Classification of periodontitis and the causes of the development of the problem. What are: current types of classification of periodontitis Exacerbation of chronic periodontitis microbial

Ambiguous interpretations of the forms of periodontal inflammation and the main methods of treatment have given rise to many classifications proposed by the world's leading experts in this field of dentistry.

Periodontitis is an inflammatory disease of the periodontium, i.e. connective tissues surrounding the root of the tooth.

It is necessary to classify periodontitis according to a number of features because, with different forms of the course of this disease, treatment tactics can have significant differences.

Origin Classification

Infectious

This form of periodontitis is the most common. The reason for its occurrence is the microflora, most often penetrating into the periodontium from the root canal through the apical foramen.

Other ways of infection are the marginal (marginal) periodontium (with deep periodontal and bone pockets) and the periodontium of the adjacent tooth (with the formation of a cyst of a significant size that has grown to involve the roots of neighboring teeth in the process).

Photo: Marginal and lateral periodontitis

The possibility of microflora entering the periodontal area with the blood flow is regarded by a number of doctors as unlikely and is usually allowed for periodontitis with an unexplained etiology (cause).

Traumatic

Occurs when the periodontium is exposed to a load that exceeds its physiological capabilities.

Such an overload can be acute and short-term (blow, bruise) or chronic (tooth overload with a protruding filling, fixed or removable prosthesis, in case of malocclusion, with bad habits - holding a smoking pipe with front teeth, etc.).

Periodontal injury depends not only on the intensity of the traumatic factor, but also on the state of the periodontium itself. If the periodontium is severely damaged or significantly lost, for example, due to periodontal disease, then even a normal, physiological load can become traumatic.

medical

Occurs when irritating effects on periodontal drugs. This may be the action of erroneously applied substances that are not intended for use in the oral cavity, or necessary preparations, but in violation of the required technology or recommended concentration.

Photo: Medicamentous (arsenic) periodontitis

Medical periodontitis can be caused by outdated methods of treatment (when treating canals according to Dubrovin with a solution of "aqua regia"), long-term application of arsenic pastes in the treatment of pulpitis.

If the technology of intracanal whitening is violated, undesirable complications in the form of periodontitis may also occur.

Traumatic and drug-induced periodontitis at first can behave as aseptic, but the easy accession of infection quickly translates these forms of inflammation into an infectious one.

Video: periodontitis

Classification of periodontitis according to ICD-10 (WHO)

The international organization approached the classification of periodontitis comprehensively. She proposed a classification that takes into account not only the acute or chronic course of the disease, but also the most common types of complications.

This approach to the examination and treatment of various forms of periodontitis helps to more fully influence all the mechanisms of the development of the pathological process, as well as to combine the actions of various specialists (for example, a dentist-therapist, a dentist-surgeon and an ENT).

In the ICD-10, periodontitis is designated in section K04 - diseases of the periapical tissues.

K04.4 Acute apical periodontitis of pulpal origin

Acute apical periodontitis is one of the classic variants, with a clearly defined cause and clinical manifestations. The primary task of the doctor is to remove the severity of the process, as well as the source of infection.

K04.5 Chronic apical periodontitis

Apical granuloma - there is a long-standing focus of infection. With a large size of the granuloma, surgical methods of treatment should also be considered, for example, resection, truncation of the root tip.

K04.6 Periapical abscess with fistula:

• dental
• dentoalveolar,
• periodontal abscess of pulpal origin.

Fistulas are divided depending on what the message is with:

• K04.60 Having communication [fistula] with maxillary sinus.
• K04.61 Having communication [fistula] with the nasal cavity.
• K04.62 Having communication [fistula] with the oral cavity.
• K04.63 Having communication [fistula] with skin.
• K04.69 Periapical abscess with fistula, unspecified

Photo: Fistula with communication with the oral cavity (left) and with the skin (right)

These diagnoses imply the possibility of close collaboration with ENT specialists. If there is a fistulous passage in the maxillary sinus, it will not do without sinusitis.

If the process is old, old, then it is quite possible that the fistula is also formed and after the elimination of the cause it will not resolve itself. Surgical excision should be considered.

K04.7 Periapical abscess without fistula

• dental abscess,
• Dentoalveolar abscess
• Periodontal abscess of pulpal origin,
• Periapical abscess without fistula.

K04.8 Root cyst

• K04.80 Apical and lateral.

