Chronic generalized periodontitis of moderate severity

Symptoms and Diagnosis of Moderate Chronic Generalized Periodontitis

Clinical Presentation and Patient Complaints

The clinical picture of moderate chronic generalized periodontitis is characterized by more noticeable symptoms compared to mild stages. Patients commonly report:

• Bleeding Gums: Often spontaneous or easily provoked during brushing, flossing, or eating.
• Gingival Soreness or Pain: Discomfort or tenderness in the gums may be present.
• Bad Breath (Halitosis): Persistent unpleasant breath odor.
• Tooth Mobility: A noticeable loosening of one or more teeth.
• Tooth Displacement or Drifting: Changes in tooth position, leading to gaps or misalignment.
• Gingival Recession: Gums may appear to be pulling away from the teeth, making teeth look longer.
• Pus Exudation: Purulent discharge may be expressed from periodontal pockets upon gentle pressure.

While the patient's general systemic condition, as a rule, is not overtly disturbed by the periodontal disease itself at this stage, an in-depth medical examination may reveal alterations in the immune system, signs of mild endogenous intoxication (due to chronic inflammation), or deviations in other organs and systems that could be associated with or exacerbated by the periodontal pathology.

Objective Findings and Diagnostic Criteria

Upon clinical examination of the oral cavity in a patient with moderate chronic generalized periodontitis, the following signs are typically revealed:

• Chronic Gingival Inflammation: More evident signs of inflammation such as hyperemia (redness), edema (swelling), and easy bleeding on probing. There may be areas with purulent discharge from clinical pockets.
• Dental Deposits: Significant supra- and subgingival dental plaque and calculus (mineralized and non-mineralized) are usually present.
• Tooth Mobility: Pathological tooth mobility of Grade I-II (detectable movement horizontally and possibly slightly vertically) is observed in affected teeth.
• Tooth Displacement: Possible drifting or pathological migration of teeth.

The key diagnostic criteria that allow a diagnosis of "chronic generalized periodontitis of moderate severity" (corresponding to Stage II or moderate Stage III periodontitis in some newer classifications) include:

• Presence of Periodontal Pockets: Probing depths generally ranging up to 5-6 mm, indicating significant clinical attachment loss.
• Radiographic Evidence of Bone Resorption: X-ray examination shows resorption (loss) of the bone tissue of the alveolar process, typically extending to involve 1/3 to 1/2 (approximately 33-50%) of the height of the interdental septum. Bone loss is often horizontal but may include early vertical defects.

Diagnostic Procedures and Consultations

To comprehensively examine the patient and establish a diagnosis of chronic generalized periodontitis of moderate severity, the following scope of diagnostic procedures is recommended:

1. Detailed Patient Questioning (Anamnesis): Including dental and medical history, symptoms, oral hygiene habits, and risk factors.
2. Clinical Oral and Periodontal Examination: Visual inspection, assessment of plaque and calculus, gingival inflammation.
3. Periodontal Probing: Measurement of probing pocket depths, clinical attachment levels, bleeding on probing, and furcation involvement.
4. Assessment of Tooth Mobility.
5. Schiller-Pisarev Test (Historical): An iodine-based stain to highlight inflamed gingival areas due to glycogen content.
6. Plaque Indices: Indication and quantification of "dental" plaque to assess oral hygiene status.
7. Radiographic Examination: It is imperative to conduct an X-ray examination, most commonly an orthopantomogram (panoramic X-ray) and/or a full-mouth series of periapical and bitewing radiographs, to assess bone levels accurately.
8. Systemic Health Assessment: A clinical blood test (Complete Blood Count - CBC) and a blood glucose test (to screen for diabetes) should be performed, particularly as systemic health can influence periodontal disease.
9. Consultations: A patient with periodontitis of moderate severity should ideally be consulted by an orthopedic dentist (prosthodontist or restorative dentist) to evaluate occlusal factors and restorative needs. If indicated by general health findings or risk factors, consultation with an internist or relevant medical specialist is also advisable.

Treatment of Moderate Chronic Generalized Periodontitis

The course of treatment for chronic generalized periodontitis of moderate severity is comprehensive and typically consists of 6-10 dental visits over a period of 20-30 days for the active treatment phase, followed by ongoing maintenance.

