Severe chronic generalized periodontitis

Clinical Symptoms and Diagnosis of Severe Chronic Generalized Periodontitis

Patient Complaints and Systemic Impact

The clinical picture of severe chronic generalized periodontitis is typically characterized by prominent and often distressing patient complaints:

• Bleeding and Soreness of the Gums: Often spontaneous or occurring with minimal provocation.
• Bad Breath (Halitosis): Persistent and often offensive.
• Tooth Mobility: Significant loosening of teeth, which may interfere with function.
• Misalignment or Drifting of Teeth: Gaps may appear, or teeth may change position.
• Difficulty Chewing Food: Due to pain, tooth mobility, or poor occlusal stability.
• Gingival Recession: Making teeth appear longer.
• Pus Exudation (Suppuration): From periodontal pockets, either spontaneously or on pressure.

As a rule, the general condition of the patient may be disturbed. An in-depth systemic examination of patients with severe periodontitis can reveal signs of endogenous intoxication (due to the chronic inflammatory burden), alterations in the immune system, and deviations or exacerbations of conditions in other organs and systems that may be pathogenetically associated with or influenced by the extensive periodontal inflammatory-dystrophic process.

Objective Clinical and Radiographic Findings

An objective oral examination of patients with severe chronic generalized periodontitis is characterized by:

• Pronounced Chronic Gingival Inflammation: Marked redness, swelling, loss of normal contour, and often suppuration from periodontal pockets.
• Periodic Exacerbations and Abscess Formation: Acute flare-ups with periodontal abscesses are common.
• Abundant Dental Deposits: Significant amounts of both supra- and subgingival plaque and calculus.
• Traumatic Articulation (Occlusion): Abnormal or excessive biting forces on already compromised teeth.
• Pathological Tooth Mobility: Typically Grade II-III mobility (significant movement horizontally and often vertically).
• Tooth Displacement and Drifting.

The key diagnostic criteria that allow a diagnosis of "chronic generalized severe periodontitis" (corresponding to Stage III or Stage IV periodontitis in newer classifications, often with a high Grade of progression) are:

• Presence of Deep Periodontal Pockets: Generally probing depths greater than 5-6 mm, often much deeper.
• Severe Alveolar Bone Resorption: Radiographic evidence showing thinning, dissolution, and loss of the bone tissue of the alveolar process extending to more than ½ of the root length. In very advanced cases, complete absence of interdental bone tissue around certain teeth is possible. Bone loss patterns can be horizontal, vertical (angular), or a combination. Furcation involvement in multi-rooted teeth is common.

Diagnostic Procedures and Consultations

When examining patients with suspected severe chronic generalized periodontitis, the following diagnostic manipulations are performed to confirm the diagnosis and formulate a comprehensive treatment plan:

1. Thorough Patient Questioning (Anamnesis): Detailed dental and medical history, symptom review, risk factor assessment.
2. Comprehensive Clinical Oral and Periodontal Examination.
3. Periodontal Probing: Meticulous measurement of pocket depths, clinical attachment levels, bleeding on probing, suppuration, and furcation involvement around all teeth.
4. Determination of Tooth Mobility: Grading the mobility of each tooth.
5. Plaque and Calculus Assessment: Indication and quantitative assessment of "dental" plaque and calculus.
6. Schiller-Pisarev Test (Historical): May be performed but is less critical than probing and radiographic assessment.
7. Radiographic Examination: Essential for severe periodontitis. An orthopantomogram (panoramic X-ray) and/or a full-mouth series of periapical radiographs are necessary to accurately assess the extent and pattern of bone loss around all teeth.
8. Systemic Health Evaluation: A clinical blood test (CBC) and a blood test for glucose are performed to assess general health and screen for conditions like diabetes that significantly impact periodontal disease.
9. Consultations: Patients with severe chronic generalized periodontitis will require consultation with an orthopedic dentist (prosthodontist or restorative dentist) for planning complex restorative and prosthetic treatment, including occlusal management and splinting. Consultation with an internist or other medical specialists may be necessary if systemic conditions are present or suspected.