Root cyst requires either long-term exposure or more drastic (surgical).

With conservative treatment, the cystic cavity should be drained, as well as the microflora that supports the growth of the cyst should be eliminated. In addition, it is necessary to destroy the inner lining of the cyst, allowing the restoration of bone tissue.

According to Lukomsky

Classification according to Lukomsky is by far the most popular in practical dentistry. With a small volume, it covers and characterizes all clinically significant forms of periodontitis, in the diagnosis and treatment of which there may be fundamental differences.

Acute periodontitis

Acute periodontitis is divided into:

• serous. Complaints of discomfort or soreness, aggravated by tapping on the tooth. There may be a feeling of distension. The intensity of complaints is gradually increasing. On examination, a large filling or a significant defect in the crown of the tooth is revealed, the probing and thermal test of which are painless.
• purulent. Complaints of severe, tearing, throbbing pain, which increases significantly at the slightest touch to the tooth (when closing the mouth). Swelling of the adjacent soft tissues is possible, as well as an increase and soreness of the nearest lymph nodes. Often, acute purulent periodontitis is accompanied by general body disorders: weakness, fever, chills.

Chronic forms of periodontitis may be the result of acute, but may also occur as initially chronic. Complaints are usually not expressed or very insignificant, for example, in the form of mild pain when tapping on the tooth.

The tooth may have a large filling or be severely decayed, often discolored.

The main method for diagnosing chronic periodontitis is radiography, it is also a method of differential diagnosis between individual forms of chronic periodontal inflammation.

Granulating

Radiographically, it is manifested by an uneven expansion of the periodontal fissure in the region of the apical foramen. The expansion does not have clear contours, the dimensions range from 1–2 to 5–8 mm.

Granulomatous

In the picture it looks like a rounded focus of destruction of the bone structure with clear, contrasting edges.

It can be located both in the region of the root apex, in contact with it, and border a significant part of the lower third of the tooth root. With further progression of the process, it develops into a periradicular cyst.

Fibrous

It manifests itself in the form of a uniform expansion of the periodontium, either only in the region of the root apex, or throughout its entire length. In this case, often the bone wall of the tooth socket does not show signs of destruction.

If such a process is observed in a tooth previously subjected to endodontic treatment, if there are no complaints and the condition of the root filling is not satisfactory, then treatment is not required.

Chronic in the acute stage

Clinically manifested as acute periodontitis, but has radiographic signs of chronic. Often accompanied by the appearance of swelling (periostitis) and / or the presence of fistulous passages with active purulent discharge.

Chronic periodontitis is a serious complication of untreated or untreated caries. It is a source of very active microflora that can give both local complications (periostitis, osteomyelitis, abscesses and phlegmon of the maxillofacial region) and cause general harm to the body (sepsis).

Periodontal lesions are especially dangerous during pregnancy. Therefore, the task of each person is to prevent the appearance of any form of periodontitis and contact the dentist in a timely manner to provide qualified assistance.

Periodontitis is a common inflammatory disease in the periapical tissues. According to statistics, more than 40% of diseases of the dentoalveolar system are periodontal inflammations, only caries and pulpitis are ahead of them.

Periodontal disease affects literally all age groups - from young to old. Percentages based on 100 visits to the dentist for pain in the teeth:

• Age from 8 to 12 years - 35% of cases.
• Age 12-14 years - 35-40% (loss of 3-4 teeth).
• From 14 to 18 years old - 45% (with the loss of 1-2 teeth).
• 25-35 years old - 42%.
• Persons over 65 years old - 75% (loss of 2 to 5 teeth).

If periodontitis is not treated, chronic foci of infection in the oral cavity lead to pathologies of the internal organs, among which endocarditis is the leader. All periodontal diseases in general, one way or another, affect the state of human health and significantly reduce the quality of life.

ICD code 10

In dental practice, it is customary to classify diseases of the periapical tissues according to ICD-10. In addition, there is an internal classification, which was compiled by specialists from the Moscow Medical Dental Institute (MMSI), it is accepted in many medical institutions of the post-Soviet space.

