Chronic periodontitis in the stage of exacerbation of the mcb. How to understand the forms of periodontitis: classification will help in the treatment of the disease? Acute periodontitis is divided into

Periodontal inflammation for many years has been of great and genuine interest to researchers, including in terms of systematization of this disease. It must be said that the classification of periodontitis in a variant that would suit everyone and would not raise questions or complaints has not actually been created at this point in time.

Important! This disease, along with periodontitis and periodontal disease, is one of the causes of early tooth loss, as it affects the periodontal tissues that firmly hold the tooth in the hole - that is, the ligamentous apparatus itself.

General information about the disease

Periodontium is a connective tissue that fills the entire area located between the tooth (more precisely, its root) and the bone bed. The inflammatory process that occurs in this space is called periodontitis. There are vessels and nerves in the periodontium, the purpose of which is to nourish the tooth with all the substances it needs (yes, not only the pulp does this), so its role is difficult to overestimate. Its main functions are to reduce and evenly distribute the load that falls on the bone tissue during the intake and chewing of food.

The development of the disease can be caused by various reasons, but the most likely and common include the following:

• infectious tissue damage: periodontitis in this case can be a complication if it is ignored for a long time (this is the most common cause) or be associated with inflammation of adjacent tissues in other diseases, for example, sinusitis or osteomyelitis,
• consequences of a certain treatment: during the treatment of various inflammatory processes, in particular pulpitis, a variety of medicines are used, which, if they enter the tissues, can cause irritation and allergic reactions,

Important! When it comes to the treatment of pulpitis, it is very important to consult a professional doctor. He must send you for x-rays without fail, you need to do this more than once. Pictures are obtained during the treatment process, monitoring the quality of work and eliminating possible errors.

• primary disease: if you start or pulpitis, then tooth decay occurs, and sources of inflammation can penetrate into the periodontium,
• poor quality: the doctor may make a mistake and seal the canals poorly, thereby provoking the penetration of the infection inside. Poorly done work can cause an inflammatory process in the area that was not affected at all during the treatment. Also, for example, the banal breaking off of the instrument and its untimely removal from the canals of the tooth can cause the appearance of the disease,
• weakened immunity: it also happens that the problem manifests itself after viral infections, colds or during periods of stress, hormonal changes. Even simple hypothermia can increase the risk of getting a problem.

Disease classification

There are a large number of different options for systematizing the disease. But despite this fact, all of them, along with advantages, have certain disadvantages. As for Russia, the methods of WHO and some individual representatives of the medical profession deserve the greatest respect here. Among the latter, Lukomsky's variant stands out clearly.

For example, the World Health Organization version has many advantages, but its use is hampered by the imperfect diagnostic methods used in practice. Be sure to read about this type of classification in full detail below.

In Russian dentistry, a classification that focuses on the forms of the disease and its exacerbations is still popular.

So, periodontitis can be both ordinary and purulent, chronic and acute, drug-induced, infectious and traumatic. Most often, it occurs at the top of the tooth root and is called "apical", much less often, patients are tormented by the marginal form of the disease, which first affects the gum or mucous membrane.

Apical or apical periodontitis

Clinical manifestations of the apical form of the disease are found in patients in most cases, that is, apical periodontitis is one of the most common forms.

The disease got this name because of its localization, since the top of the tooth root is affected, and if no measures are taken, then periodontal disease also occurs. The course of the disease can take place in different ways, and depending on this factor, either acute or chronic forms of periodontitis are distinguished, as well as either infectious or non-infectious nature of the disease. At the same time, the symptoms of the acute form are pronounced, in particular:

• throbbing pain, which is sharp and intense in nature,
• increased pain after any mechanical impact on the tooth: in the process of eating, chewing food, closing the jaws, during daily oral hygiene with a brush,
• radiating pain to other areas, such as the neck, ear or eye,
• swelling of the soft tissues of the mucosa on the affected side,
• tooth mobility,
• redness or blueness of the gums associated with circulatory disorders: the symptom is quite alarming, and untimely treatment can lead to tooth loss,
• bleeding gums: it can disturb even during hours of relative rest and at night,
• swollen lymph nodes,
• increase in body temperature: in this case it is insignificant,
• headache and general weakness.

The process of inflammation is characterized by the fact that periods of exacerbation are replaced by remission. This is very dangerous, as some people lose their vigilance as a result and are in no hurry to seek qualified help.

As for the vivid symptoms, it manifests itself precisely in the stage of exacerbation and may indicate the development of a serous and even purulent process. When it occurs, you feel:

• pain while eating
• the appearance of fistulas on the gums, as well as purulent discharge,
• unpleasant pungent odor from the mouth,
• swelling of the soft tissues of the face.

Disease in the chronic stage

The transition of the disease to the chronic stage usually occurs in the absence of proper treatment, however, in some cases, a chronic disease develops initially. Symptoms with this scenario are rather weak, these include darkening of the enamel and mild pain in the tooth when pressure is applied to it.

There are three types of chronic stage of periodontitis:

1. : foci of inflammation are characterized by blurring, the gum becomes red, there is a slight pain (it occurs arbitrarily, mainly due to temperature irritants) and slight discomfort, an unpleasant odor is felt from the mouth of a sick person, a fistula with purulent discharge may form. This form is characterized by increased activity and very quickly contributes to the destruction of bone tissue, which is gradually replaced by loose granulation,
2. : a granuloma develops around the tissues, which is a cavity, the shell of which consists of fibrous tissue, and inside it is filled with granulations. The focus has a rounded shape, its edges are outlined clearly and clearly, with complications, a periradicular cyst may form. They talk about a granuloma when the formation does not exceed 0.5 centimeters in diameter, and about a cyst when a dense sac with pus reaches a size of 1 or more centimeters. In the presence of a granuloma near the root of the tooth, the patient experiences practically no discomfort and anxiety, therefore, destructive processes can occur imperceptibly for the time being, especially if a person ignores annual preventive examinations,
3. : this stage is characterized by loss of sensitivity and pain, the pulp becomes necrotic, which leads to the appearance of a fetid odor from the mouth and indicates the development of a gangrenous process. The upper part of the tooth root expands, the periodontal gap is deformed, the tooth itself becomes mobile. Diagnosis is much more complicated, since there are no complaints of discomfort and pain, the problem can only be noticed with the help of an x-ray.

