in the acute stage.

Acute periodontitis

The development of the inflammatory process in acute periodontitis is due to its localization in a limited area of ​​tissue and pronounced protective reactions surrounding this area. The increase in inflammatory phenomena is accompanied by exudation, first in the serous phase, then purulent, with the formation of microabscesses, which, merging, form a purulent focus.

Clinical picture
Acute periodontitis is characterized by moderate pain in the area of ​​the affected tooth. Pain, periodic or constant, occurs for no apparent reason or after eating hot food. The pain lasts several hours with more or less long “light” intervals, increases and disappears gradually. Patients note increased pain when biting on a tooth, a feeling of “an overgrown tooth,” at night, when the body is in a horizontal position. This is facilitated by both the predominance of the influence of the parasympathetic nervous system during sleep and the redistribution of blood in a horizontal position of the body: its increased flow to the inflammatory focus, increased pressure, increased swelling. Therefore, patients often have disturbed sleep, they limit their food intake due to pain when eating, and they feel weak and tired. However, these symptoms are not associated with intoxication, which is absent in acute periodontitis.
Upon external examination, no changes are noted. There is often no clinically detectable enlargement and tenderness of the lymph nodes in the early stages of the disease.
In the oral cavity, the causative tooth can be mobile no more than grade I, if periodontitis is not observed in this area. There is a cavity in the crown of the tooth, but there may also be a recently placed filling. If periodontitis develops as a result of acute trauma, the crown of the tooth may be intact. Probing a carious cavity is painless, however, when pressing on a tooth with a probe, pain may occur as a result of increased mechanical pressure on the periapical inflammatory focus. Therefore, probing must be carried out with a sharp probe and without significant pressure. The color of the tooth crown is usually not changed; percussion causes sharp pain, and with periapical periodontitis, vertical percussion is more painful than horizontal. In the area of ​​the mucous membrane of the gums and the transitional fold of the vestibule of the mouth, slight swelling can be detected; palpation in this area is painless or slightly painful.
As the inflammatory process enters the purulent stage, the severity of clinical symptoms increases. Patients complain of constant, severe aching pain in the area of ​​the causative tooth and the inability to chew. Often, patients cannot close their jaws due to pain when biting on a tooth and come to the appointment with their mouths slightly open. Body temperature may rise to subfebrile levels. Patients look tired and complain of weakness due to lack of sleep, inability to eat and stress. Upon examination, in some cases, slight swelling of the soft tissues can be determined according to the location of the diseased tooth. One or more lymph nodes become enlarged and painful. Percussion of the tooth causes sharp pain. The mucous membrane of the gums and the transitional fold of the vestibule of the mouth is swollen, hyperemic in the tooth area, the periosteum is thickened due to developed infiltration. Palpation in this area is painful. Tooth mobility can increase to degree II.
On an x-ray, pathological changes in bone tissue in the area of ​​\u200b\u200bthe inflammatory focus are not determined; expansion of the periodontal gap due to edema may be observed.
The results of electroodontodiagnosis show the death of the pulp.
The picture of peripheral blood does not change significantly; in some cases, a slight increase in the number of leukocytes (up to 10-11 thousand in 1 μl) and ESR is noted.
Differential diagnosis

Acute periodontitis should be differentiated from the following conditions .

Acute diffuse or exacerbation of chronic pulpitis, especially in cases where, with pulpitis, inflammatory phenomena spread beyond the pulp of the tooth, to the periodontium, and pain occurs when the tooth is percussed. Diagnosis is helped by the paroxysmal nature of pain during pulpitis, and the occurrence of pain is provoked by chemical and thermal irritants. With periodontitis, pain is often spontaneous and constant. Probing the bottom of a carious cavity in case of pulpitis causes an attack of pain, but in case of periodontitis it is painless. With pulpitis, there are no inflammatory phenomena in the periosteum and soft tissues. The results of electroodontodiagnostics reveal the non-viability of the pulp in periodontitis, while in pulpitis the threshold of its sensitivity is reduced to varying degrees.
- Acute purulent periostitis, in which inflammation develops in the periosteum and soft tissues. In this case, patients have pronounced collateral edema, the periosteum is infiltrated, an abscess is formed in it, which is determined by the presence of severe pain and the symptom of fluctuation. Spontaneous pain in the tooth, as well as pain when biting and percussion, is significantly reduced or disappears. Mild or moderate symptoms of intoxication are noted, which is confirmed by temperature reaction and clinical blood test data.
- Acute odontogenic osteomyelitis, in which intoxication is severe, accompanied by severe hyperthermia, chills, and impaired autonomic functions. The inflammatory infiltrate is localized on both the vestibular and lingual (palatal) sides. There is mobility of several teeth. The pain of the causative tooth is less than that of neighboring teeth.
- Inflammation or suppuration of a radicular or follicular cyst. In the presence of such a cyst, displacement and mobility of a group of teeth and bulging of the jaw area are possible. When bone tissue becomes thinner or destroyed, the flexibility of the bone wall or a defect in it is determined. When removing necrotic decay from the tooth root canal and after expanding the apical foramen, cystic contents (or pus) can be obtained in sufficient quantities if the cyst is located in the upper jaw. Making a diagnosis is not difficult after performing an x-ray.
- Acute or exacerbation of chronic sinusitis, in which diffuse pain is noted with irradiation in the upper jaw. With sinusitis, one-sided congestion and discharge from the corresponding half of the nose of a serous or purulent nature are noted. An x-ray of the paranasal sinuses reveals diffuse darkening of the maxillary sinus.