However, ICD-10 still remains officially recognized and used in the documentation; periodontitis is described in it as follows:

It should be recognized that there is still some confusion in the classification of periodontal diseases, this is due to the fact that in addition to the internal systematization of MMIS adopted by dental practitioners in the countries of the former CIS, in addition to ICD-10, there are also WHO classification recommendations. These documents that deserve respect and attention do not have big differences, however, the section "chronic periodontitis" can be interpreted variably. In Russia and Ukraine there is a clinically justified definition of "fibrous, granulating, granulomatous periodontitis", while in ICD-10 it is described as an apical granuloma, in addition, in the international classification of diseases of the 10th revision there is no nosological form "chronic periodontitis in the acute stage ”, which is used by almost all domestic doctors. This definition, adopted in our educational and medical institutions, in ICD-10 replaces the code - K04.7 "periapical abscess without fistula formation", which completely coincides in the clinical picture and pathomorphological justification. However, in the sense of documenting diseases of the periapical tissues, ICD-10 is generally accepted.

Causes of periodontitis

Etiology, causes of periodontitis are divided into three categories:

1. Infectious periodontitis.
2. Periodontitis caused by trauma.
3. Periodontitis provoked by medication.

Pathogenetic therapy depends on etiological factors, its effectiveness is directly determined by the presence or absence of infection, the degree of change in the trophism of periodontal tissues, the severity of injury or exposure to aggressive chemical agents.

1. Periodontitis caused by infection. Most often, periodontal tissue is affected by microbes, among which hemolytic streptococci (62-65%), as well as saprophytic streptococci and staphylococci, non-hemolytic (12-15%) and other microorganisms are "leading". Epidermal streptococci are normally present in the oral cavity without causing inflammatory processes, however, there is a subspecies - the so-called "green" streptococcus, which contains a surface protein element. This protein is able to bind salivary glycoproteins, combine with other pathogenic microorganisms (yeast-like fungi, veionella, fusobacteria) and form specific plaques on the teeth. Bacterial compounds destroy tooth enamel, simultaneously throwing toxins through the gum pockets and root canals directly into the periodontium. Caries and pulpitis are among the main causes of infectious periodontitis. Other factors may be viral and bacterial infections that enter the periodontium through the blood or lymph, such as influenza, sinusitis, osteomyelitis. In this regard, infectious inflammatory processes in the periodontium are combined into the following groups:

• Intradental periodontitis.
• Extradental periodontitis.

1. Periodontitis caused by traumatic injury. Such an injury can be a blow, bruise, hit when chewing a solid element (pebble, bone). In addition to single injuries, there is also chronic traumatization provoked by incorrect dental treatment (incorrectly applied filling), as well as malocclusion, pressure on a number of teeth in the course of professional activities (wind instrument mouthpiece), bad habits (biting teeth with hard objects - nuts, the habit of gnawing handles , pencils). In chronic tissue damage, at first, forced adaptation to overload occurs, and repeated trauma gradually translates the compensation process into inflammation.
2. Periodontitis caused by a drug factor, as a rule, is the result of incorrect therapy in the management of pulpitis or the periodontium itself. Strong chemicals penetrate the tissues, provoking inflammation. It can be tricresolphor, arsenic, formalin, phenol, resorcinol, phosphate cement, paracin, filling materials, and so on. In addition, all allergic reactions that develop in response to the use of antibiotics in dentistry also belong to the category of drug-induced periodontitis.

The most common causes of periodontitis can be associated with pathologies such as chronic gingivitis, periodontitis, pulpitis, when periodontal inflammation can be considered secondary. In children, periodontitis often develops against the background of caries. Factors that provoke inflammation of the periodontium can also be due to non-compliance with the rules of oral hygiene, vitamin deficiency, and a lack of trace elements. It should be noted that there are somatic diseases that contribute to the development of periodontitis:

• Diabetes.
• Chronic pathologies of the endocrine system.
• Cardiovascular diseases, which can also provoke a chronic focus of infection in the oral cavity.
• Chronic pathologies of the broncho-pulmonary system.
• Diseases of the digestive tract.

Summarizing, we can distinguish the 10 most common factors provoking periodontitis:

• Inflammatory process in the pulp, acute or chronic.
• Gangrenous lesions of the pulp.
• Overdose of medications in the treatment of pulpitis (treatment period or amount of the drug).
• Traumatic periodontal injury during pulp treatment or canal treatment. Chemical trauma during sterilization, sanitation of the canal.
• Traumatic periodontal damage during filling (pushing through the filling material).
• Residual pulpitis (root).
• Penetration of the infection located in the canal beyond the apex.
• An allergic reaction of periodontal tissues to medicines or decay products of microorganisms - causative agents of inflammation.
• Infection of the periodontium through the blood, lymph, less often by contact.
• Mechanical traumatization of the tooth - functional, therapeutic (orthodontic manipulations), malocclusion.

