Periodontal diseases: gingivitis, periodontitis, periodontomas

Etiology and Pathogenesis of Chronic Inflammatory Periodontal Diseases

The Role of Dental Deposits (Plaque and Calculus)

The primary etiological (causative) factor for most chronic inflammatory periodontal diseases (gingivitis and periodontitis) is considered to be **dental deposits**, specifically microbial dental plaque (a biofilm) and calculus ("tartar," which is mineralized plaque). Dental deposits form on tooth surfaces due to:

• Insufficient or Ineffective Oral Hygiene: Failure to regularly and adequately remove plaque through brushing and interdental cleaning.
• Anatomical Features of the Dentoalveolar System: Factors like crowded teeth, malocclusion, overhanging restorations, or poorly fitting dental appliances can create plaque-retentive areas that are difficult to clean.
• Changes in the Qualitative and Quantitative Composition of Oral Microflora: An imbalance in the oral microbiome, with an overgrowth of specific pathogenic bacteria (e.g., *Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola* in periodontitis), contributes to disease initiation and progression.
• A Decrease in the Body's Protective Factors: Impaired local or systemic immune responses can make an individual more susceptible to the effects of dental plaque.

Progression from Gingivitis to Periodontitis

When the dynamic balance between the pathogenic effect of dental plaque (microbial attack and their byproducts like toxins and enzymes) and the protective host immune-inflammatory response of the periodontium and the body as a whole is disturbed, chronic inflammation develops in the gingival tissues – this is **chronic catarrhal gingivitis**. At this stage, the inflammation is confined to the gingiva, and the condition is reversible. If high-quality, complete treatment (professional plaque and calculus removal, and establishment of effective patient oral hygiene) is carried out at this stage, the inflammatory process can be stopped, and gingival health can be restored.

However, as a rule, patients may not seek help at this early stage due to mild or absent symptoms, or the initial treatment might be inadequate or not maintained by the patient.

If the pathogenic exposure to dental plaque continues, particularly in a susceptible individual or in the presence of modifying systemic risk factors, further pathological changes occur, and gingivitis progresses to **periodontitis**. This transition is characterized by:

• Destruction of the Periodontal Attachment: The connective tissue fibers (periodontal ligament) that attach the gingiva and tooth to the alveolar bone are destroyed.
• Formation of Periodontal Pockets: The junctional epithelium migrates apically (towards the root tip) along the root surface, creating a deepened gingival sulcus, now termed a periodontal pocket.
• Epithelial Proliferation into the Pocket: The oral epithelium grows down along the root surface lining the pocket.
• Formation of Subgingival Dental Deposits (Calculus): Plaque and calculus form on the root surface within the periodontal pocket, which in turn perpetuates inflammation and contributes to further pocket deepening and attachment loss.
• Alveolar Bone Loss: The inflammatory process leads to resorption of the alveolar bone that supports the teeth.

Key Pathological Components of Chronic Generalized Periodontitis

A long-term inflammatory process in the periodontal tissues leads to atrophy of cellular elements within the gingiva and periodontal ligament, and eventually, destruction of the alveolar bone tissue, which may be replaced by granulation tissue (an inflammatory, highly vascular tissue). These pathological changes are accompanied by impaired microcirculation and metabolic processes within the periodontal tissues, and the development of complex host immune and autoimmune reactions.

Thus, the main pathological components and interconnected links of chronic generalized periodontitis include:

• Supra- and subgingival dental deposits (plaque and calculus).
• Chronic inflammatory process within the periodontal tissues.
• Formation and deepening of periodontal pockets.
• Progressive loss of periodontal attachment and alveolar bone.
• Impaired tissue trophism (nutrition) and microcirculation within the periodontal tissues.

These pathological manifestations often form a "vicious circle," where each component exacerbates the others. Therefore, for effective treatment of chronic generalized periodontitis, it is necessary to comprehensively address and disrupt all these pathological links.