Treatment of acute periodontitis

In cases where it is advisable to preserve the causative tooth (the crown of the tooth is intact, the root canal is passable, conditions for endodontic treatment are favorable), measures are taken aimed at opening and emptying the purulent focus and creating conditions for the constant outflow of exudate. Treatment is carried out under a wire or.
Teeth that have mobility of III-IV degrees, significant destruction of the coronal part, when it is not possible to ensure a full opening of the root canal by endodontic means when it is narrowed and curvature, obturation of the lumen by a denticle or a foreign body, are subject to removal. The tooth must also be removed if the treatment is ineffective.
After tooth extraction for acute periodontitis, it is not recommended to curettage the hole, as this contributes to the destruction of the “demarcation zone” and the spread of infection into the bone. In order to prevent the development of the inflammatory process, it is recommended to wash the hole with antiseptic solutions and carry out 2-3 novocaine blockades using the type of conduction anesthesia with a 0.5% solution of novocaine* in an amount of 5-7 ml. Warm oral baths with antiseptics or herbal decoctions are prescribed locally. It is advisable to prescribe physiotherapy: UHF, GNL and aerotherapy.
General treatment should be comprehensive. Analgesics should be prescribed to relieve pain; non-steroidal anti-inflammatory drugs; hyposensitizing drugs; vasoactive agents; vitamin therapy and immunostimulants.
Acute periodontitis usually occurs with an inflammatory reaction of the normergic type, so antibiotics and sulfonamides are not prescribed. In weakened patients with a sluggish inflammatory reaction or with a complicated course of the disease accompanied by intoxication, it is recommended to use antibiotic therapy in order to prevent the spread of inflammation to surrounding tissues. The outcome of the disease is favorable. Adequate treatment leads to recovery. After improper treatment, the process enters the chronic stage.

Chronic periodontitis

This is a chronic infectious and inflammatory periodontal disease. The disease can develop without a clinically pronounced acute stage, or be the outcome of the acute stage (when treatment was not carried out or it was inadequate).
With the development of chronic periodontitis, the constant and long-term entry into periodontal tissue of microorganisms from the oral cavity is important, which, by releasing exo- and endotoxins, cause tissue sensitization. The development of the chronic inflammatory process occurs according to the hypoergic type. In the chronic stage, proliferative processes are perverted, since the development of granulation tissue (with the participation of macrophages and histiocytes) due to the osteoclasts contained in it leads to lacunar (axillary) osteoclastic resorption of bone tissue. The degree of intensity of the ongoing processes of destruction and regeneration, with a variable predominance of one over the other, the level of immunity, the characteristics of nonspecific reactions, the degree of virulence of the microflora influence the formation of fibrous, granulating or granulomatous periodontitis.

The most favorable outcome of an acute process, independent or after conservative treatment. It is characterized by the fact that granulation tissue is replaced by coarse fibrous fibrous tissue with frequent osteosclerosis along the periphery (Fig. 8-2, 8-3). Morphologically, the periodontium is thickened, dense, and there is an overgrowth of fibrous tissue. With fibrous periodontitis, there is increased (excessive) formation of cement at the root of the tooth, which can cause hypercementosis. There are no clinical symptoms for this form of the disease. It is extremely rare that mild signs of exacerbation occur, accompanied by slight pain when biting on a tooth or percussion. Fibrous periodontitis is usually diagnosed only by radiography. Radiographs show widening or narrowing of the periodontal fissure, and its ossification is possible. The bone plate of the alveoli is often sclerotic and thickened. Reactive hypercementosis, characterized by thickening of the tooth root area, is often noted. EDI data becomes most important in cases where the root canal is not sealed.

Rice. 8-2.

Rice. 8-3.

Errors may occur when the radiograph is incorrectly assessed when, as a result of an unsuccessful projection, a mental or incisive foramen is superimposed on the apex of the tooth root, which is taken to indicate the presence of a granuloma or cyst in this area. With the pneumatic type of the maxillary sinus, the latter can overlap the projection of the apex of the tooth root and also be mistaken for a cyst. The diagnosis is clarified after repeated radiographs with a slightly changed projection. In the absence of perihilar granulomas or cysts, the periodontal fissure of the projected teeth will appear unchanged on the radiograph, and the teeth will be intact.

The most active form of chronic odontogenic inflammatory process, it is characterized by the formation and spread of granulation tissue into the wall of the dental alveoli and adjacent bone tissue, up to the skin surface of the face (Fig. 8-4, 8-5). Granulation tissue replaces destroyed bone. Periodic exacerbations of the inflammatory process activate the process with the formation of a fistula.

Rice. 8-4.

Rice. 8-5.

From this focus of odontogenic infection, microorganisms and their metabolic products enter the body, causing its sensitization. Due to the occurrence of a resorptive process in the alveolar bone, toxic products of inflammation are absorbed into the blood to a greater extent than in other forms. Intoxication decreases after an exacerbation of the process and the formation of a fistula, through which purulent contents are separated. Closing the fistula after a short time often again leads to an exacerbation of the inflammatory process and increased intoxication. Granulating periodontitis in its clinical course is dynamic, remission is short-lived, and asymptomatic periods are rare.