Pathogenesis of periodontitis

The pathogenetic mechanism of the development of periodontal tissue inflammation is due to the spread of infection and toxins. Inflammation can be localized only within the boundaries of the affected tooth, but it is also able to capture neighboring teeth, the soft tissues of the gums surrounding them, sometimes even tissues of the opposite jaw. The pathogenesis of periodontitis is also characterized by the development of phlegmon, periostitis with a running chronic process and its subsequent exacerbation. Acute periodontitis develops very quickly, inflammation proceeds according to the anaphylactic, hyperergic type with a sharp reactive response of the body, increased sensitivity to the slightest stimulus. If the immune system is weakened or the irritant is not too active (malovirulent bacteria), periodontitis becomes chronic, often asymptomatic. A permanent periapical focus of inflammation affects the body in a sensitizing way, which leads to chronic inflammatory processes in the digestive organs, heart (endocarditis), and kidneys.

The way infection enters the periodontium:

• Complicated pulpitis provokes the entry of toxic contents into the periodontium through the apical opening. This process is activated by eating, chewing function, especially in case of malocclusion. If the cavity of the affected tooth is sealed, and necrotic decay products have already appeared in the pulp, any chewing movement pushes the infection upwards.
• Injury to the tooth (impact) provokes the destruction of the dental bed and periodontium, the infection can penetrate into the tissue by contact if oral hygiene is not observed.
• The hematogenous or lymphogenous route of infection of periodontal tissue is possible with viral diseases - influenza, tuberculosis, hepatitis, while periodontitis occurs in a chronic, often asymptomatic form.

Statistics say that the most common is the descending route of infection with streptococci. The data for the last 10 years is as follows:

• Strains of non-hemolytic streptococci - 62-65%.
• Strains of alpha-hemolytic green streptococci (Streptococcus mutans, Streptococcus sanguis) - 23-26%.
• Hemolytic streptococci - 12%.

Periodontitis of the tooth

Periodontium is a complex connective tissue that is part of the periodontal tissue complex. Periodontal tissue fills the space between the teeth, the so-called periodontal gaps (between the plate, the wall of the alveolus and the cementum of the tooth root). Inflammatory processes in this area are called periodontitis, from the Greek words: near - peri, tooth - odontos and inflammation - itis, the disease can also be called pericementitis, since it directly concerns the dental cement of the root. Inflammation is localized at the top - in the apical part, that is, at the top of the root (apex in translation top) or along the edge of the gums, less often the inflammation is diffuse, diffuse throughout the periodontium. Periodontitis of the tooth is considered a focal inflammatory disease, which refers to diseases of the periapical tissues in the same way as pulpitis. According to the practical observations of dentists, periodontal inflammation is most often the result of chronic caries and pulpitis, when the decay products of a bacterial infection, toxins, microparticles of the dead pulp enter the hole from the root hole, causing infection of the dental ligaments and gums. The magnitude of focal lesions of bone tissue depends on the period, duration of inflammation and the type of microorganism - the pathogen. The inflamed root shell of the tooth, adjacent tissues interfere with the normal process of eating, the constant presence of an infectious focus provokes a pain symptom, often unbearable during an exacerbation of the process. In addition, toxins enter the internal organs with the bloodstream and can be the cause of many pathological processes in the body.

Periodontitis and pulpitis

Periodontitis is a consequence of pulpitis, therefore, pathogenetically, these two diseases of the dentition are related, but are considered different nosological forms. How to distinguish between periodontitis and pulpitis? Most often it is difficult to differentiate the acute course of periodontitis or pulpitis, so we offer the following criteria for distinguishing, presented in this version:

It is imperative to differentiate periodontitis and pulpitis, as this helps to build the right therapeutic strategy and reduces the risk of exacerbations and complications.

Periodontitis in children

Unfortunately, periodontitis in children is increasingly being diagnosed. As a rule, inflammation of periodontal tissues provokes caries - a disease of civilization. In addition, children rarely complain about dental problems, and parents neglect preventive examinations by a pediatric dentist. Therefore, according to statistics, children's periodontitis accounts for about 50% of all cases of treatment in dental institutions.