Diagnosis of Periodontal Diseases

A comprehensive periodontal examination is essential for diagnosing gingivitis and periodontitis. This includes:

1. Medical and Dental History: Including smoking habits, systemic diseases, medications, family history of periodontal disease, and oral hygiene practices.
2. Clinical Examination:
   • Visual Inspection: Assessing gingival color, contour, consistency, and presence of plaque/calculus.
   • Periodontal Probing: Measuring probing depths around each tooth to detect periodontal pockets, clinical attachment loss (CAL), and bleeding on probing (BOP). This is key to differentiate gingivitis from periodontitis.
   • Assessment of Tooth Mobility.
   • Evaluation of Furcation Involvement (for multi-rooted teeth).
   • Assessment of Gingival Recession.
3. Radiographic Examination: Dental radiographs (typically bitewings and a full-mouth series of periapical X-rays, or a panoramic radiograph for screening) are crucial for assessing alveolar bone levels, identifying patterns of bone loss (horizontal or vertical), and detecting subgingival calculus or other dental pathologies.
4. Microbiological Testing (in some cases): May be used in aggressive or refractory periodontitis to identify specific pathogenic bacteria and guide antibiotic therapy, though not routinely done for common chronic periodontitis.

Treatment Principles for Periodontal Diseases

General Goals of Therapy

The primary goals of periodontal therapy are:

• To eliminate or control the microbial etiology (dental plaque).
• To arrest the progression of disease.
• To reduce inflammation and eliminate periodontal pockets.
• To restore periodontal health and function.
• To prevent recurrence of disease.
• To prevent tooth loss.

Treatment typically involves phases: initial non-surgical therapy, surgical therapy (if needed), restorative therapy, and long-term maintenance therapy.

Achieving Stable Remission in Periodontitis

While it is hardly possible to completely "cure" fully developed periodontitis in the sense of regenerating all lost tissues back to their original state, achieving a state of **stable remission** is quite achievable with comprehensive treatment and diligent long-term maintenance. Stable remission implies stopping or significantly slowing down the pathological process (primarily the atrophy of the alveolar process and further attachment loss) at the level at which treatment was initiated. This involves controlling inflammation, eliminating pockets, and maintaining excellent oral hygiene and regular professional care to prevent disease reactivation.

Differential Diagnosis of Common Periodontal Conditions

Differentiating between various periodontal states is crucial for appropriate treatment planning.

Complications and Systemic Impact of Periodontal Diseases

Untreated periodontal diseases can lead to:

• Progressive attachment and bone loss.
• Increasing tooth mobility.
• Tooth migration or flaring.
• Formation of periodontal abscesses.
• Eventual tooth loss.
• Impaired masticatory function and nutritional intake.
• Aesthetic concerns (e.g., gingival recession, "black triangles," elongated teeth).
• Halitosis (bad breath).

Furthermore, there is growing evidence linking chronic periodontal disease to various systemic health conditions, including cardiovascular disease, diabetes mellitus (a bidirectional relationship), adverse pregnancy outcomes, respiratory diseases, and rheumatoid arthritis. The chronic inflammation and bacterial load associated with periodontitis are thought to contribute to these systemic effects.

Prevention of Periodontal Diseases

Prevention is key and involves:

• Effective Daily Oral Hygiene: Meticulous plaque removal through twice-daily brushing with fluoride toothpaste and daily interdental cleaning (flossing, interdental brushes).
• Regular Professional Dental Care: Dental check-ups and professional cleanings (prophylaxis or periodontal maintenance) at intervals recommended by the dental professional (typically every 3-6 months depending on risk).
• Healthy Lifestyle Choices: Avoiding tobacco use, managing systemic conditions like diabetes, and maintaining a balanced diet.
• Early Detection and Treatment of Gingivitis: To prevent progression to periodontitis.

When to Seek Dental/Periodontal Care

Individuals should seek professional dental or periodontal evaluation if they notice:

• Gums that bleed regularly during brushing, flossing, or eating.
• Red, swollen, or tender gums.
• Persistent bad breath.
• Gums that are receding or pulling away from the teeth.
• Pus between the teeth and gums when pressed.
• Loose or separating teeth.
• A change in the way teeth fit together when biting.
• A change in the fit of partial dentures.

Early diagnosis and intervention provide the best opportunity for successful management and preservation of periodontal health.