Clinical picture

During chronic granulating periodontitis, periods of exacerbations and remissions of the inflammatory process are distinguished. During periods of exacerbation, patients complain of periodically appearing pain in the area of ​​the causative tooth. From the anamnesis it becomes clear that the tooth has been bothering the patient for a long time. Initially, the pain is paroxysmal in nature, intensifying when biting, swelling of the gums is noted, the mucous membrane of which in the area of ​​the affected tooth is swollen, hyperemic and pasty. A painful infiltrate is palpated in the projection of the root apex.
After some time, after frequent exacerbations, a fistula forms, from which serous or purulent exudate begins to be released, and the pain subsides somewhat. In some cases, the growth of granulation tissue extends under the periosteum, under the mucosa or into the soft tissue, forming a subperiosteal, submucosal or subcutaneous odontogenic granuloma. The localization of odontogenic granuloma can be different. Most often, it opens in the area of ​​projection of the apex of the tooth root on the vestibular side. This is explained by the fact that the outer wall of the alveoli is thinner. Granulations often grow around the mouth of the fistula tract. Subperiosteal or submucosal granulomas are located according to the location of the causative tooth. Subcutaneous granuloma, emanating from the frontal group of teeth of the upper jaw, can be localized at the wing of the nose, the inner corner of the eye, in the infraorbital region. Granuloma, originating from the upper premolars, is localized in the infraorbital and zygomatic areas; from the molars - in the zygomatic and upper parts of the buccal region. Subcutaneous granuloma emanating from the teeth of the lower jaw is usually localized accordingly: from the frontal group of teeth - in the chin area; from premolars and molars - in the lower parts of the buccal and submandibular region. It is extremely rare that granuloma spreads to distant areas and opens in the lower parts of the neck or temporal region. Clinically, odontogenic granuloma exists for a long time painlessly, without causing complaints. It is defined as a compaction or neoplasm of a round shape, dense consistency with clear contours, painless or slightly painful on palpation, limited mobility due to the presence of a dense connective tissue cord connecting it to the alveolus of the causative tooth. In the absence of acute inflammation, the mucous membrane or skin over the formation does not change color. Sometimes there is retraction of the skin due to its adhesion to the granuloma. The size of the granuloma usually does not exceed 0.5-1.0 cm. In cases where there is an exacerbation of chronic granulating periodontitis, the granuloma increases in size and becomes painful. The skin or mucous membrane over it is hyperemic, sometimes cyanotic, collateral edema is not expressed or is mild. Gradually, a focus of softening appears and increases in the center of the granuloma, fluctuation is determined, which indicates abscess formation. In cases where patients do not seek help and treatment is not carried out, the skin or mucous membrane over the abscess becomes thinner and breaks through. The abscess empties, and if left untreated, a fistula will subsequently form.
During the period of remission, the pain in the area of ​​the causative tooth subsides or is insignificant, causing a feeling of discomfort. Pain often occurs when biting on a tooth and when eating hot food, less often - spontaneously, for no apparent reason. If there is a carious cavity, pain may occur when food debris gets into it. Removing them with a toothpick often leads to relief.
The general condition of the patients does not suffer. Due to the lack of pain and good health, they postpone visiting the doctor, contributing to the further development of the inflammatory process. During this period, the fistula tracts may close. Closure of the fistula tract occurs rarely: in case of stabilization of the inflammatory process or after successful conservative treatment. Then, according to the mouth of the fistula, a pinpoint scar is determined, which indicates that the functioning fistula has closed on its own. If the fistula is functioning, then a small amount of serous or serous-purulent discharge is released from its mouth, and granulations may bulge. When the mouth of the fistula is located on the face, it may be covered with a moist serous or bloody crust with maceration of the skin around it. When probing the fistula through the mouth with a thin button-shaped probe, the instrument is directed towards the causative tooth. With long-term existence of granulomas, regional lymphadenitis acquires the character of chronic hyperplastic.
When examined in the oral cavity, the causative tooth is usually motionless. The tooth cavity is opened, and a partial outflow of exudate occurs through it. The mucous membrane of the gums covering the alveolar process in the area of ​​​​the projection of the apex of the root of the causative tooth may not be changed or slightly swollen.
Granulating periodontitis differs in the originality of the pathomorphological picture. When examining an extracted tooth, fragments of dark red granulation tissue are visible in certain areas of the root; the surface of the root is rough. Microscopically, growths of granulation tissue are detected at various stages of its maturation. Resorption of bone and hard tissues of the tooth root is observed.
Diagnosis of chronic granulating periodontitis confirmed by X-ray examination of the causative tooth. The radiograph reveals a small focus of bone tissue destruction in the area of ​​the root apex with unclear contours. Bone destruction sometimes spreads to the alveoli of adjacent teeth. Granulating periodontitis of molars leads to resorption of the interradicular bone septum. In this case, on the radiograph, the roots of the teeth are visible against the background of an area of ​​osteolysis of bone tissue that does not have clear boundaries. In some cases, partial resorption of the tooth root is detected. The source of rarefaction often has a triangular shape, its apex is directed from the root of the tooth and is compared to a candle flame. There is no periodontal gap in this area, the compact lamina of the alveoli is destroyed and is not projected on the radiograph. In some cases, a similar focus of rarefaction appears at the bifurcation of the roots of the molars. This occurs when the bottom of the carious cavity is perforated, either during the spread of the carious process, or during preparation of the carious cavity. Electroodontometry helps in diagnosis; its data is most valuable in the initial stages of the disease, when the X-ray picture is not sufficiently pronounced.

A less active form of chronic periodontitis, characterized by stabilization of the inflammatory process (Fig. 8-6,8-7).

Rice. 8-6.

Rice. 8-7.

It can develop both independently and with stabilization of the granulating process. It is characterized by the formation of granulation tissue and a surrounding connective tissue (fibrous) capsule in the area of ​​the root apex of the causative tooth. The fibrous capsule is a kind of protective barrier against the penetration of microbes, toxins and decay products into the body. In this case, a relatively stable balance arises between the activity of the microflora and the resistance of the organism. It may remain asymptomatic for a long time. In some patients, granulation tissue, destroying the bone (especially in the upper jaw), spreads under the periosteum, a subperiosteal granuloma appears, and in the projection of the apex of the tooth root it can be palpated in the form of a clearly limited, dense, low-painful formation with a smooth surface.

According to the morphological structure there are three forms of chronic granulomatous periodontitis .

. Simple granulomas- structured by connective granulomatous tissue with peripheral fibrosis.
- Epithelial granulomas. They contain epithelium that moved here from the epithelial islands of Malasse. This granuloma can lead to the formation of radicular cysts, as well as primary cancer of the jaw.
- Cyst granulomas- proliferative, the epithelium in them is oriented towards the formation of cysts. Secretion from the epithelium, an increase in intracystic hydrostatic pressure leads to compressive resorption of the bone along the periphery and growth of the cyst.

According to the X-ray picture, they are distinguished:

Apical granuloma, localized strictly at the apex of the tooth root;
- lateral granuloma, localized on the side of the tooth root;
- apical-lateral granuloma, located on the side of the apex of the tooth root;
- interradicular granuloma, found in multi-rooted teeth at the site of root bifurcation.

An x-ray reveals a focus of bone tissue destruction, which has a round or oval shape with clear contours; the apices of the roots of teeth turned into granuloma are often resorbed. Often a rim of compaction is identified around the vacuum, characteristic of reactive osteosclerosis. There is no periodontal gap in the region of the rarefaction area; the compact lamina of the alveoli at this level is destroyed. The dimensions of the rarefaction area usually do not exceed 0.5 cm. If there are rarefactions up to 1 cm in diameter, they speak of the development of cystogranuloma. If its dimensions exceed more than 1 cm, then a diagnosis is made - a radicular cyst. The chronic inflammatory process contributes to the destruction of root cement and reactive, excessive deposition of replacement cement. This in some cases leads to hypercementosis, which is radiographically defined as a “club-shaped” thickening of the apex of the tooth root.

