Chronic Periodontitis

Localized
Generalized

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Learning Outcomes
1. Describe the development of a
periodontal pocket.
2. Relate clinical characteristics to the
histopathologic changes for chronic
periodontitis.
3. Compare the gingival pocket with the
periodontal pocket.
4. Determine the severity of PD activity
using clinical data.

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Common Characteristics
 Onset - any age; most common in
adults
 Plaque initiates condition
 Subgingival calculus common
finding
 Slow-mod progression; periods of
rapid progression possible
 Modified by local factors/systemic
factors/stress/smoking
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Extent & Severity
 Extent:
– Localized: 30% of sites affected
– Generalized > 30% of sites affected

 Severity: entire dentition or individual

teeth/site
– Slight = 1-2 mm CAL
– Moderate = 3-4 mm CAL
– Severe =  5 mm CAL

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Clinical Characteristics
 Deep red to
bluish-red tissues
 Thickened
marginal gingiva
 Blunted/cratered
papilla
 Bleeding and/or
suppuration
 Plaque/calculus
deposits
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Clinical Characteristics
 Variable pocket
depths
 Horizontal/vertical
bone loss
 Tooth mobility

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Pathogenesis – Pocket
Formation
 Bacterial
challenge initiates
initial lesion of
gingivitis
 With disease
progression &
change in
microorganisms
 development of
periodontitis

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Pocket Formation
 Cellular & fluid inflammatory
exudate  degenerates CT
 Gingival fibers destroyed
 Collagen fibers apical to JE
destroyed  infiltration of
inflammatory cells & edema
 Apical migration of junctional
epithelium along root
 Coronal portion of JE detaches
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Pocket Formation
 Continued
extension of JE
requires healthy
epithelial cells!
 Necrotic JE slows
down pocket
formation
 Pocket base
degeneration less
severe than lateral
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Pocket Formation
 Continue inflammation:
– Coronal extension of gingival margin
– JE migrates apically & separates from
root
– Lateral pocket wall proliferates &
extends into CT
– Leukocytes & edema
• Infiltrate lining epithelium
• Varying degrees of degeneration &
necrosis

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Development of Periodontal
Pocket

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Continuous Cycle!
 Plaque  gingival inflammation 
pocket formation  more plaque

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Histopathology
 Connective Tissue:
– Edematous
– Dense infiltrate:
• Plasma cells (80%)
• Lymphocytes, PMNs
– Blood vessels proliferate, dilate & are
engorged
– Varying degrees of degeneration in addition
to newly formed capillaries, fibroblasts,
collagen fibers in some areas

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Histopathology
 Periodontal pocket:
– Lateral wall shows most severe
degeneration
– Epithelial proliferation & degeneration
– Rete pegs protrude deep within CT
– Dense infiltrate of leukocytes & fluid
found in rete pegs & epithelium
– Degeneration & necrosis of epithelium
leads to ulceration of lateral wall,
exposure of CT, suppuration

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Clinical & Histopathologic
Features
 Clinical :  Histopathology:
1. Pocket wall 1. Vasodilation &
bluish-red vasostagnation
2. Smooth, shiny 2. Epithelial
surface proliferation,
3. Pitting on edema
pressure 3. Edema &
degeneration of
epithelium

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Clinical & Histopathologic
Features
 Clinical:  Histopathology:
1. Pocket wall may 1. Fibrotic changes
be pink & firm dominate
2. Bleeding with 2.  blood flow,
probing degenerated,
3. Pain with thin epithelium
instrumentation 3. Ulceration of
pocket
epithelium

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Clinical & Histopathologic
Features
 Clinical :  Histopathology:
1. Exudate 1. Accumulation of
2. Flaccid tissues inflammatory
products
2. Destruction of
gingival fibers

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Root Surface Wall
 Periodontal disease affects root
surface:
– Perpetuates disease
– Decay, sensitivity
– Complicates treatment
 Embedded collagen fibers
degenerate  cementum exposed
to environment
 Bacteria penetrate unprotected root

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Root Surface Wall
 Necrotic areas of cementum form;
clinically soft
 Act as reservoir for bacteria
 Root planing may remove necrotic
areas  firmer surface

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Classification of Pockets
 Gingival:
– Coronal migration of gingival margin
 Periodontal:
– Apical migration of epithelial
attachment
• Suprabony:
– Base of pocket coronal to height of alveolar crest
• Infrabony:
– Base of pocket apical to height of alveolar crest
– Characterized by angular bony defects

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Periodontal Pocket
 Suprabony pocket

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Inflammatory Pathway
 Stages I-III – inflammation degrades
gingival fibers
– Spreads via blood vessels:
 Interproximal:
 Loose CT  transseptal fibers 
marrow spaces of cancellous bone
 periodontal ligament  suprabony
pockets & horizontal bone loss
transseptal fibers transverse
horizontally

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Inflammatory Pathway
 Interproximal:
– Loose CT  periodontal ligament 
bone  infrabony pockets & vertical
bone loss  transseptal fibers
transverse in oblique direction

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Inflammatory Pathway
 Facial & Lingual:
– Loose CT  along periosteum 
marrow spaces of cancellous bone 
supporting bone destroyed first 
alvoelar bone proper  periodontal
ligament  suprabony pocket &
horizontal bone loss

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Inflammatory Pathway
 Facial & Lingual:
– Loose CT  periodontal ligament 
destruction of periodontal ligament
fibers  infrabony pockets & vertical or
angular bone loss

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Stages of Periodontal Disease

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Periodontal Pathogens
 Gram negative organisms dominate
 P.g., P.i., A.a. may infiltrate:
– Intercellular spaces of the epithelium
– Between deeper epithelial cells
– Basement lamina

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Periodontal Pathogens
 Pathogens include:
– Nonmotile rods:
• Facultative:
– A.a., E.c.
• Anaerobic:
– P. g., P. i., B.f., F.n.
– Motile rods:
• Facultative:
– C.r.
– Spirochetes:
• Anaerobic, motile:
– Treponema denticola

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Periodontal Disease Activity
 Bursts of activity followed by periods of
quiescence characterized by:
– Reduced inflammatory response
– Little to no bone loss & CT loss
 Accumulation of Gram negative
organisms leads to:
– Bone & attachment loss
– Bleeding, exudate
– May last days, weeks, months

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Periodontal Disease Activity
 Period of activity followed by period of
remission:
– Accumulation of Gram positive bacteria
– Condition somewhat stabilized
 Periodontal destruction is site specific
 PD affects few teeth at one time, or
some surfaces of given teeth

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Overall Prognosis
 Dependent on:
– Client compliance
– Systemic involvement
– Severity of condition
– # of remaining teeth

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Prognosis of Individual Teeth
 Dependent on:
– Attachment levels, bone height
– Status of adjacent teeth
– Type of pockets: suprabony, infrabony
– Furcation involvement
– Root resorption

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Subclassification of Chronic
Periodontitis
Severity Pocket CAL Bone Tooth Furcation
Depths Loss Mobility

Early 4-5 mm 1-2 mm Slight

horizontal

Moderate 5-7 mm 3-4 mm Sl – mod  

horizontal

Advanced > 7 mm  5 mm Mod-  

severe
horizontal
vertical
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