Important! Recently, with such serious lesions as periodontitis, doctors advise patients to undergo not an x-ray, but a computed tomography. This diagnostic method allows you to more accurately determine the nature of the problem, as well as the condition of the tissues surrounding the tooth. The accuracy of diagnostic data allows for the most effective treatment.

Chronic form in the acute stage

A chronic disease can worsen with some frequency. While there is a remission, the person does not feel any discomfort. However, the following symptoms may indicate the onset of an exacerbation:

• swelling of tissues in the area of ​​​​inflammation, and not only the gums, but also parts of the face,
• the appearance of fistulas with pus,
• the appearance of acute pain (although it may not be),
• fever and swollen lymph nodes.

Ignoring an exacerbation can lead to serious troubles and complications, to intoxication of the whole body, so a visit to a doctor is mandatory.

Types of disease, based on the causes of development

Due to its formation (etiology), periodontitis has a different pathogenesis (i.e., the causes of formation) and is divided into the following types:

1. infectious: this form is associated with the action of toxins that secrete harmful microorganisms that managed to penetrate into periodontal tissues and provoked the process of inflammation. The most striking example of this is pulpitis not cured in time,
2. : occurs as a result of the impact of traumatic factors on periodontal tissues. For example, it can be various bruises resulting from blows, accidents, falls, fights. The reason is the occupation of traumatic sports. Often the disease occurs in children due to a mobile lifestyle and poor self-control. In addition, a lesion of this form can also occur with constant overload of the teeth, when a prosthesis, bridge or even a filling was installed poorly,
3. drug: the appearance of this form is facilitated by the action of a chemical, for example, arsenic paste. The problem can also appear as a result of long-term antibiotic treatment. Periodontitis can also be caused by poor-quality cleaning of the canals, as a result of which the remaining organic material becomes the cause of pus in the root of the tooth. It is also possible that during the filling it was not possible to fill the entire cavity, and pathogenic bacteria penetrate into the remaining free space, which leads to inflammation of the tissues. Here we can talk about the occurrence of an allergy in the patient to the components of various drugs and medicines.

Types of periodontitis, based on origin (etiology)

Due to its formation (etiology), periodontitis is divided into:

1. Infectious. This form of the disease is associated with the action of toxins that secrete harmful microorganisms that managed to penetrate into the bone tissue and provoked the process of inflammation.
2. . It occurs as a result of the impact of traumatic factors on periodontal tissues, for example, various bruises resulting from blows.
3. Medical. The appearance of this form is facilitated by the action of a chemical, for example, arsenic paste.
4. Iatrogenic. It is caused by poor-quality cleaning of the canals, as a result of which the remaining organic material becomes the cause of pus in the root of the tooth. It is also possible that during the filling it was not possible to fill the entire cavity, and pathogenic bacteria penetrate into the remaining free space, which leads to inflammation of the tissues.

Classification according to Lukomsky

This version of the classification is very popular in our country - it involves the following division:

1. acute periodontitis, which may have either form,
2. chronic, subdivided into fibrous, granulating and granulomatous forms, respectively.

Classification according to ICD-10 (WHO)

The classification of periodontitis from the World Health Organization (WHO) is based on a comprehensive approach to this topic, since it includes not only the chronic form and acute manifestation of the disease, but also the typical, most common types of complications. Periodontitis in the ICD-10 is placed in section K04, that is, in the one that is devoted to diseases of the apical tissues:

• K04.4: Acute apical periodontitis of a tooth of pulpal origin. This option is one of the classic ones, while the cause of the disease and its manifestations are indicated clearly and clearly. For the dentist, the first task is to relieve the severity of inflammation and eliminate the source of infection with conservative methods of treatment,
• K04.5: Chronic apical periodontitis. The focus of infection becomes an apical granuloma, which can grow to a very large size, in which case surgery and surgery are applicable,
• K04.6: Periapical abscess with fistula. In turn, it is subdivided into dental, dentoalveolar and periodontal abscesses of pulpal origin. Fistulas can communicate with the oral and nasal cavities, skin and maxillary sinus, depending on this factor, they are classified according to
• K04.7: Periapical abscess without fistula. It can present as a dental, periodontal, and dentoalveolar abscess, as well as a periapical variant without a fistula,
• K04.8: A radicular cyst, which may be lateral or apical and requires a more serious approach to treatment, including surgical intervention. The conservative option is based on the drainage of the cyst cavity and the elimination of the microflora that supports its growth.

How is the treatment carried out

It is important to tune in to the fact that the treatment process will take a fairly long period of time. In this case, the doctor will have to visit more than once. The most important thing that the main manipulations will be aimed at is to eliminate the inflammatory process and try to save the tooth. This can be done through therapeutic methods. It is also worth paying special attention to oral care at home, taking medications prescribed by a doctor.

Important! If left untreated, it is fraught with complications. And we are talking here not only about the formation of cysts and fistulas, but also about osteomyelitis, sepsis or blood poisoning.

First of all, due to the fact that the disease most often occurs as a result of untreated pulpitis, it is with him that treatment should begin. The doctor without fail performs depulpation or removal of the nerve, then lays the drug, designed to eliminate the inflammatory process, including from the tissues around the root. From above, the medicines are closed with a temporary filling (if the process is purulent or sharp, the tooth is left open). In particularly severe cases, it may be necessary to incise the gums and install a drain. Then, the doctor will monitor the condition of the tissues by means of X-rays, and after their restoration, he will install a permanent filling.

How to prevent the development of pathology

On a note! The main factor contributing to the prevention of the onset of the disease is proper attention to oral hygiene and timely visits to the dentist. Annual preventive examinations will help to detect the problem in time and proceed with its immediate elimination.