Clinical picture

Chronic granulomatous periodontitis in remission clinically does not manifest itself in any way, exacerbation occurs rarely. It is most often discovered accidentally during an X-ray examination. As a result of the development of subperiosteal granuloma, according to the projection of the apex of the root of the causative tooth, a small, painless bulge with clear contours will be determined. Upon microscopic examination, it can be found that the granuloma in appearance resembles a round or oval-shaped sac made of a dense shell with a smooth surface and one edge can be tightly fused to the root of the tooth. The process is not accompanied by the formation of fistulas. With exacerbation of chronic inflammation, the clinical picture differs little from that of acute periodontitis and exacerbation of chronic granulating periodontitis. EDI data indicate pulp necrosis. However, the characteristic x-ray picture does not raise doubts about the diagnosis.

Features of the course of periodontitis

The clinical course of each form of chronic periodontitis has its own characteristics, which must be taken into account when diagnosing the disease and choosing a treatment method in elderly and senile people. Acute periodontitis rarely occurs in older people, but a process resembling the picture of acute periodontitis is quite common, but less pronounced. This refers to the pain reaction, swelling of the surrounding soft tissues, and the general condition of the body. Regional lymphadenitis occurs much less frequently. Usually, even with the rapid course of periodontitis, only the formation of an infiltrate occurs along the transitional fold near the causative tooth, after the opening of which fistulas often remain. They can exist for years, and therefore exacerbations of periodontitis are rare. With prolonged disease, exudate can be released through the periodontal fissure into the periodontal pocket. The indicated localizations of fistulas, the absence of lush granulations at their mouths, scanty purulent discharge, long-term functioning without a tendency to close are characteristic of periodontitis in the elderly,
Traumatic periodontitis in the elderly has a chronic course. This feature is explained by the fact that the disease occurs due to the influence of a constant traumatic factor, and not a one-time injury, due to irrational prosthetics or impaired articulation due to the loss of a significant number of teeth.

It is worth noting some features of the X-ray images of teeth affected by chronic periodontitis in elderly people. Thus, with chronic fibrous periodontitis, the periodontal fissure may not be widened on an x-ray. With granulomatous periodontitis, the bone tissue at the edges of the granuloma blocks X-rays more intensely than in neighboring areas and therefore appears sclerotic. The areas of bone facing the granuloma and constituting its outer border have clear, even edges. The outer sections of the sclerotic bone areas have uneven, indistinct edges. Similar bone changes in the circumference of the lesion can be observed on an x-ray and with granulating periodontitis. Repeated radiographic examinations carried out several years later do not reveal significant changes in the size and shape of areas of bone loss in the periapical region.

Differential diagnosis

In the acute stage, chronic periodontitis is differentiated from the same diseases as acute periodontitis. In the remission stage, three forms of chronic inflammation are differentiated, mainly based on radiographic data. In addition, periodontitis is differentiated from the following diseases:

A radicular cyst, in which there is displacement of the teeth and deformation of the jaw due to bulging of the outer compact plate. Its thinning with a radicular cyst leads to the appearance of the symptom of “parchment crunch” - pliability when pressing on the bulging area of ​​the wall of the compact plate, or to the discovery of a defect in the bone, which is not observed with periodontitis. X-ray data helps to make a more accurate diagnosis;
. chronic osteomyelitis. Radiologically, large areas of rarefaction of bone tissue are determined, onto which shadows of developing or formed sequestral capsules are projected. In chronic osteomyelitis, depending on the localization of the process, Vincent's symptom can be clinically determined;
- bone neoplasms such as ameloblastoma or osteoblastoclastoma. Diagnostics is aided by morphological and x-ray data; bone tumors have a characteristic x-ray picture in size and pattern;
- lymphadenitis of the buccal, submandibular and submental lymph nodes in nonspecific and specific inflammatory diseases. Odontogenic granuloma does not have such a characteristic localization as the lymph nodes. With lymphadenitis, there is no cord leading to the causative tooth;
- in the case of specific osteomyelitis (actinomycotic, tuberculous and syphilitic), multiple lesions are often identified. In the area of ​​such infiltration, several fistula tracts often open. With actinomycosis, the exudate is often lumpy, and with tuberculosis it has the appearance of a curdled mass. Diagnostics is helped by the results of morphological, bacteriological and immunological studies; - pyogenic granuloma, which often occurs as a result of skin inflammation against the background of endocrinopathy during furunculosis, atheromatosis, pyodermatitis, not associated with the causative tooth.

Surgical treatment of chronic periodontitis

The indication for surgical treatment of chronic periodontitis is the lack of possibility of its conservative treatment. A radical method of treatment is tooth extraction.

Indications for tooth extraction:

Tooth mobility III-IV degree;

Significant destruction of the crown, when it is impossible or impractical to restore it;

The presence of severe concomitant pathology or mental illness, making complex surgical intervention impossible, undesirable or unpromising.

After tooth extraction, you should carefully curettage the bottom of the socket, since the remaining fragments of granulation tissue can provoke further development of inflammation, the appearance and growth of cysts.

Tooth-preserving operations include:

Resection of the apex of the tooth root;

Hemisection of the tooth;

Root amputation;

Tooth replantation;

Tooth transplantation

Materials used: Surgical dentistry: textbook (Afanasyev V.V. et al.); under general ed. V. V. Afanasyeva. - M.: GEOTAR-Media, 2010

When chewing food, the chewing muscles develop significant pressure. It would turn into a destructive force that embeds the tooth into the socket if there were no morphological structures in the periodontium capable of absorbing and distributing it to the surrounding bone tissue. The term “periodontium”, as is known, combines gum tissue, tooth sockets, periodontium (pericementum) and cementum of the tooth root, which have a genetic relationship and common function. Of greatest interest from the point of view of perception of chewing pressure is the periodontium, otherwise called pericementum.

The periodontium is located in the space between the socket wall and the root surface. This space is called the periodontal fissure (Fig. 23).

