PERIODONTITIS (periodontitis; grech, peri around, near + odus, odontos tooth + - itis; synonym pericementitis) — inflammation of a periodontium.
Depending on localization patol. process in periodontium (see) distinguish apical (apical) P., at Krom the inflammation develops between a top of a fang and a wall of a tooth socket, and regional (marginal) P., at Krom the inflammation begins with edge of a gum. The most frequent option of inflammatory defeat of a periodontium is the apical Item.
According to the most widespread kliniko-anatomic classification offered I. G. Lukomsky (1955), P. also the aggravated chronic shares on acute (serous, purulent), chronic (granulating, granulematozny, fibrous).
On extent of distribution patol. P.'s process divide on focal and diffusion.
The etiology and a pathogeny
most often are P.'s Reasons an infection, an injury, toxic effect of medicines. In its pathogeny the great value is attached to allergic reorganization of reactivity of a periodontium under the influence of a sensitization by streptococci, microbic toxins and decomposition products of a pulp. Apical P. can develop as a result of direct penetration of pathogenic microorganisms from the channel of a fang in a periodontium at pulpitis (see) or caries (see. Caries of tooth ). The inflammation can move to a periodontium from a number of the located centers of an inflammation at osteomyelitis jaws (see), antritis (see) or from a parodontalny pocket at periodontosis (see). At P. find usually not separate species of microbes, but their various associations. As a part of flora gram-positive cocci (generally streptococci prevail and staphylococcus), are also sowed laktobakterin, korinebakteriya, yeast-like fungi.
The item arises at damage of a periodontium as a result of blow, perforation of a fang, operative measures on tooth and in the field of a periodontium (a cystectomy, an oncotomy, turning of tooth) or as a result of long impact on a periodontium of the injuring factors (a professional injury, incorrectly made seals and dentures, mistakes during the performing orthodontic treatment, an occlusal injury). The item as a result of an injury most often meets in the field of cutters and canines since they are most subject to traumatic influences. '
P. can result from toxic impact on a periodontium of strong pharmaceuticals (arsenous paste, paraformaldehyde, anti-Forminum, formalin, phenol, strong acids), and also in response to introduction to a periodontium at treatment of a pulpitis of pins, phosphate-cement, a paratsin, resorcin - formalin paste or under the influence of harmful ingredients of other sealing materials.
Regional P. develops as a result of a mechanical injury (badly konturirovanny or deeply advanced under a gingiva crown, excess of sealing material or a foreign body in an interdental space, an injury a toothpick) or a chemical injury (strong acids, alkalis) of edge of a gum and the subsequent infection. Regional P. always accompanies generalized diseases parodonta (see).
In morfol. the relation apical periodontitis represents an acute or chronic inflammation of the periodontal sheaf (periodontium) filling a crack between a fang and a wall of a tooth socket. In patol, process also fabrics, adjacent to a periodontium — solid tissues of tooth (cement, dentine), a bone wall of a tooth socket, a periosteum etc. in a varying degree can be involved.
Depending on character of an inflammation acute P. can be serous or purulent. At serous P. swelling and reddening of a periodontium in the field of a top of a fang is macroscopically noted a nek-swarm. Microscopically reveal a moderate plethora and hypostasis of fabrics of a periodontium. As a rule, the periodontium in certain sites is impregnated with serous exudate with small impurity of leukocytes and kruglokletochny elements. Only in places find preferential perivascular compact accumulations of leukocytes (fig. 1, a). Serous P.'s progressing causes its transition to purulent P., at Krom macroscopically in a reinforced and plethoric periodontium yellowish ochazhka — pustules are visible. In case of purulent fusion of a periodontium on the surface of a fang only its separate fragments remain, other part of a root is naked, covered with pus. Quite often in a painful tooth observe a peristatic hyperemia and hypostasis of a periosteum of an alveolar shoot and a mucous membrane of a gingiva. Microscopically in the thickness of the periodontium surrounding a top of a fang against the background of a sharp hyperemia focal and diffusion leukocytic infiltrates are visible. As a rule, multiple microabscesses as a result of which merge in okoloverkhushechny area larger abscesses are formed are observed (fig. 1, b). Usually around abscess the zone of a perifocal serous inflammation which in the form of a belt delimits abscess from surrounding fabrics forms. In other cases distribution of serous and purulent and purulent process on adjacent sites of a bone tissue is noted. At the same time patol, process is followed by an insignificant or moderate resorption of a bone wall of a tooth socket, and also cement of a fang. Acute P. in certain cases passes into chronic.
Depending on the nature of fabric reaction distinguish the granulating, granulematozny, fibrous and aggravated chronic Item. At the granulating P. of a makrs-skopicheska on certain sites of a top of a root of the extracted tooth scraps of juicy granulyatsionny fabric of dark red color are visible. A surface of a root uneven, rough, with single or multiple uzura. Microscopically in a circle of a top of a fang the growth of granulyatsionny fabric which does not have a clear boundary at various stages of maturing is found (fig. 1, c). In the field of growth of granulyatsionny fabric the intensive resorption of solid tissues of fang (cement and dentine), and also a bone wall of a tooth socket is observed (fig. 1, d). Granulations replace a bone tissue and in some cases, rezorbirovav compact substance of a bone of a jaw and destroying a periosteum, burgeon in near - maxillary soft tissues. Along with a rassasyvaniye of solid tissues of tooth and bone on the periphery of the inflammatory center also their new growth is observed. In sites of a bone tissue, adjacent to the inflammatory center, everywhere reveal a hyperemia, hypostasis, focal and diffusion limfogistiotsitarny infiltrates. There is substitution of marrow connecting fabric.