It should be remembered that any pain when eating, injury or prolonged action of medications become a reason for a mandatory visit to the dentist. Naturally, the rule of preventive examination, which should be performed at least once every six months, is not canceled. The sooner the disease is detected, the less losses will be its treatment.

Pay special attention to the prevention of the disease in your children. After all, it is dangerous and can directly affect the formation of a permanent bite in the absence of measures for the treatment of milk teeth.

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Periodontitis- inflammation of the tissues surrounding the root / roots of the tooth.

Code according to the international classification of diseases ICD-10:

The reasons

Pathogenesis. Under the influence of infection, toxins, drugs or trauma, hyperergic type inflammation develops in the periodontium, which also involves the surrounding soft tissues. In trauma, a rupture of the vascular-nerve bundle occurs. Sometimes the process extends to neighboring teeth. The process usually progresses rapidly, but in patients with reduced immunity, the process initially becomes chronic. During the progression of the process, inflammatory changes capture the cortical plate of the hole, and then the adjacent bone tissue, where foci of osteoporosis, rarefaction and destruction are formed. The periapical focus has a sensitizing effect on the body, leading to the development of diseases of certain organs and systems.
Classification. According to the nature of the course, acute and chronic periodontitis are distinguished. Acute (by the type of exudative) periodontitis is divided into serous and purulent. Chronic periodontitis is divided into fibrous, granulating and granulomatous. Separately allocate exacerbation of chronic periodontitis.

Symptoms (signs)

Clinical manifestations depend on the nature of the process.
. Acute periodontitis. Sharp pains in the area of ​​the "causal" tooth, aggravated by touching it. The pain is caused by the accumulation of exudate in the periodontal space. The color of the “causative” tooth is changed, the tooth is mobile, it may have a carious cavity, but it may be intact. Probing the entrance to the tooth cavity and the mouths of the canals is painless, the reaction to percussion is sharply painful. the gum is edematous, hyperemic, sharply infiltrated. Submandibular lymph nodes are enlarged, painful on palpation. The body temperature is increased to 37-37.5 ° C .. With the formation of a subperiosteal abscess or a breakthrough of pus, the severity of symptoms decreases .. The duration of the acute stage ranges from 2-3 days to 1.5 weeks.
. Chronic periodontitis .. It proceeds sluggishly, accompanied by bad breath and a feeling of discomfort when eating .. There is a large carious cavity connected to the tooth cavity, however, probing the orifices of the canals is painless, temperature tests are not pronounced, percussion is weak or painless .. Threshold of electrical excitability more than 100 µA. ).
instrumental data. In acute periodontitis, radiological manifestations are not detected. In chronic periodontitis, radiographically clearly determine the picture of one form or another of the lesion: .. with fibrous periodontitis - the appearance of fuzziness of the cortical plate of the hole and the expansion of the periodontal gap .. with granulating periodontitis - the presence of a focus of rarefaction of bone tissue of irregular shape with fuzzy contours .. with granulomatous periodontitis - the center of destruction of the correct form with clear edges.
Differential Diagnosis. Chronic deep caries. Acute purulent pulpitis. Chronic gangrenous pulpitis. periodontal abscess. Acute or chronic osteomyelitis of the alveolar process of the jaw. Chronic sinusitis.

Treatment

TREATMENT
Conservative e (instrumental) methods are aimed at preserving the tooth. At the same time, the passage of all root canals of the tooth with subsequent instrumental processing, as well as the impact on the inflammatory focus in the apex area, is considered mandatory. The endodontic instrument (reamers, files, etc.) is strictly calibrated according to the length of the root, for which its length is initially determined either by radiological or instrumental (with the help of an apex locator) method. The root canal prepared as a result of endodontic and medical treatment is filled with gutta-percha or other special material. The tooth is restored with a filling, inlay, crown. All stages of treatment and dynamic observation are controlled by radiographs. For faster relief of the inflammatory process and stimulation of ossification processes, physiotherapeutic methods of exposure are widely used: UHF and microwave therapy, electrophoresis, ultrasound, etc.
Surgical methods vary depending on the tasks and can be combined with conservative methods. In the presence of an abscess, it is opened to create an outflow of exudate. To eliminate the focus of destruction after filling the root canal, the operation of resection of the root apex is performed. Hemisection is used to preserve individual roots. In some cases, the "causal" tooth must be removed. It is also possible to replant the tooth.
General treatment indicated for acute process or exacerbation of chronic inflammation; it includes the use of antibiotics, antipyretics and pain medications. Often, even with an asymptomatic course of chronic periodontitis, endodontic treatment is carried out against the background of antibiotic therapy, which additionally serves as a prevention of the development of transient bacteremia.
Complications. Periostitis or osteomyelitis of the alveolar process. Phlegmon of soft tissues. Sinusitis.
Synonym. Apical periodontitis.

ICD-10. K04 Diseases of the pulp and periapical tissues

Periodontitis is an inflammation of the periodontium, characterized by a violation of the integrity of the ligaments that hold the tooth in the alveolus, the cortical plate of the bone surrounding the tooth, and bone resorption from small sizes to the formation of large cysts.

Classification

Classification by clinical course

Acute periodontitis . Depending on the nature of the exudate, acute serous and acute purulent are distinguished. But this distinction is not always possible, moreover, the transition of the serous form to the purulent one occurs quite quickly and depends on certain conditions.

Chronic periodontitis. It is divided on the basis of the nature and degree of damage to periodontal tissues and bone. Allocate chronic fibrous periodontitis , chronic granulating and chronic granulomatous periodontitis .

Chronic periodontitis in the acute stage. According to the clinical course, it is similar to acute forms, but has its own characteristics, for example, the presence of destructive changes in the bone tissue.

Origin

Infectious periodontitis . It develops due to the penetration of bacteria and their toxins into periodontal tissues with the subsequent development of inflammation in them.