The width of the periodontal fissure at different levels of the root is not the same. Thus, at the mouth of the alveolus the width of the periodontal fissure is 0.23 ± 0.07 mm, in the cervical third - 0.117 ± 0.05 mm, in the middle third - 0.133 ± 0.03 mm, and in the apical third - 0.195 ± 0.05 mm (A. S. Shcherbakov). It follows from this that in the middle part of the socket the periodontal fissure has a narrowing, which has given rise to some authors to compare its configuration with an hourglass. The narrowing of the periodontal gap in the middle third is explained by the nature of the physiological mobility of the tooth. During lateral movements, the greatest inclination of the root is observed in the area of ​​the apex and at the level of the neck of the tooth. At this time, the tooth acts as a double-armed lever with a fulcrum located approximately in the middle third of the root. This explains the narrowing of the periodontal fissure in its middle third.

Statistical processing of the data obtained from measuring the width of the periodontal fissure showed that there is no significant difference in the width of the periodontium in different groups of teeth, as well as in different sides (vestibular and oral) (A. S. Shcherbakov).

The periodontal gap is repeatedly rebuilt during life in accordance with the changed function. The restructuring is expressed in apposition and resorption of the bone of the socket and increased cement deposition. Bone apposition is observed on the distal side of the alveolar wall of the interdental septa, and resorption is observed on the medial side, which is associated with the tendency of the teeth to move in the mesial direction.

The size of the periodontal gap is also influenced by other factors, among which are age and various pathological processes occurring in it.

According to I.G. Lukomsky, an unerupted but already formed tooth has a narrower periodontal gap than a tooth that has erupted and is involved in chewing. With the removal of the tooth from its function, the width of the periodontal gap decreases. The reliability of this position has been proven statistically (A. S. Shcherbakov).

Periodontium is a dense connective tissue. From the point of view of function, its main substance with its functionally oriented connective tissue fibers is of greatest interest.

The system of oriented connective tissue fibers of the periodontium is best described in conjunction with similar structures of the marginal periodontium. The marginal periodontium, thanks to a complex network of collagen fibers, ensures a tight fit of the gum edge to the neck of the tooth, preventing its detachment both when food moves along the crown and during excursions of the tooth itself during chewing. In addition, it forms the bottom of the physiological gingival pocket.

In the marginal periodontium, according to A. S. Shcherbakov, the following are distinguished:

• 1) a dentogingival group of fibers, originating from the cement and fan-shapedly distributed in the gum;
• 2) the dentoperiosteal group of fibers, which begins below the place of attachment of the first group and, bending around the top of the alveolar process, is woven into the periosteum.

On the approximal sides, instead of the second group, an interdental group of fibers is observed. Its fibers form a powerful ligament 1-1.2 mm wide, running horizontally above the interdental septum from one surface of the root to the other (Fig. 23, 8). With the help of these fibers and the alveolar bone, the individual teeth are combined into a continuous single chain, the dental arch, acting as a single unit in which the stress or movement of one element causes a corresponding stress or movement of the others.

The marginal periodontium without sharp boundaries passes into the pericementum (periodontium). In connective tissue it is distinguished by the following groups of fibers:

• 1) functionally oriented;
• 2) directed along the vessels and nerve trunks;
• 3) not having a specific direction and forming the basis of loose connective tissue.

Functionally oriented fibers are represented by two groups: oblique dentoalveolar and apical (Fig. 23, 12-13). In the periodontium of multi-rooted teeth, in addition, there is a group of fibers located in the area of ​​root bifurcation.

In cross sections, periodontal fibers have a radial or tangential course. The latter can be directed both clockwise and counterclockwise.

Oblique periodontal fibers suspend the tooth in the socket and perceive chewing pressure directed along the vertical axis of the tooth or at an angle to it. Radial and tangential fibers hold the tooth as it rotates around its longitudinal axis.

The position about the functional orientation of collagen fibers is beyond doubt. Another thing is controversial. Some (Lantz, Lonz) consider the functional structure to be innate, others (Eschler, Eschler) argue that it arises after the teeth erupt and are included in the function. We believe that the functional orientation of the fibers is innate, formed during the period of tooth eruption. However, the nature of the function of individual groups of teeth (incisors, molars), as well as the individual characteristics of the closure of the dentition and the type of food can leave a certain imprint on the structure of the periodontium. Consequently, congenital structures are the background against which the function creates its lifetime pattern.

Periodontitis is a disease characterized by the spread of the inflammatory process from the gums to the underlying tissues. The disease manifests itself progressive periodontal destruction , as well as bone tissue in the interdental

partitions.

Periodontium has a small thickness (only 0.2-0.25 mm), however, during the inflammatory process in this tissue, a person suffers from very severe pain. In addition, his tooth becomes loose and the surrounding bone tissue dissolves.

Types of periodontitis

Experts divide periodontitis into several different types. Depending on the location of the disease, the diagnosis determines apical or apical periodontitis (in this case, the inflammatory process affects the area of ​​the apex of the tooth root), as well as marginal (this form of the disease involves damage to periodontal tissue along the root of the tooth) and diffuse (the ligamentous apparatus as a whole is affected) periodontitis.

Classification depending on the cause of the disease determines infectious , traumatic And medicinal forms of the disease. Infectious form - the result of damage to periodontal tissues by pathological microorganisms. Sometimes this is how an exacerbation of advanced caries or pulpitis is expressed.

Medicinal periodontitis - consequence of getting into periodontium drugs that have an aggressive effect on tissue. Such medications are used in the process of dental treatment. In this case, the so-called allergic periodontitis . Traumatic periodontitis manifests itself as a consequence of acute and chronic dental trauma. This could be either a blow or a dislocation, or the result of an incorrect one.

Assessing the clinical picture of periodontitis, experts distinguish acute And chronic form of the disease. In turn, acute periodontitis is divided into serous And purulent , and chronic – on granulomatous , granulating And fibrous . All these forms have characteristic features that can be seen even in the photo.

Causes

Most often, periodontitis in children and adults manifests itself as a consequence of exposure to infection. In more rare cases, the cause of periodontitis is injury or an impact on the body. If the infection affects the pulp so severely that it cannot serve as a barrier to the infection penetrating inside, then the pathological processes spread deep into the gums. As a result, bacteria easily penetrate to the top of the tooth, affecting the surrounding tissues.