Therapy for moderate chronic periodontitis is aimed primarily at:

• Eliminating periodontal pathogenic factors (thorough removal of dental deposits, occlusal adjustment via selective grinding of teeth, correction of anatomical issues like high frenum attachments via plastic surgery of the vestibule or frenum, etc.).
• Stopping or controlling inflammation in the gums.
• Eliminating or reducing periodontal pockets.
• Stabilizing the dental rows (addressing tooth mobility).
• Normalizing tissue trophism (nutrition), microcirculation, and protective immune reactions within the periodontal tissues.

Initial Therapy (Non-Surgical Phase)

This phase focuses on controlling the infection and inflammation:

1. First Visit: After a thorough examination and formulation of a comprehensive treatment plan, the gums are treated antiseptically (e.g., with 0.12% or 0.06% chlorhexidine solution, 1% hydrogen peroxide solution, or historically, 0.2% furacilin solution). Then, supragingival and accessible subgingival dental deposits (plaque and calculus) are meticulously removed. Complete removal of dental deposits is often accomplished over 2-4 visits, although, with modern techniques and adequate time, it can sometimes be done in a single, longer visit (full-mouth disinfection).
2. Oral Hygiene Instruction (OHI): The patient is thoroughly educated on the rules of effective oral hygiene. This includes assistance in choosing an appropriate toothbrush and toothpaste, and detailed recommendations and demonstrations on the use of interdental cleaning aids like dental floss or interdental brushes. At this stage of moderate periodontitis, toothpastes with anti-inflammatory and antimicrobial properties may be recommended.
3. Home Care Regimen: The patient is also advised to perform oral baths or rinses at home with antiseptic solutions (e.g., chlorhexidine, furacilin – historical) or decoctions of medicinal herbs (e.g., chamomile, sage, calendula) 3-4 times a day for about 20 minutes after meals, during the initial phase of treatment. Oral hygiene effectiveness must be monitored and reinforced throughout the treatment.
4. Addressing Hopeless Teeth and Irritants: During the same initial visits, decisions are made regarding the extraction of severely decayed or periodontally hopeless teeth (e.g., teeth with Grade III mobility). Defective fillings or improperly made prostheses that contribute to plaque retention are identified for replacement. Selective grinding of teeth may be performed to eliminate traumatic occlusal contacts.
5. Local Medication Application: The first visit often concludes with an application of medication on the gums and introduction into the clinical pockets of a paste or gel. Historically, this might consist of an antimicrobial drug (e.g., metronidazole) combined with a non-steroidal anti-inflammatory drug (NSAID) (e.g., acetylsalicylic acid, ortofen/diclofenac). With pronounced suppuration, local application of proteolytic enzymes (e.g., trypsin, stomatozyme, imozimase – historical) or sorbents (e.g., helevin, digispon – historical) might also be considered.
6. Systemic Medications (if indicated): Systemic metronidazole might be prescribed: for example, on the first day - 0.5 g 2 times a day (with an interval of 12 hours), on the second day - 0.25 g 3 times (after 8 hours), and for the next 4 days - 0.25 g 2 times (after 12 hours). Other systemic antibiotics (e.g., amoxicillin, doxycycline) may be chosen based on clinical judgment and microbial profile if available.

Adjunctive Therapies

It is advisable to combine the treatment of moderate chronic generalized periodontitis with adjunctive physiotherapeutic procedures (typically a course of 3-7 procedures), which can have antimicrobial and anti-inflammatory effects:

• Short ultraviolet rays (UVR) application to the gums.
• Gum hydromassage.
• Anode-galvanization or iontophoresis of medicinal substances, such as nicotinic acid, from the anode.
• Local hypothermia (cryotherapy).

On the second visit (typically after 2-3 days), the patient's compliance with oral hygiene recommendations is assessed, often by staining plaque with an iodine-iodide-potassium solution (disclosing solution). The removal of any remaining accessible dental deposits continues. Pockets may be irrigated with antiseptic solutions from a syringe with a blunt needle. Application to the gums and introduction into pockets of a mixture like metronidazole and an NSAID (historical approach) or other modern local delivery antimicrobials might be performed.