Traumatic periodontitis . Caused as a result of exposure to the periodontal traumatic factor. This can be a severe single injury, such as a blow or a bruised tooth. And there may be a long-term, low-intensity microtrauma, for example, an overestimated filling, a “straight” bite, overload of teeth, or bad habits.

Medical periodontitis . It occurs due to the penetration of potent chemicals, such as arsenic paste, formalin, phenol, etc.

Classification of periodontitis ICD-10

Acute apical periodontitis NOS

K04.5 Chronic apical periodontitis

Apical granuloma

dental

dentoalveolar

dental abscess

Dentoalveolar abscess

K04.8 Root cyst

apical (periodontal)

periapical

K04.80 Apical and lateral

K04.81 Residual

Classification of periodontitis

Periodontitis (periodontitis) - inflammation of the tissues located in the periodontal gap (periodontitis), - can be infectious, traumatic and drug-induced.

Infectious periodontitis occurs with the introduction of autoinfection located in the oral cavity. The root sheath at the top of the tooth is more often affected, less often - the marginal periodontium.

Traumatic periodontitis develops as a result of both a single (blow, bruise) and chronic injury (violation of occlusion when the height of the tooth is increased by an artificial crown, filling; in the presence of bad habits - holding nails in the teeth, biting threads, husking seeds, cracking nuts, etc.). Drug-induced periodontitis can occur in the treatment of pulpitis, when potent medicinal substances are used in the treatment of the canal, and also due to an allergic reaction of the periodontium to drugs. In clinical practice, infectious apical periodontitis is the most common.

According to the clinical picture and pathoanatomical changes, inflammatory periodontal lesions can be divided into the following groups (according to I.G. Lukomsky): I. Acute periodontitis 1. Serous (limited and diffuse) 2. Purulent (limited and diffuse)

II. Chronic periodontitis 1. Granulating 2. Granulomatous 3. Fibrous

III. Chronic periodontitis in the acute stage.

WHO classification of periodontitis (ICD-10)

K04 Diseases of the periapical tissues

K04.4 Acute apical periodontitis of pulpal origin

Acute apical periodontitis NOS

K04.5 Chronic apical periodontitis t

Apical granuloma

K04.6 Periapical abscess with fistula

dental

dentoalveolar

periodontal abscess of pulpal origin.

K04.60 Having communication [fistula] with maxillary sinus

K04.61 Communicating [fistula] with nasal cavity

K04.62 Having a communication [fistula] with the oral cavity

K04.63 Having communication [fistula] with skin

K04.69 Periapical abscess with fistula, unspecified

K04.7 Periapical abscess without fistula

dental abscess

Dentoalveolar abscess

Periodontal abscess of pulpal origin

Periapical abscess without fistula

K04.8 Root cyst

apical (periodontal)

periapical

K04.80 Apical and lateral

K04.81 Residual

K04.82 Inflammatory paradental

K04.89 Root cyst, unspecified

K04.9 Other and unspecified diseases of periapical tissues

Acute periodontitis

Acute periodontitis - acute periodontal inflammation.

Etiology. Acute purulent periodontitis develops under the influence of mixed flora, where streptococci(mostly non-hemolytic, as well as green and hemolytic), sometimes staphylococci and pneumococci. Possible rod-shaped forms (gram-positive and gram-negative), anaerobic infection, which is represented by an obligate anaerobic infection, non-fermentative gram-negative bacteria, veillonella, lactobacilli, yeast-like fungi. With untreated forms of apical periodontitis, microbial associations include 3-7 species. Pure cultures are rarely isolated. With marginal periodontitis, in addition to the listed microbes, a large number of spirochetes, actinomycetes, including pigment-forming ones. Pathogenesis. Acute inflammatory process in the periodontium primarily occurs as a result of infection penetration through the hole in the apex of the tooth, less often through the pathological periodontal pocket. The defeat of the apical part of the periodontium is possible with inflammatory changes in the pulp, its necrosis, when the abundant microflora of the tooth canal spreads into the periodontium through the apical opening of the root. Sometimes the putrefactive contents of the root canal are pushed into the periodontium during chewing, under the pressure of food.

Marginal, or marginal, periodontitis develops as a result of infection penetrating through the gingival pocket in case of injury, ingestion of medicinal substances, including arsenic paste, on the gum. Microbes that have penetrated into the periodontal gap multiply, form endotoxins and cause inflammation in periodontal tissues.

Of great importance in the development of the primary acute process in periodontium are some local features: the absence of outflow from the pulp chamber and canal (the presence of an unopened pulp chamber, fillings), microtrauma during active chewing load on a tooth with an affected pulp.

Common causes also play a role: hypothermia, past infections, etc., but most often the primary effect of microbes and their toxins is compensated by various non-specific and specific reactions of periodontal tissues and the body as a whole. Then there is no acute infectious-inflammatory process. Repeated, sometimes prolonged exposure to microbes and their toxins leads to sensitization, antibody-dependent and cellular reactions develop. BUT antibody-dependent reactions develop as a result of immunocomplex and IgE conditioned processes. Cellular responses reflect a delayed-type hypersensitivity reaction..

The mechanism of immune reactions, on the one hand, is due to a violation of phagocytosis, the complement system and an increase in polymorphonuclear leukocytes; on the other hand, by the multiplication of lymphocytes and the release of lymphokines from them, causing the destruction of periodontal tissues and resorption of the nearby bone.

Various cellular reactions develop in the periodontium: chronic fibrous, granulating or granulomatous periodontitis. Violation of protective reactions and repeated exposure to microbes can cause the development of an acute inflammatory process in the periodontium, which in essence is an exacerbation of chronic periodontitis. Clinically, they are often the first symptoms of inflammation. The development of pronounced vascular reactions in a rather closed periodontal space, an adequate response protective reaction of the body, as a rule, contribute to inflammation with a normergic inflammatory reaction.

The compensatory nature of the response of periodontal tissues in the primary acute process and exacerbation of the chronic is limited by the development of an abscess in the periodontium. It can be emptied through the root canal, gingival pocket when opening the periapical lesion or extracting a tooth. In some cases, under certain general and local pathogenetic conditions, a purulent focus is the cause of complications of an odontogenic infection, when purulent diseases develop in the periosteum, bone, and perimaxillary soft tissues.