The most common causative agents of this disease are streptococci , in more rare cases it manifests itself under the influence staphylococci , pneumococci , as well as other harmful microorganisms. They secrete toxins, which, together with the products of pulp decomposition, end up in the periodontium, getting there through the root canals or formed periodontal pocket. In addition, pathological microorganisms can penetrate there hematogenous or lymphogenous way.

Periodontitis sometimes develops as a complication of untreated disease.

Symptoms

Symptoms of periodontitis in the acute form of the disease, they are determined by the localization of the pathological process, as well as the manifestation of protective reactions that surround the affected area of ​​​​tissue. The patient notes the manifestation of moderate pain in the area of ​​the tooth that was affected. This place can hurt from time to time or constantly. Sometimes there is a reaction to hot food. Often the pain intensifies when a person bites something on this tooth. When the body is in a horizontal position, a sensation may be noted: grown tooth“, since in a supine position swelling increases and pressure in the affected area increases. As a result, the patient often cannot get enough sleep and eat food, and therefore feels overwhelmed and tired. However, in the acute form of the disease, intoxication of the body is not observed. External signs are usually absent. The tooth may be only slightly mobile, and the crown may have a carious cavity or one that was recently placed.

If the inflammation progresses to the purulent stage, the symptoms become more pronounced. A person almost constantly feels intense, aching pain; it is difficult for him to chew. Often, with this form of the disease, it is difficult for a person to close his jaw due to pain, so he constantly opens his mouth. Against the background of an inflammatory process, the patient's temperature rises to low-grade numbers.

Patients with acute periodontitis feel constant weakness due to poor sleep, stress and the inability to eat normally. Upon examination, you can detect slight swelling at the site of the lesion. There is also enlargement and tenderness of one or more lymph nodes. When the tooth is percussed, a sharp pain is observed. The tooth becomes more mobile. When establishing a diagnosis, differential diagnosis is important, since some symptoms are characteristic of other diseases.

Chronic periodontitis sometimes develops bypassing the acute stage of the disease. But often it is the initial exacerbation that gives way to the chronic course of the disease. In some cases, the clinical picture of the disease is unexpressed. In this case, there are no symptoms, which becomes the reason for untimely consultation with a doctor.

Chronic fibrous periodontitis has a sluggish course. The patient does not complain of pain, and if pain does occur, it is aching in both children and adults. Therefore, it is easiest to diagnose this form of the disease using radiography. In this case, there is a deformation (moderate thickening of the periodontium) around the apex of the tooth root (apical periodontitis).

Granulomatous periodontitis is expressed by the appearance of a shell of connective tissue, which looks like a sac, is attached to the apex of the tooth root and is filled with granulation tissue. This education is called granuloma . There is usually no pain with this form of the disease. Only during biting can mild pain sometimes appear. Due to the absence of symptoms, patients may not seek help for a long time. As a result, the condition worsens, and over time, stages of exacerbation of periodontitis may appear, when surgical treatment will have to be applied.

The course of granulating periodontitis involves the appearance of granulation tissue in periodontitis. This form of the disease is the most active. This tissue grows very quickly, so over time the cortical plate of the alveoli is destroyed, and the formed granulations come out. An open channel appears through which pus emerges, which is released during granulating periodontitis. There are several such fistulas, and microbes can enter the body through them, and the chronic course of the disease worsens. If the fistula tract closes, granulating periodontitis progresses, and the patient suffers from severe pain and swelling of the soft tissues.

The onset of the granulating form of the disease is characterized by the appearance of periodic pain in the gums, which can disappear and appear randomly. The pain may become more intense when biting food, in the cold, or with a cold. The tooth moves a little. In the presence of fistulas and purulent discharge, an unpleasant odor is observed.

At chronic granulating periodontitis periods of exacerbation and remission of the disease are periodically observed. An exacerbation provokes the manifestation of noticeable symptoms described above, and during remission, pain or discomfort in the area of ​​​​the affected tooth appears slightly. The fistula tracts may close at this time.

Thus, each form of periodontitis has its own characteristics of the course. All this must be taken into account when making a diagnosis, and differential diagnosis is a very important point. Acute forms of the disease are very rarely diagnosed in elderly people. But at the same time, both apical and marginal periodontitis can occur acutely in elderly patients - with severe pain, swelling and deterioration in general condition.

Traumatic periodontitis occurs chronically in older people, since the disease develops under the influence of a constant traumatic factor. As a rule, this is the result of improper prosthetics or the absence of a large number of teeth.

Diagnostics

If the patient suspects the development of periodontitis, the dentist initially conducts an examination, during which he determines the presence redness, swelling, wounds, fistulas. Feeling the teeth makes it possible to guess which of them is the source of infection. The doctor checks the mobility of the teeth and performs percussion. It is also important to interview the patient, during which it is necessary to find out what kind of pain bothers the person and whether there are other symptoms.

An informative method for making a diagnosis is an x-ray examination. The resulting x-ray should be carefully examined by an experienced specialist, since the picture differs in different forms of periodontitis. With the development of an acute form of the disease, the image shows an expansion of the periodontal gap due to edema.

In addition, it is scheduled to conduct electroodontic diagnostics , which indicates the death of the pulp. Laboratory blood tests do not change significantly, sometimes the ESR and the number of leukocytes increase slightly. Acute periodontitis should be differentiated from some forms pulpitis , With acute purulent periostitis , acute odontogenic osteomyelitis , exacerbations sinusitis . Chronic periodontitis during its exacerbation should be differentiated from the same diseases.

Diagnosis of chronic granulating periodontitis will be made possible by studying the results of an X-ray examination of a diseased tooth. It identifies the focus of destruction of bone tissue, which has unclear contours and is located in the area of ​​the root apex.

In chronic fibrous periodontitis, there is a widening of the periodontal fissure, but the inner cortical plate is preserved. In chronic grayulomatous periodontitis, enlarged lymph nodes are observed, and x-rays show a rounded focus of destruction of bone tissue.

The doctors

Treatment

If a patient develops acute periodontitis of a tooth, it should initially be determined whether it is advisable or whether it should be preserved. If the causative tooth has a intact crown, a passable root canal, and favorable conditions for endodontic therapy are determined, then an attempt is made to save the tooth. In this case, the purulent focus is opened, after which it is emptied. It is important to create conditions for the outflow of exudate. Before starting treatment, conduction or infiltration anesthesia is practiced.