Treatment of Severe Chronic Generalized Periodontitis

The course of treatment for severe chronic generalized periodontitis is intensive, often consisting of 8-12 or more visits and lasting 20-40 days for the active phase, depending on the condition of the dentition, patient compliance, and the chosen treatment tactics. It requires a highly individualized and often multidisciplinary approach.

Treatment Goals and Challenges

The primary goals are to arrest disease progression, reduce inflammation, eliminate infection, reduce pocket depths, stabilize teeth, improve function and aesthetics where possible, and ultimately, to maintain the remaining dentition for as long as feasible. However, due to the advanced nature of tissue destruction, complete regeneration is often not possible, and the prognosis for some teeth may be questionable or poor.

Initial Phase: Disease Control and Oral Hygiene

1. First Visit and Treatment Planning: After a thorough examination and diagnosis, a comprehensive rehabilitation plan for the oral cavity and treatment of periodontal pathology is outlined. This includes:
   • Identifying teeth that are to be extracted (often those with pocket depths greater than 8-10 mm, Grade III mobility, or severe bone loss making them non-restorable).
   • Collaborating with an orthopedic dentist to plan prosthetic treatment, which may involve selective grinding of teeth to eliminate traumatic occlusion, temporary splinting of mobile teeth, direct provisional restorations, and planning for permanent prostheses with splinting elements if needed.
2. Initial Periodontal Therapy (Multiple Visits): During the first 3-4 visits, the focus is on:
   • Meticulous removal of supra- and subgingival dental deposits (scaling and root planing).
   • Irrigation of periodontal pockets with antiseptic solutions (e.g., 0.12% chlorhexidine, 1% hydrogen peroxide, historically 0.2% furacilin).
   • Application of antimicrobial/anti-inflammatory pastes or gels to the gums or direct injection into periodontal pockets (e.g., containing antiseptics, metronidazole, proteolytic enzymes like trypsin, stomatozyme, imozimase – historical use of enzymes; or sorbents like helevin, digispon – historical).
3. Oral Hygiene Instruction (OHI): Intensive education and training on proper oral hygiene techniques, selection of toothbrushes and toothpastes (often with anti-inflammatory/antimicrobial effects), and use of interdental cleaning aids (floss, interdental brushes). Home care may include oral baths with 0.06% chlorhexidine, 0.2% furacilin, 1% hydrogen peroxide, or herbal decoctions (chamomile, sage, calendula) 3-4 times daily for 20 minutes after meals during the acute control phase. Oral hygiene effectiveness is monitored throughout treatment.

Pharmacological Therapy (Systemic and Local)

• Systemic Antibiotics: Often indicated in severe chronic generalized periodontitis, especially during active phases or if aggressive features are present.
  • Metronidazole may be prescribed, for example: day 1 - 0.5 g twice daily (12-hour interval); day 2 - 0.25 g three times daily (8-hour interval); next 4 days - 0.25 g twice daily (12-hour interval). Metronidazole is typically taken with or after meals.
  • With persistent suppuration from periodontal pockets or in the presence of significant concomitant systemic pathology, other antibiotics like lincomycin (e.g., 0.5 g four times daily, 1-2 hours before meals for 5-10 days) or a combination of amoxicillin and metronidazole may be prescribed. Antibiotic choice should ideally be guided by microbial testing if available.
• Adjunctive Physiotherapeutic Treatment: A course of 5-7 procedures may be prescribed in parallel with drug therapy to aid in antimicrobial and anti-inflammatory effects:
  • Short ultraviolet irradiation of the gums.
  • Gum hydromassage.
  • Anode-galvanization or iontophoresis of medicinal substances with nicotinic acid from the anode.
  • Local hypothermia.
  • Helium-neon laser (LLLT).