Pathological anatomy. In an acute process in the periodontium, the main phenomena of inflammation appear - alteration, exudation and proliferation.

Acute periodontitis is characterized by the development of two phases - intoxication and a pronounced exudative process.

In the phase of intoxication, various cells migrate - macrophages, mononuclear cells, granulocytes, etc. - into the zone of accumulation of microbes. In the phase of the exudative process, inflammation increases, microabscesses form, periodontal tissues melt and a limited abscess forms. At microscopic examination in the initial stage of acute periodontitis, one can see hyperemia, edema and a small leukocyte infiltration of the periodontal area in the circumference of the root apex. During this period, perivascular lymphohistiocytic infiltrates containing single polynuclear cells are found. With the further increase of inflammatory phenomena, leukocyte infiltration intensifies, capturing more significant areas of the periodontium. Individual purulent foci are formed - microabscesses, periodontal tissues are melted. Microabscesses are interconnected, forming an abscess. When a tooth is removed, only separate preserved areas of sharply hyperemic periodontium are revealed, and the rest of the root is exposed and covered with pus.

An acute purulent process in the periodontium causes changes in the tissues surrounding it (the bone tissue of the walls of the alveolus, the periosteum of the alveolar process, the perimaxillary soft tissues, the tissues of the regional lymph nodes). First of all, the bone tissue of the alveoli changes. In the bone marrow spaces adjacent to the periodontium and located over a considerable distance, bone marrow edema and a varying degree of pronounced, sometimes diffuse, infiltration by neutrophilic leukocytes are noted. In the region of the cortical plate of the alveolus, lacunae appear, filled with osteoclasts, with a predominance of resorption (Fig. 7.1, a). In the walls of the hole and mainly in the area of ​​its bottom, a restructuring of the bone tissue is observed. The predominant resorption of the bone leads to the expansion of the holes in the walls of the hole and the opening of the bone marrow cavities towards the periodontium. There is no necrosis of bone beams (Fig. 7.1, b). Thus, the restriction of the periodontium from the bone of the alveoli is violated. In the periosteum covering the alveolar process, and sometimes the body of the jaw, in the adjacent soft tissues - gums, perimaxillary tissues - signs of reactive inflammation are recorded in the form of hyperemia, edema, and inflammatory changes - also in the lymph node or 2-3 nodes, respectively, to the affected periodontium of the tooth . They show inflammatory infiltration. In acute periodontitis, the focus of inflammation in the form of an abscess is mainly localized in the periodontal gap. Inflammatory changes in the bone of the alveoli and other tissues are reactive, perifocal in nature. And it is impossible to interpret reactive inflammatory changes, especially in the bone adjacent to the affected periodontium, as its true inflammation.

Clinical picture . In acute periodontitis, the patient indicates pain in the causative tooth, aggravated by pressure on it, chewing, and also by tapping (percussion) on its chewing or cutting surface. The sensation of "growth", elongation of the tooth is characteristic. With prolonged pressure on the tooth, the pain subsides somewhat. In the future, pain intensifies, becomes continuous or with short light intervals. They often pulsate.

Thermal exposure, the adoption by the patient of a horizontal position, touching the tooth, and biting increase pain. The pain spreads along the branches of the trigeminal nerve. The general condition of the patient is satisfactory. On external examination, there are usually no changes. Observe the increase and soreness of the lymph node or nodes associated with the affected tooth. In some patients, there may be an unsharply pronounced collateral edema of the perimaxillary soft tissues adjacent to this tooth. His percussion is painful both in the vertical and in the horizontal direction.

The mucous membrane of the gums, the alveolar process, and sometimes the transitional fold in the projection of the tooth root is hyperemic and edematous. Palpation of the alveolar process along the root, especially corresponding to the opening of the apex of the tooth, is painful. Sometimes, when pressing the instrument on the soft tissues of the vestibule of the mouth along the root and the transitional fold, an impression remains, indicating their swelling.

Diagnostics Temperature irritants, electrodontometry data indicate the absence of pulp reaction due to its necrosis. On the radiograph in the acute process of pathological changes in the periodontium, it is possible not to detect or to detect an expansion of the periodontal gap, blurring of the cortical plastics of the alveoli. With exacerbation of the chronic process, changes occur that are characteristic of granulating, granulomatous, rarely fibrous periodontitis. As a rule, there are no blood changes, but some patients may have leukocytosis (up to 9-10 9 /l), moderate neutrophilia due to stab and segmented leukocytes; ESR is often within the normal range.

Differential Diagnosis . Acute periodontitis is differentiated from acute pulpitis, periostitis, osteomyelitis of the jaw, suppuration of the root cyst, acute odontogenic sinusitis.

Unlike pulpitis in acute periodontitis, the pain is constant, with diffuse inflammation of the pulp - paroxysmal. In acute periodontitis, in contrast to acute pulpitis, inflammatory changes are observed in the gum adjacent to the tooth, percussion is more painful. In addition, the data of electroodontometry help the diagnosis.

Differential diagnosis of acute periodontitis and acute purulent periostitis of the jaw is based on more pronounced complaints, a febrile reaction, the presence of collateral inflammatory edema of the perimaxillary soft tissues and diffuse infiltration along the transitional fold of the jaw with the formation of a subperiosteal abscess.

Percussion of the tooth with periostitis of the jaw is not painful, in contrast to acute periodontitis. According to the same, more pronounced general and local symptoms, a differential diagnosis of acute periodontitis and acute osteomyelitis of the jaw is carried out. Acute osteomyelitis of the jaw is characterized by inflammatory changes in the adjacent soft tissues on both sides of the alveolar process and the body of the jaw. In acute periodontitis, percussion is sharply painful in the area of ​​one tooth, in osteomyelitis - several teeth. Moreover, the tooth, which was the source of the disease, reacts to percussion less than neighboring intact teeth. Laboratory data - leukocytosis, ESR, etc. - allow us to distinguish between these diseases.