As a rule, the practice is to remove temporary teeth, the crown part of which is severely destroyed, as well as those teeth that are highly mobile. Those teeth for which treatment is ineffective are also removed.

After tooth extraction, the resulting hole should be washed with antiseptics and 2-3 novocaine blockades should be made. Rinsing with antiseptics or herbal decoctions is also practiced. Sometimes physical procedures are prescribed.

General treatment of periodontitis must be carried out comprehensively. Conservative treatment involves the use of analgesics, hyposensitizing drugs, and non-steroidal drugs with an anti-inflammatory effect. Modern treatment methods include taking vitamins and.

As a rule, the course of acute periodontitis or exacerbation of the chronic form of the disease occurs with inflammation of the normergic type. That is why therapy with antibiotics and sulfonamides is not practiced.

Treatment with antibiotics carried out only if a complication of the disease develops, accompanied by intoxication of the body, or a sluggish inflammatory reaction is noted. This helps prevent the spread of the disease to nearby tissues. If the treatment of dental periodontitis was carried out in a timely and correct manner, the person will fully recover. But if gross mistakes were made during therapy, or the patient did not consult a doctor at all, practicing exclusively treatment with folk remedies, then the process can become chronic. As a consequence, the cost of such delay can be very high.

Treatment of chronic periodontitis is long-term. However, sometimes conservative therapy is ineffective and surgical intervention is required. In this case, the most radical method is tooth extraction. After this, the doctor performs a thorough curettage of the bottom of the socket to completely remove parts of the granulation tissue. If they remain, they can cause subsequent inflammatory processes, as well as the growth of cysts.

Some tooth-preserving operations are also practiced. This tooth root amputation , tooth root apex resection , replantation , hemisection or tooth transplantation .

Prevention

The main method of prevention to prevent periodontitis is the timely elimination of all diseases associated with the condition of the teeth. The correct approach to the sanitation of the oral cavity allows you to prevent the development of pulpitis and caries, and, consequently, prevent periodontitis. If caries does affect a tooth, then it is necessary to cure it as soon as possible, since periodontitis develops when the hard tissues of the tooth are destroyed and the pulp dies.

It is important to pay special attention to your diet, including as little sugar-containing foods as possible and as many unprocessed vegetables, fruits, and dairy products as possible. If possible, any trauma to the teeth should be avoided to avoid traumatic periodontitis.

Don't forget about oral hygiene. You need to brush your teeth in the evening and in the morning, and after eating you need to rinse your mouth and use dental floss. It is especially important to rinse your mouth after sweet foods and foods. Experts recommend drinking plenty of fluids, because dehydration can be one of the factors contributing to the development of periodontitis.

Complications

With periodontitis, the patient may experience general complications. These are signs of general poisoning of the body, constant headaches, a feeling of weakness, increased body temperature. Autoimmune diseases of the heart, joints, and kidneys may subsequently develop as complications. Such processes occur due to a stable increase in the immune system cells in the patient’s body, which can subsequently destroy the cells of their body.

Frequent complications are , fistulas, less often in patients can develop, , cellulitis of the neck . Due to the opening of the fistula, purulent discharge can enter the maxillary sinus, which contributes to the development.

List of sources

• Artyushkevich A.S. Trofimova E.K. Clinical periodontology. - Minsk: Interpressservice 2002;
• Borovsky E.V., Maksimovsky V.S., Maksimovskaya L.N. Therapeutic dentistry. - M.: Medicine, 2001;
• Leontyev V.K., Pakhomov G.N. Prevention of dental diseases. - M., 2006;
• Dmitrieva. L.A. Modern aspects of clinical periodontology / L.A. Dmitrieva. - M.: MEDpress. 2001.

The inflammatory process in the dental pulp, caused by its infection as a result of advancement into the thickness of the dental substance, is not the final stage of tooth damage. If you endure the painful stage of pulpitis and do not undergo timely cleaning and filling of the root canals, the nerve endings will die and decompose after some time, and the pain associated with inflammation of the pulp will cease to bother you. However, the process of spreading the infection will not stop, and over time, pathogenic microorganisms will penetrate the connective tissue layer between the root and the jaw bone (periodontium), and cause an inflammatory process in it.

Sight radiograph: there is an expansion of the periodontal gap in the area of ​​the 6th tooth

The inflammatory process in the tissue surrounding the tooth root can have an acute course - with the formation of exudate or formation, severe pain, swelling and even manifestations of general intoxication of the body in the form of weakness, poor health, hyperthermia. At the same time, chronic forms of inflammation of the root sheath may develop, which may not have pronounced symptoms, but in the absence of treatment procedures lead to undesirable consequences.

What is a chronic form of inflammation of the tissue surrounding the root, and what is its treatment?

What is chronic fibrous periodontitis

With chronic inflammation of the periodontium, a change in the structure of the tissues adjacent to the tooth root occurs. At the same time, the nature of these pathological changes determines the specific type of chronic inflammatory process. In accordance with this, the following types of chronic periodontal inflammation are distinguished:

1. Fibrous periodontitis

The fibrotic form of chronic periodontal inflammation is most common in elderly patients. This is due to age-related slowing of metabolism and a decrease in the ability to form new blood vessels. In childhood, fibrous inflammation of the root membrane occurs in very rare cases. This disease develops with equal probability in both men and women. The time of year does not affect the incidence of this type of periodontitis.

With fibrous periodontitis, the inflammatory process usually develops in the area of ​​the apex of the tooth root (apical zone). This disease can develop as a complication of the primary one, or be a consequence of other chronic forms of periodontal inflammation. Pathological changes in the fibrous form of chronic periodontitis consist in the proliferation of fibrous tissue with coarse fibers - similar to that which forms during scarring of wounds. The affected periodontal tissue is characterized by the presence of small foci of the inflammatory process that occurs with the formation of an infiltrate. In addition, in the area of ​​inflammation, sclerotic degeneration of blood vessel tissue occurs.

Although in the case of fibrous inflammation the periodontal area adjacent to the apex of the tooth root thickens, no pathological changes in the bone jaw are observed in this disease. However, if a fibrotic inflammatory process is detected in the periodontium, treatment should not be postponed indefinitely, since it is possible that it may develop into granulating or granulomatous periodontitis - especially with constant infection of the apical zone of the root membrane, for example, through the root canal.