The inflammatory process of periodontium can be divided into 2 categories:

1. Periodontitis of milk teeth.
2. Periodontitis of permanent teeth.

Otherwise, the classification of inflammation of the periapical tissues in children is systematized in the same way as periodontal disease in adult patients.

Complications of periodontitis

Complications that provoke inflammation of the periapical tissues are conventionally divided into local and general.

Complications of periodontitis of a general nature:

• Persistent headache.
• General intoxication of the body (most often with acute purulent periodontitis).
• Hyperthermia sometimes up to critical levels of 39-40 degrees.
• The chronic course of periodontitis provokes many autoimmune diseases, among which rheumatism and endocarditis are in the lead, kidney pathologies are less common.

Complications of periodontitis of a local nature:

• Cysts, fistulas.
• Purulent formations in the form of abscesses.
• The development of a purulent process can lead to neck phlegmon.
• Osteomyelitis.
• Odontogenic sinusitis with a breakthrough of the contents into the maxillary sinus.

The most dangerous complications are caused by a purulent process, when pus spreads in the direction of the jaw bone tissue and exits into the periosteum (under the periosteum). Necrotization and melting of the tissue provoke the development of an extensive phlegmon in the neck. With purulent periodontitis of the upper jaw (premolars, molars), the most common complication is submucosal abscess and odontogenic sinusitis.

It is very difficult to predict the outcome of complications, since the migration of bacteria occurs quickly, they are localized in the jaw bone, spreading to nearby tissues. The reactivity of the process depends on the type and form of periodontitis, the state of the body and its protective properties. Timely diagnosis and therapy help reduce the risk of complications, but often this does not depend on the doctor, but on the patient himself, that is, on the timing of seeking dental care.

Diagnosis of periodontitis

Diagnostic measures are not only important, they are, perhaps, the main criterion that determines the effective treatment of periodontal inflammation.

Diagnosis of periodontitis involves the collection of anamnestic data, examination of the oral cavity, additional methods and methods of examination to assess the state of the apex and all periapical zones. In addition, diagnostics should reveal the root cause of inflammation, which is sometimes very difficult to do if the patient does not seek help in a timely manner. Acute conditions are easier to assess than to diagnose a running, chronic process.

In addition to the etiological reasons, assessment of the clinical manifestations of periodontitis, the following points are important in the diagnosis:

• Resistance or intolerance to drugs or dental material to avoid drug reactions.
• The general condition of the patient, the presence of concomitant pathological factors.
• Acute inflammation of the oral mucosa and assessment of the red border of the lips.
• The presence of chronic or acute inflammatory diseases of internal organs and systems.
• Threatening conditions - heart attack, cerebrovascular accident.

The main diagnostic load falls on the X-ray examination, which helps to accurately differentiate the diagnosis of diseases of the periapical system.

Diagnosis of periodontitis involves the determination and recording of such information according to the recommended examination protocol:

• Process stage.
• Process phase.
• Presence or absence of complications.
• Classification according to ICD-10.
• Criteria that help determine the state of the dentition - permanent or temporary teeth.
• channel patency.
• Localization of pain.
• condition of the lymph nodes.
• Tooth mobility.
• The degree of pain on percussion, palpation.
• Changes in the structure of the periapical tissue on x-ray.

It is also important to correctly assess the characteristics of the pain symptom, its duration, frequency, localization zone, the presence or absence of irradiation, dependence on food intake and temperature stimuli.

What measures are taken to examine the inflammation of periodontal tissue?

• Visual inspection and inspection.
• Palpation.
• Percussion.
• External examination of the facial area.
• Instrumental examination of the oral cavity.
• Channel sounding.
• Thermodiagnostic test.
• Bite assessment.
• Beam imaging.
• Electrodontometric examination.
• Local radiograph.
• Orthopantomogram.
• Radiovision method.
• Evaluation of the index of oral hygiene.
• Determination of the periodontal index.

Differential diagnosis of periodontitis

Since periodontitis is pathogenetically associated with previous inflammatory destructive conditions, it is often similar in clinical manifestations to its predecessors. Differential diagnosis helps to separate similar nosological forms and choose the right tactics and treatment strategy, this is especially important for the management of chronic processes.