Purulent periodontitis should be differentiated from suppuration of the periradicular cyst. The presence of a limited protrusion of the alveolar process, sometimes the absence of bone tissue in the center, displacement of the teeth, in contrast to acute periodontitis, characterize a festering periradicular cyst. On the radiograph of the cyst, an area of ​​bone resorption of a round or oval shape is found.

Acute purulent periodontitis must be differentiated from acute odontogenic inflammation of the maxillary sinus, in which pain can develop in one or more adjacent teeth. However, congestion of the corresponding half of the nose, purulent discharge from the nasal passage, headache, general malaise are characteristic of acute inflammation of the maxillary sinus. Violation of the transparency of the maxillary sinus, detected on the radiograph, allows you to clarify the diagnosis.

Treatment. Therapy of acute apical periodontitis or exacerbation of chronic periodontitis is aimed at stopping the inflammatory process in the periodontium and preventing the spread of purulent exudate into the surrounding tissues - the periosteum, maxillary soft tissues, bone. Treatment is predominantly conservative. Conservative treatment is more effective with infiltration or conduction anesthesia with 1-2% solutions of lidocaine, trimecaine, ultracaine.

Blockade contributes to a more rapid subsidence of inflammatory phenomena - the introduction of the type of infiltration anesthesia 5-10 ml of 0.25-0.5% anesthetic solution (lidocaine, trimecaine, ultracaine) with lincomycin into the vestibule of the mouth along the alveolar process, respectively, the affected and 2-3 adjacent teeth. The decongestant effect is provided by the introduction of the transitional fold of the homeopathic remedy "Traumeel" in the amount of 2 ml or external dressings with the ointment of this drug.

It must be borne in mind that without the outflow of exudate from the periodontium (through the canal of the tooth), blockades are ineffective, often ineffective. The latter can be combined with an incision along the transitional fold to the bone, with perforation with a burr of the anterior wall of the bone, corresponding to the near-apical section of the root. This is also shown with unsuccessful conservative therapy and an increase in inflammation, when it is not possible to remove a tooth due to some circumstances. With the ineffectiveness of therapeutic measures and an increase in inflammation, the tooth should be removed. Tooth extraction is indicated in case of its significant destruction, obstruction of the canal or canals, presence of foreign bodies in the canal. As a rule, tooth extraction leads to a rapid subsidence and subsequent disappearance of inflammatory phenomena. This can be combined with an incision along the transitional fold to the bone in the region of the root of a tooth affected by acute periodontitis. After tooth extraction during the primary acute process, curettage of the hole is not recommended, but it should only be washed with a solution of dioxidine, chlorhexidine and its derivatives, gramicidin. After tooth extraction, pain may increase, body temperature may rise, which is often due to the trauma of the intervention. However, after 1-2 days, these phenomena, especially with appropriate anti-inflammatory drug therapy, disappear.

To prevent complications after tooth extraction, antistaphylococcal plasma can be introduced into the dental alveolus, washed with streptococcal or staphylococcal bacteriophage, enzymes, chlorhexidine, gramicidin, an iodoform swab, a sponge with gentamicin can be left in the mouth. The general treatment of acute or exacerbation of chronic periodontitis consists in the appointment of pyrazolone drugs inside - analgin, amidopyrine (0.25-0.5 g each), phenacetin (0.25-0.5 g each), acetylsalicylic acid (0.25-0.5 g each). 0.5 g). These drugs have analgesic, anti-inflammatory and desensitizing properties. Individual patients, according to indications, are prescribed sulfanilamide preparations (streptocid, sulfadimesin - 0.5-1 g every 4 hours or sulfadimethoxine, sulfapiridazine - 1-2 g per day). However, the microflora, as a rule, is resistant to sulfanilamide preparations. In this regard, it is more expedient to prescribe 2-3 pyrozolone drugs (acetylsalicylic acid, analgin, amidopyrine), 1/4 tablet each, 3 times a day. This combination of drugs gives an anti-inflammatory, desensitizing and analgesic effect. In debilitated patients burdened with other diseases, especially the cardiovascular system, connective tissue, kidney diseases, antibiotics are treated - erythromycin, kanamycin, oletethrin (250,000 IU 4-6 times a day), lincomycin, indomethacin, voltaren (0, 25 g) 3-4 times a day. Foreign experts after the extraction of a tooth for an acute process necessarily recommend antibiotic treatment, considering such therapy also as a prevention of endocarditis, myocarditis. After tooth extraction in acute periodontitis, in order to stop the development of inflammatory phenomena, it is advisable to apply cold (an ice pack on the area of ​​soft tissues corresponding to the tooth for 1-2-3 hours). Further, warm rinses, sollux are prescribed, and when inflammation subsides, other physical methods of treatment are prescribed: UHF, fluctuorization, electrophoresis of diphenhydramine, calcium chloride, proteolytic enzymes, exposure to helium-neon and infrared lasers.

Exodus. With proper and timely conservative treatment, in most cases of acute and exacerbation of chronic periodontitis, recovery occurs. (Insufficient treatment of acute periodontitis leads to the development of a chronic process in the periodontium.) acute periostitis, osteomyelitis of the jaw, abscess, phlegmon, lymphadenitis, inflammation of the maxillary sinus may develop.

Prevention is based on the sanitation of the oral cavity, timely and correct treatment of pathological odontogenic foci, functional unloading of teeth with the help of orthopedic methods of treatment, as well as on hygiene and health measures.

The inflammatory process in the area of ​​the connective tissues surrounding the root of the tooth is called periodontitis.

The classification of the disease is of great importance, because the various forms of this pathology require an individual approach when choosing therapy.

Features of symptoms are determined using three schemes: classification by origin, according to ICD-10 (WHO) and according to Lukomsky.

Origin

The classification of periodontitis by origin is as follows:

Medicamentous and traumatic types of the disease may first manifest as aseptic periodontitis, but under the influence of pathogenic flora, they gradually become infectious.