Why does fibrous periodontitis develop?

Most often, this disease develops due to bite pathology, leading to increased pressure on the root membrane. Because of this, a change in the structure of the periodontium begins, which consists of the replacement of normal connective tissue with fibrous tissue. As a result of this, the periodontal fissure expands, and inflammatory foci containing infiltrate appear in it. Malocclusion can occur, for example, due to wearing an incorrectly fitted denture or other orthodontic structure.

Another common cause of fibrous periodontitis is infection of the periodontium by pathogenic microflora, which occurs in the absence of treatment for inflammation of the dental pulp. Also, chronic fibrous periodontitis can develop as a complication after acute periodontal inflammation. This disease may be accompanied by a granulating or granulomatous form of inflammation at an early stage of development of the inflammatory process or, on the contrary, at the final stages of their treatment, manifesting itself in an increase in the width of the periodontal fissure.

Symptoms of chronic fibrous periodontitis

With this disease, the patient has virtually no pain, although in some cases, when tapping on the tooth from above, a slight pain occurs. If the disease is odontogenic in nature, then the causative tooth usually has a carious cavity.

In some cases, chronic periodontitis develops under a filled tooth. This happens when the root canal was not completely cleaned and filled during treatment of pulpitis. The source of infection remaining inside the canal leads to infection of the periodontal tissue near the apical foramen and the development of the inflammatory process.

Sometimes, in the case of a fibrotic inflammatory process in the periodontium, the color of the tooth changes.

Clinical picture during exacerbation of chronic fibrous periodontitis

Fibrous inflammation of periodontal tissue in the remission phase, as a rule, does not give any pronounced symptoms. However, exacerbation of chronic fibrous periodontitis makes itself felt with such signs as:

• painful sensations due to mechanical impact on the causative tooth - for example, while chewing food;
• redness and swelling of the gums in the area of ​​the apical part of the root of the causative tooth;
• severe pain without affecting the diseased tooth - occurs during the transition of chronic fibrous inflammation of the periodontium into serous or purulent inflammation;
• facial asymmetry and signs of general intoxication that occur during transition.

The symptomatic picture that occurs during exacerbation of fibrous periodontitis is not specific. Similar symptoms may occur with other forms of chronic periodontal inflammation. Therefore, establishing an accurate diagnosis requires a detailed examination of the affected area.

Treatment of chronic fibrous periodontitis

The success of treating the disease largely depends on the accuracy of the diagnosis. Since in chronic fibrous periodontitis there are practically no external signs of inflammation - tapping on the tooth does not cause pain, insertion of a dental instrument into the tooth canal is painless, there is no swelling or hyperemia of the gums in the apical region - an accurate diagnosis can only be established based on the results of a targeted x-ray of the area adjacent to the tooth. causative tooth.

6 tooth of the lower jaw after endodontic root canal treatment

implies the exclusion of diseases such as:

• average caries;
• chronic gangrenous inflammation of the dental pulp;
• granulating periodontitis;
• granulomatous periodontitis.

The main evidence in favor of fibrous periodontitis is an increase in the width of the periodontal fissure in the apical region or along the entire length of the tooth root, visible on an x-ray. In addition, in some cases the patient exhibits pathological changes such as:

• thickening and deformation of the tooth root caused by excessive deposition of secondary cement;
• an increase in the thickness of the cortical plate of the alveolar process near the zone of the inflammatory process.

Additional diagnostic methods for fibrous periodontitis are thermal testing and electroodontodiagnosis. The effect of cold water on the tooth does not cause pain in the patient. This indicates the death of the pulp. When the causative tooth is exposed to electricity, tooth sensitivity is noted at a current strength of at least one hundred microamps, which indicates necrosis of the pulp tissue and the spread of infection to the periodontium.

In rare cases, fibrous inflammation also develops in the periodontium of primary teeth. In such a situation, diagnosis is complicated by the fact that the periodontal gap with baby teeth is wider than with permanent teeth.

Treatment procedures for fibrous chronic periodontitis

Fibrous inflammation of the periodontium is treated endodontically - that is, involving therapeutic manipulations inside the causative tooth. This treatment includes the following steps:

• treatment of a carious cavity to remove dead pulp and affected dentin;
• if the causative tooth was previously filled, remove the filling and open the sealed canals;
• mechanical cleaning of root canals;
• treatment of root canals with antiseptic drugs;
• temporary filling of root canals with filling material containing calcium hydroxide;
• filling dental canals with permanent material;
• filling the cavity of the causative tooth.

If the cause of fibrotic periodontium is not infection of the root membrane through the apical foramen of a diseased tooth, but an incorrect bite, then measures are necessary to eliminate this negative factor leading to chronic injury. So, if the bite is distorted by an insufficiently precisely fitted prosthesis, then the prosthetic procedure should be repeated. To do this, it is necessary to accurately depict jaw movements in all directions. This task is accomplished using a device called an articulator.

As a rule, the prognosis for fibrous periodontitis is favorable - but only if the patient consults a doctor in time and receives professional dental care. Delaying treatment increases the risk of developing an acute form of the disease due to prolonged penetration of pathogenic bacteria into the tissue adjacent to the root. An acute inflammatory process can lead to the formation of purulent masses and the spread of infection to the periosteum and jawbone. This may require lengthy and complex treatment. In severe cases, the doctor may be forced to remove the causative tooth. With the development of inflammation that occurs with the formation of pus, infection through the blood of the brain and other organs is possible, as well as the occurrence of general blood poisoning, which can result in the death of the patient.

A complication of fibrous periodontitis is not only the development of acute inflammation of the root membrane, but also the transition of the disease to other forms of chronic periodontitis, which are more difficult to treat and the prognosis of which is much less favorable. When treating such diseases, conservative methods are often not enough, and it becomes necessary to remove part of the root of the diseased tooth, or the entire tooth. Prolonged lack of treatment leads to the spread of pathology to nearby teeth and destruction of the jaw bone tissue. Therefore, if you have a carious tooth, which for some reason could not be cured in time, and which has stopped hurting, it is important to see a dentist as soon as possible and undergo treatment for the inflammatory process in the periodontium while still at the fibrotic stage.