1. Acute apical periodontitis is differentiated from diffuse pulpitis, gangrenous pulpitis, exacerbation of chronic periodontitis, acute osteomyelitis, periostitis.
2. The purulent form of periodontitis should be separated from periradicular cysts similar in symptoms. Periradical cysts are characterized by signs of bone resorption, which does not happen with inflammation of the periodontium. In addition, the periradicular cyst strongly bulges in the area of ​​the alveolar bone, provokes displacement of the teeth, which is not typical for periodontitis.

Treatment of periodontitis

Treatment of periodontitis is aimed at solving such problems:

• Relief of the focus of inflammation.
• Maximum preservation of the anatomical structure of the tooth and its functions.
• Improving the general condition of the patient and the quality of life in general.

What does the treatment of periodontitis include?

• Local anesthesia, anesthesia.
• Providing access to the inflamed channel by opening.
• Expansion of the cavity of the tooth.
• Providing access to the root.
• Probing, passage of the canal, often its unsealing.
• Channel length measurement.
• Mechanical and drug treatment of the canal.
• If necessary, remove the necrotic pulp.
• Placement of temporary filling material.
• After a certain period of time, the installation of a permanent seal.
• Restoration of the dentition, including a damaged tooth, endodontic therapy.

The whole process of treatment is accompanied by regular monitoring using X-rays, in the case when standard conservative methods do not lead to success, the treatment is carried out surgically up to amputation of the root and extraction of the tooth.

What criteria guides the doctor in choosing a method of treatment of periodontitis?

• Anatomical specificity of the tooth, the structure of the roots.
• Severe pathological conditions - tooth trauma, root fracture, and so on.
• The results of previous treatment (several years ago).
• The degree of accessibility or isolation of the tooth, its root, canal.
• The value of the tooth in terms of functional as well as aesthetic.
• Possibility or lack thereof in terms of tooth restoration (tooth crown).
• Condition of periodontal and periapical tissues.

As a rule, therapeutic measures are painless, carried out under local anesthesia, and a timely visit to the dentist makes the treatment effective and fast.

1. Medical periodontitis is a conservative treatment, surgery is rarely used.
2. Traumatic periodontitis - conservative treatment, perhaps surgical intervention to excise bone particles from the gums.
3. Infectious purulent periodontitis. If the patient applied on time, the treatment is carried out conservatively, a running purulent process often requires surgical manipulations up to tooth extraction.
4. Fibrous periodontitis is treated with topical drugs and physiotherapy, standard conservative treatment is ineffective and there is no indication for it. Rarely, surgery is used to excise rough fibrous formations on the gums.

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 (hit, bruise) and chronic injury (violation of occlusion when the height of the tooth is overestimated 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-fermenting 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. An acute inflammatory process in the periodontium primarily occurs as a result of the penetration of infection through a hole in the apex of the tooth, less often through a 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 the penetration of infection 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 protective response 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 slight 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 varying degrees 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 - the 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 intensify 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 the instrument is pressed 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 reveal or to detect the expansion of the periodontal gap, the fuzziness of the cortical plasty of the alveolus. 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 preparations 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 due to 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.