Surgical Phase (Open Curettage)

After the initial phase of controlling inflammation in the gums, treatment proceeds to eliminate or reduce periodontal pockets if they persist and are >4-5mm with bleeding. For periodontitis of moderate severity, "open" curettage (periodontal flap surgery with debridement) is often performed for this purpose. In an outpatient (polyclinic) setting, it is advisable to perform this operation on one segment of the jaw at a time (e.g., in the area of six teeth). In a hospital setting, it might be performed for all teeth of one jaw in a single session. Open curettage involves reflecting a gingival flap to gain access to root surfaces and bone defects for thorough debridement of granulation tissue and calculus. The procedure is typically completed by suturing the flap and applying a gingival protective dressing (periodontal pack) for 1-2 days.

Home care recommendations after open curettage include:

• Applying local hypothermia (cold packs) to the postoperative wound area to reduce swelling.
• Using antiseptic mouth baths or rinses.
• Maintaining thorough but gentle hygienic care of the oral cavity, avoiding direct trauma to the surgical site.
• Limiting the diet to soft, non-irritating foods, avoiding rough, spicy items.

In subsequent visits, quality control of previous operations is performed, and open curettage of periodontal pockets in other areas of the mouth is carried out, preferably with appropriate antibiotic coverage if deemed necessary by the clinician.

Restorative and Maintenance Phase

After removing dental deposits, eliminating other periodontal pathogenic factors, controlling the inflammatory process in the gums, and eliminating or reducing periodontal pockets, the periodontitis typically goes into a state of remission.

At this stage, therapeutic measures for moderate chronic generalized periodontitis should be aimed at normalizing microcirculation, nervous trophism (tissue health), and homeostasis of the periodontal tissues. To a large extent, these processes tend to normalize on their own after the elimination of the microbial attack and the inflammatory process.

To further support these healing processes, physiotherapy (a course of 5-10 procedures) may be prescribed:

• Cathode-galvanization or iontophoresis from the cathode of substances like nicotinic acid, aloe extract, heparin, etc.
• Darsonvalization of the gums (high-frequency electrotherapy).
• Local hypo-/hyperthermia (alternating cold/warm applications).

It is also permissible to administer injections of vitamins, stimulating agents, or other drugs along the transition fold (mucobuccal fold) – typically a course of 10-12 injections (this is a less common practice in many modern periodontal protocols).

After the completion of the active treatment course, a patient with moderate chronic generalized periodontitis should be enrolled in a dispensary observation (periodontal maintenance) program, and a follow-up examination is prescribed in 2-3 months initially, then at regular intervals.

All subsequent therapeutic and prophylactic measures for a patient with moderate chronic generalized periodontitis should be aimed at maintaining the protective forces of the periodontium and preventing the re-formation of pathogenic dental deposits. For this purpose, periodic follow-up examinations and courses of "maintenance" therapy are carried out at intervals of 2-3 months initially, and then, if stable, every 3-6 months. Their main goals are to monitor and control oral hygiene, ensure timely removal of any new dental deposits, stimulate tissue health (trophism), microcirculation, and the protective forces of periodontal tissues to prevent exacerbation and further progression of the disease.

Differential Diagnosis of Periodontal Conditions

Differentiating moderate chronic generalized periodontitis from other periodontal states is key:

Complications and Prognostic Factors

Untreated moderate periodontitis can progress to severe periodontitis, leading to:

• Increased tooth mobility and eventual tooth loss.
• Formation of periodontal abscesses.
• Pathological tooth migration.
• Impaired masticatory function and aesthetics.
• Potential impact on systemic health (e.g., cardiovascular disease, diabetes control).

Prognostic factors include severity at diagnosis, patient compliance, smoking status, systemic health, and effectiveness of plaque control.

Prevention and Long-Term Management

While established bone loss is largely irreversible, progression can be halted. Long-term management focuses on:

• Meticulous personal oral hygiene.
• Regular professional periodontal maintenance therapy (typically every 3-4 months, sometimes 6 months if very stable).
• Management of risk factors (smoking cessation, diabetes control).
• Addressing any new or recurrent sites of active disease promptly.

When to Seek Specialized Periodontal Care

Patients exhibiting signs of moderate periodontitis, such as noticeable gum bleeding, bad breath, loose teeth, or gum recession, should seek comprehensive dental evaluation. Referral to a periodontist (a dental specialist in gum diseases) may be indicated for:

• Diagnosis and management of moderate to severe periodontitis.
• Cases requiring surgical periodontal therapy.
• Complex cases with significant bone loss or furcation involvement.
• Patients with systemic conditions impacting periodontal health.