According to ICD-10

This classification was proposed by the World Health Organization in order to take into account not only the main forms of periodontitis, but also the peculiarities of the complications that arise. This approach helps to more accurately select the methods of therapy and unite the efforts of specialists in the process of diagnosis and treatment.

The following forms of periodontitis are recognized:

1. acute apical- a classic version of the disease, in which it is necessary to remove the severity of the process and remove the source of infection:
2. chronic apical- an outdated focus with education. Surgical methods of influence are not excluded;
3. periapical abscess without fistula;
4. periapical abscess with- describes the etiology of the disease, taking into account the location of the gingival fistulas. When the infection passes into the maxillary sinus, you will need to consult an ENT doctor;
5. - requires either long-term conservative therapy with drainage of the cystic cavity, or rapid surgical intervention.

The success and duration of periodontal treatment depends on the timely visit to the doctor. An advanced form of the disease can lead to tooth loss and the development of dangerous complications.

According to Lukomsky

This type of diagnosis in modern dentistry is most in demand, since it describes all types of periodontitis, taking into account their specific differences.

Acute periodontitis is of two types:

Chronic apical periodontitis

Most often, the chronic stage is the result of acute periodontitis, although with weak immunity it sometimes develops on its own. Inflammation causes mild discomfort only when chewing food. However, a sluggish chronic process makes itself felt under the influence of cold or after suffering colds.

Orthopantomogram for periodontitis

Three forms of this pathology are known:

• fibrous. There is an expansion of the periodontium, in which the bone tissue has no signs of pathology. If such a process is detected after filling or endodontic treatment, additional therapy can be dispensed with. It is possible to determine the disease only with the help of an x-ray, where a noticeable increase in the periodontal gap will be recorded;
• granulating. In the region of the upper part of the root, a granular (granulation) red tissue is formed, which increases in size very quickly. This leads to the destruction of the bone and the periodic appearance of mild aching pain. In parallel, a fistula often forms on the gum, from which a small amount of pus can periodically come out. On x-ray, the inflammatory process looks like a darkening of an irregular shape;
• granulomatous. It looks like destruction of bone tissue near the upper or in the region of the lower third of the tooth root. Without timely therapy, the pathology gradually develops into a periradicular cyst. These formations come in different shapes, but are filled with pus and have the same structure. Symptoms of granulomatous periodontitis appear as an intermediate state between the mild fibrous form and the active stage of granulomatous periodontitis. At first, the disease does not actually manifest itself, but over time, it more and more actively reminds of itself with increasing pain.

Chronic periodontitis, as a rule, passes without a pronounced etiology. There is either a slight pain, or a certain discomfort when chewing and tapping on the tooth.

Exacerbation of the chronic form

Sluggish infectious processes in the periodontal area are periodically exacerbated, causing swelling of the gums, swelling of the cheeks, pronounced pain.

The following factors provoke changes in symptoms:

An exacerbation of chronic periodontitis on an x-ray looks like a chronic form, but all the symptoms of an acute stage are observed. Until the focus of infection is completely eliminated, sluggish inflammatory processes will periodically worsen.

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Periodontitis of teeth and its treatment:

An extensive classification of periodontitis, taking into account the characteristics of different forms of the course of the disease, is needed in order to select a more effective method of therapy. The picture of changes in the area of ​​the tops of the dental roots is so different that it requires an individual approach to the choice of medicines and methods of treatment itself. The duration of therapy also has its own characteristics. For example, the fibrous form of periodontitis requires several visits to the doctor during the week, and the granulating and granulomatous form is treated for at least two months with the use of special preparations. The sooner the patient seeks help from a dentist, the greater the chance of saving a bad tooth.

For many years, periodontal inflammation has not disregarded researchers, during which time they have proposed a large number of different options for systematizing the disease. However, to date, they have not been able to develop and come to a unified classification of periodontitis that fully meets the requirements of clinicians, and thus allows to achieve the determination of the resistant status of this pathology within the clinical and morphological level.

The classification of periodontitis developed by the World Health Organization, which, of course, has many advantages, does not solve this problem. The difficulty of developing and implementing such a classification can be associated with the imperfection of diagnostic methods that are used in clinical settings, when there is no correlation between the clinical manifestations of the disease and the nature of morphological changes.

When considering the classifications that are used on different continents, one can notice their obvious differences and contradictions. For example, in Russia and almost the entire post-Soviet space, the classification is still in progress, where the main emphasis is placed on serous, purulent, acute, chronic periodontitis. And also - on the form of an aggravated course of the disease. Plus on fibrous, granulating, granulomatous, etc.

In order to better understand the essence of the issue, you should get acquainted with the classification of periodontitis closer. The classification of periodontitis is carried out due to education (etiology), as well as characteristic features and developed methods of WHO and individual authors. In our country, the classification according to Lukomsky, WHO is used.

Based on origin (etiology)

Infectious. It develops as a result of the activation of bacteria and the toxins they secrete that have penetrated the bone tissue, after which the development of inflammatory processes in the periodontium begins.

Traumatic. This type is the result of exposure to periodontal tissues of traumatic factors. Severe one-time injuries, for example, blows or bruises of the teeth, can serve as such factors. It is not excluded the influence of long-term sluggish, low-intensity microtraumas, for example, protruding fillings, the presence of a “straight” bite, overload of the dentition, as well as the impact of bad habits.

medical. The formation of this type of periodontitis is such a factor as the penetration of a strong chemical, for example, arsenic paste.

Classification

There are many of them, but in our country these days they use the development of Lukomsky.

Acute periodontitis:

1. Serous;
2. Purulent.

Chronic periodontitis:

1. Fibrous;
2. Granulating;
3. Granulomatous.

In the late nineties, the World Health Organization proposed another variation of this classification:

• acute apical periodontitis;
• chronic apical periodontitis;
• periapical abscess with fistula;
• periapical abscess without fistula;
• radicular cyst;
• unspecified diseases of the dental pulp.