Acute apical periodontitis.
Acute periodontitis is characterized by the presence of a sharp localized pain of a permanent nature. Initially, in acute periodontitis, mild aching pain is noted, which is localized and corresponds to the area of ​​the affected tooth.
Later, the pain becomes more intense, tearing and throbbing, sometimes radiating, which indicates a transition to purulent inflammation. Acute apical process lasts from 2-3 days to 2 weeks. It is conditionally possible to identify 2 stages or phases of the course of acute periodontal inflammation:
First stage. The phase of periodontal intoxication occurs at the very beginning of inflammation. It is characterized by the occurrence of long, continuous pains of a aching nature. Sometimes this is accompanied by increased sensitivity when biting on an aching tooth. On the part of the tissues surrounding the tooth, no visible changes are determined, with vertical percussion there is an increased sensitivity of the periodontium.
Second stage. The phase of a pronounced exudative process is characterized by continuous pain sensations. There is pain when biting on the tooth; causes pain even a light touch of the tongue to the aching tooth. Percussion of the tooth is sharply painful. Pain radiates. The appearance of exudate and inflammatory acidosis contribute to the swelling and melting of periodontal collagen fibers, which affects the fixation of the tooth, it becomes mobile (a symptom of a grown tooth). The spread of serous and serous-purulent infiltrate is accompanied by the appearance of soft tissue edema and the reaction of regional lymph nodes.
The general condition of patients suffers: malaise, headache, body temperature (due to tooth pain) rises to 37-38 ° C, leukocytosis, elevated ESR are observed.
X-ray in acute periodontitis changes in the periodontium is not observed.
Chronic apical periodontitis.
Chronic fibrous periodontitis. Diagnosis of this form is difficult, since patients do not complain and also because a similar clinical picture can be given, for example, by chronic gangrenous pulpitis.
Objectively, in chronic fibrous periodontitis, there are changes in the color of the tooth, the crown of the tooth may be intact, a deep carious cavity, probing is painless. Percussion of the tooth is often painless, there are no reactions to cold and heat. In the cavity of the tooth, a necrotically altered pulp with a gangrenous odor is often found.
In the clinic, the diagnosis of chronic fibrous periodontitis is made on the basis of an x-ray, which shows the deformation of the periodontal gap in the form of its expansion at the root apex, which is usually not accompanied by resorption of the bone wall of the alveolus, as well as the cement of the tooth root.
Fibrous periodontitis can occur as an outcome of acute inflammation of the periodontium and as a result of the treatment of other forms of chronic periodontitis, pulpitis, or occurs as a result of overload with the loss of a large number of teeth or traumatic articulation.
Chronic granulating periodontitis. It often manifests itself in the form of unpleasant, sometimes weak pain sensations (a feeling of heaviness, fullness, awkwardness); there may be slight pain when biting on a diseased tooth, these sensations occur periodically and are often accompanied by the appearance of a fistula with purulent discharge and the ejection of granulation tissue, which disappears after a while.
Hyperemia of the gums in the diseased tooth is determined; when pressing on this part of the gum with the blunt end of the instrument, a depression occurs, which does not disappear immediately after the removal of the instrument (symptom of vasoparesis). On palpation of the gums, the patient experiences discomfort or pain. Percussion of an untreated tooth causes increased sensitivity, and sometimes a pain reaction.
Often there is an increase and soreness of regional lymph nodes.
X-ray in chronic granulating periodontitis, a bone rarefaction center is found in the region of the root apex with fuzzy contours or an uneven line, destruction of cement and dentin in the region of the apex of the tooth. Chronic granulomatous periodontitis often penetrates asymptomatically, less often patients complain of discomfort and slight pain when biting.
Anamnestically, there are indications of past periodontal trauma or pain associated with the development of pulpitis. When the granuloma is localized in the region of the buccal roots of the upper molars and premolars, patients often indicate a bulging of the bone, respectively, the projection of the tops of the roots.
Objectively, the causative tooth may not have a carious cavity, the crown is often changed in color, there is a carious cavity with decay of the pulp in the canals, and finally, the tooth can be treated, but with poorly filled canals. Percussion of the tooth is often painless, with palpation on the gum from the vestibular surface, painful swelling can be noted, according to the projection of the granuloma.
An x-ray examination reveals a picture of a clearly defined rarefaction of the bone tissue of a rounded shape. Sometimes you can see the destruction of the tissues of the tooth in the apex and hypercementosis in the lateral parts of the root.
A favorable outcome of granulomatous periodontitis with timely and correct treatment is the transition to a fibrous form. In the absence of treatment or incomplete filling of the root canal, the granuloma turns into a cystogranuloma or root cyst of the tooth.
Exacerbated chronic periodontitis. More often gives an exacerbation of granulating and granulomatous periodontitis, less often - fibrous. Since the exacerbation occurs in the presence of destructive changes in the periodontium, the pain when biting on the tooth is not as sharp as in acute purulent periodontitis. As for the remaining symptoms (constant pain, collateral swelling of the soft tissues, the reaction of the lymph nodes), they can increase in the same sequence as in acute purulent periodontitis.
Objectively, there is a deep carious cavity (the tooth may be untreated or filled), the absence of pain during probing, sharp pain during percussion, both vertical and horizontal, to a lesser extent. The tooth can be changed in color, mobile. On examination, edema, hyperemia of the mucous membrane and often the skin are determined, over the area of ​​​​the causative tooth, the smoothness of the transitional fold, palpation of this area is painful. There is no reaction of tooth tissues to temperature stimuli.