Surgical Phase: Flap Operations and Regenerative Techniques

After the initial control of inflammatory phenomena, surgical treatment is often necessary to address residual deep pockets and bone defects. **Periodontal flap operations** are commonly performed (often segmentally, e.g., in the area of 6-8 teeth at a time). This involves:

• Reflecting a gingival flap to gain access to root surfaces and underlying bone.
• Thorough debridement of granulation tissue, subgingival plaque, and calculus.
• Root surface detoxification.
• Correction of osseous (bone) defects (osteoplasty, ostectomy).
• Potential use of regenerative materials (bone grafts, guided tissue regeneration - GTR membranes, growth factors) to attempt to rebuild lost periodontal structures, especially in intrabony defects. The goal is to stimulate reparative osteogenesis (bone formation).
• Repositioning and suturing the flap, sometimes with gingival margin correction (gingivectomy/gingivoplasty).

The main surgical goal in severe chronic generalized periodontitis is the elimination or significant reduction of periodontal pockets to create an oral environment maintainable by the patient and dental professional.

Restorative and Maintenance Phase

Following the active (surgical and non-surgical) treatment phase, measures are taken to normalize microcirculation and homeostasis in the periodontal tissues. This can include:

• Further physiotherapy (e.g., cathode-galvanization or iontophoresis from the cathode with nicotinic acid, aloe extract, heparin; darsonvalization of gums; local hypo-/hyperthermia) – a course of 5-10 procedures.
• Injections of medicinal substances (vitamins, stimulating agents) into the transitional fold (mucobuccal fold) – a course of 10-12 injections (less common in many modern protocols).
• "General effects" drugs aimed at improving overall host response.

Mandatory Orthopedic (Restorative/Prosthetic) Treatment: This is planned considering the functional state of the remaining periodontal tissues and the dentoalveolar system as a whole. It may involve occlusal adjustment, splinting of mobile teeth, and replacement of missing teeth with fixed or removable prostheses to restore function and stability.

It must be recognized that despite utilizing the entire arsenal of periodontal therapy means and methods, treatment of severe periodontitis is rarely completely "successful" in terms of full tissue regeneration and does not always lead to very long-term, effortless remission without diligent patient cooperation and professional support. Therefore, the efforts of dentists and public health education should be aimed primarily at the early identification and treatment of the initial stages of inflammatory periodontal pathology – namely, chronic catarrhal gingivitis and mild periodontitis – to prevent progression to severe, debilitating forms.

Differential Diagnosis of Advanced Periodontal Destruction

Severe generalized periodontitis needs to be differentiated from other conditions causing significant periodontal breakdown, though it is often the most common cause of such advanced destruction in adults.

Prognosis and Factors Influencing Outcomes

The prognosis for teeth affected by severe chronic generalized periodontitis is often guarded to poor, depending on the extent of remaining bone support, tooth mobility, furcation involvement, patient compliance, and presence of systemic risk factors. While treatment can halt disease progression and maintain teeth for a period, long-term retention of all teeth is challenging.

Factors influencing prognosis include:

• Initial severity of bone loss and pocket depth.
• Patient's commitment to oral hygiene and maintenance.
• Smoking status (smokers have a significantly poorer prognosis).
• Control of systemic diseases like diabetes.
• Effectiveness of occlusal therapy and splinting.
• Strategic value of individual teeth in an overall restorative plan.

Emphasis on Early Detection and Prevention

Given the challenges in treating severe periodontitis and the often-limited outcomes in terms of complete tissue regeneration, the primary emphasis in dental public health and clinical practice should be on:

• Preventing the initiation of gingivitis through effective oral hygiene and regular dental care.
• Early detection and treatment of gingivitis and mild periodontitis to prevent progression to more severe forms.
• Risk factor assessment and modification (e.g., smoking cessation, diabetes control).

When to Seek Specialized Periodontal Care

Patients with severe chronic generalized periodontitis require specialized care from a periodontist. Referral is indicated for:

• Diagnosis and comprehensive treatment planning for advanced disease.
• Complex surgical procedures, including regenerative therapies and mucogingival surgery.
• Management of cases refractory to initial therapy.
• Patients with significant systemic health factors complicating periodontal management.
• Long-term specialized periodontal maintenance.