The acute form of this disease is distinguished by a sharp local pain, usually constant. First, it has not pronounced aching pains, localized in the corresponding area of ​​the damaged tooth. Later they become more intense, tearing and pulsating, irradiation occurs, which indicates purulent inflammation of the initial stage. The acute phase of the apical process lasts from two to fourteen days. Two stages are considered conditional:

1. It is characterized by periodontal intoxication at the beginning of the inflammatory process. Long, aching and incessant pains are noted. It is also characterized by increased sensitivity when healthy and diseased teeth come into contact. The tissues surrounding the tooth do not have any significant changes, vertical percussion gives a high sensitivity of the periodontium.
2. It is characterized by a pronounced exudative process, continuous pain. Bite and percussion are painful, pain occurs even with a slight touch of the tongue to the affected tooth. There is a symptom of growing teeth. It is characterized by irradiation of pain sensations. Inflammatory processes affect the fixation of diseased teeth, they become mobile. Soft tissues swell, and a reaction of the lymph nodes occurs. The patient experiences general weakness, headache, fever associated with toothache, up to 39 degrees and other ailments. X-ray changes in the periodontal not notes.

Spicy. According to the properties of the exudate, it is classified - acute serous, as well as purulent. But it is not always possible to distinguish between these characteristics, and the serous form passes into a purulent form within a short time, and is directly dependent on certain factors.

Chronic. It is subdivided based on the nature and extent of damage to periodontal tissue and bones.

Classify:

fibrous. It is difficult to diagnose this form, since patients do not have any pain. And also for the reason that according to clinical manifestations it happens that it does not differ from gangrenous pulpitis. A distinctive feature of this form of periodontitis is a change in the color of the teeth, crowns are intact, strong carious cavities, probing is not painfully noticeable. With percussion, there is no pain, as well as a response to temperature stimuli. The cavity often has necrosis of the pulp with an odor that is present in gangrene. As a rule, diagnosis is made on the basis of X-ray images, where a change in the periodontal gap can be clearly seen, represented by an extension extending to the top of the root, without accompanying alveolar resorption. This form may be a consequence of the outcome of acute inflammation. It can occur due to overload or when a significant part of the teeth is lost by the patient.

granulating. Quite often it manifests itself as weak pain sensations, as well as heaviness in the places of damage, bursting, awkwardness. The patient may experience pain when diseased teeth come into contact with healthy ones. Similar symptoms can occur from time to time and are often accompanied by a fistula with pus, as well as the ejection of granulation tissue. Such processes will soon take place. It is characterized by hyperemia of the gums near the affected tooth, which causes its deepening from the impact of the end of the instrument, and after exposure, the deepening disappears only after a while. The patient feels pain from touch. On percussion, an untreated tooth is sensitive and, at times, painful. Regional lymph nodes often enlarge and become painful. X-rays show areas of rarefaction of bone tissue in the region of the root apex.

granulomatous. This type of periodontitis in most cases proceeds without symptoms, sometimes the patient still cannot avoid an unpleasant feeling and mild pain when the jaws are closed. The anamnesis may also indicate past periodontal pathologies or pains that are associated with the onset of pulpitis. At the moment of localization of the granuloma in the region of the buccal root of the upper molar and premolar, which is characterized by protrusion of the bone, according to the parameters of the root apex.

It is perfectly acceptable:

• when a diseased tooth has no cavity affected by caries;
• crown color changed;
• there is a carious cavity and canals with decayed pulp;
• a filling can be inserted in the tooth, but of poor quality.

Percussion of the teeth often does not cause pain, palpation of the gums from the vestibular surface indicates painful swelling. X-ray examination shows clearly defined rarefaction of bone tissue of a roundish shape. Sometimes visible destruction of dental tissue in the area of ​​the tops and hypercementosis in the lateral parts of the roots. If the treatment is carried out correctly and on time, then a favorable outcome is possible: this form of periodontitis turns into fibrous. When such treatment is absent or incomplete filling of the root canals is carried out, a root cyst of the tooth is formed.

Chronic, having an exacerbation stage. By the nature of the course of the disease, it is similar to periodontitis in acute forms, but at the same time it has its own distinctive features, for example, the presence of a destructive change in bone tissue.

aggravated. According to the frequency of cases, the most exacerbation occurs in granulating and granulomatous periodontitis, less - fibrous. In view of the fact that destructive changes in the periodontium are a concomitant factor of exacerbation, the patient does not experience severe pain when he bites, the pain is much less than when acute purulent periodontitis occurs.

With regard to other symptoms (persistent pain, swelling, reactions and lymph nodes), they have the same sequence as is inherent in acute purulent periodontitis. There are deep carious cavities, and it does not matter whether the teeth have been treated or not, that is, they are filled or without a filling.

Probing does not cause pain, but there are sharp pains, especially when vertical percussion is performed. It is possible to change the color of the affected teeth, they become mobile. Examination reveals edema, hyperemia of the mucosa, often of the skin. It does not react to temperature stimuli, but the patient feels pain during palpation of the tissues in the area of ​​the tooth.

Chronic fibrous periodontitis in the stage of exacerbations is characterized by less clear boundaries on x-rays, new foci of rarefaction appear in osteoporosis. Granulomatous at this stage also loses its clear boundaries: the apical parts of the teeth have rarefaction of bone tissues and other pathologies. Exacerbated chronic granulating periodontitis is characterized by the severity of corroded contours of the focus.

Finally

The presence of a large number of different variations in the classifications of periodontitis, which allows us to conclude that each of them individually does not meet modern requirements and the advisability of adopting a single version. Until now, various classifications have been proposed. The desire to make everything compact and uniform is understandable.

Why are classifications needed? Are they so important that it is impossible to do without them? The answer is very simple. To improve the quality of treatment. After all, all this, of course, affects the rapid and correct diagnosis of a disease with concomitant diseases. All this will eventually affect the adoption of a particular treatment method. So, it will improve the situation in the fight against similar diseases in the future.

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