Granulematozny periodontitis on morfol, to signs is divided into a simple tooth granuloma, a difficult tooth granuloma and kistogranu-to Lem.
Macroscopically tooth granulomas have an appearance of the spherical or oval education surrounded with a dense fibrous cover, usually with a smooth surface, soldered to a top of a fang thanks to what the granuloma quite often is taken together with a remote root. Coloring of tooth granulomas is various — from light yellow to dark red. The simple tooth granuloma is microscopically characterized by formation of the focus of the ripening granulyatsionny fabric delimited on the periphery by the fibrous capsule of various thickness (fig. 1, e). Strengthening of a productive component patol, process in a periodontium is followed by subsiding of trifocal inflammatory reaction in an adjacent bone tissue. In a circle of a tooth granuloma creation of new bone trabeculas is observed.
In a difficult tooth granuloma formation of focus of granulyatsionny fabric is followed by growth in it tyazhy an epithelium. In certain cases the epithelial component is developed so intensively that begins to prevail in gistol, a picture of a tooth granuloma.
Kistogranulema (an okolokornevy cyst) is formed of a difficult tooth granuloma as a result of vacuolar dystrophy and disintegration of epithelial cells in the central departments epithelial tyazhy where development of small slit-like gleams at which merge the cavity which is usually covered from within by the epithelium located on the subject granulyatsionny fabric is gradually formed is observed (fig. 1, e). The fibrous wall of a kisto-granuloma is soldered to a periodontium of the affected tooth (see. Odontocele ).
At fibrous P. the periodontium is thickened, has light pink coloring. Sometimes these changes develop on the limited site of a periodontium in circles of a top of a fang, in other cases process has diffusion character and a thickening of a periodontium is determined by all surface of a fang. In some cases as a result of a considerable new growth of cement the fang in the field of a top or throughout is thickened. Microscopically at fibrous P. the picture characteristic of the slow, preferential productive inflammatory process which is followed by reorganization and a sclerosis of fabric of a periodontium is observed. At this form of an inflammation in a periodontium the quantity of cellular elements is sharply reduced, collagenic fibrilla and their bunches lose functionally caused orientation. Randomly oriented coarse-fibered structures which are formed as a result of productive reactions replace fabric of a periodontium therefore the periodontium gains character of cicatricial fabric. In many sites of a periodontium find limfogistiotsitarny infiltrates (fig. 2), to a thicket melkoochagovy and perivascular is more rare, diffusion character. Sharply the number of veins which walls are thickened and exposed to a sclerosis decreases. This form hron. The item often is followed by a hypertrophy of cement of tooth. The excess mass of neogenic cement is localized or in the field of a top of a fang, or on all its surface.
The aggravated chronic P. is characterized by development in the periodontium struck hron, inflammatory process, dense leukocytic infiltrate, in Krom the centers of a necrosis and purulent fusion (fig. 3) form. Sometimes leukocytic infiltrate penetrates coarse-fibered structures of a periodontium, and in the presence of a tooth granuloma — its fibrous capsule, and spreads in surrounding fabrics: spongy substance of a bone tissue of an alveolar shoot of a jaw, periosteum, soft tissues, adjacent to a jaw.
Regional periodontitis represents the special type of defeat of peridental fabrics which is characterized by development in a regional periodontium of the descending inflammatory process (at first acute, then chronic) arising, as a rule, owing to damage of dentogingival connection and which is followed by destruction of the basic device of tooth: destruction of a periodontal sheaf, resorptive changes in a wall of a tooth socket.
The clinical picture
the Clinical picture is various and depends on localization and a type of inflammatory process in a periodontium.
Apical periodontitis, as a rule, proceeds against the background of patol, changes in a crown or a pulp of tooth.
Acute serous P. is characterized by developing of the spontaneous aching pains amplifying at a nakusyvaniye on a painful tooth. Gingiva is not changed a thicket, is less often edematous. Tooth has a carious cavity, painless during the sounding. Percussion of tooth, a palpation of a gingiva and a transitional fold are painful, tooth is slightly mobile. Increase and morbidity regional limf, nodes is noted.
Acute purulent P. is followed by increase of spontaneous constant pains, especially at hiting at to tooth, pain at the same time irradiates on the course of branches of a troytsichny nerve. At a nakusyvaniye on tooth patients have a feeling of «the grown tooth». Can have a grudge the crown unimpaired with a carious tsrotsess or the sealed-up carious cavity. At survey mobility of tooth, a hyperemia and puffiness of a gingiva and transitional fold is noted. The palpation of a gingiva and percussion of tooth are sharply painful. Tooth does not react to thermal and electric irritants. Regional limf, nodes are increased, in blood the leukocytosis, acceleration of ROE is noted. Purulent P.'s complications in a look are possible periostitis (see) and osteomyelitis of a jaw, phlegmon and abscesses of maxillofacial area (see. Person, diseases ), dontogenous antritis (see), mediastinitis (see) (fig. 4).
Chronic P. arises from acute P. or develops initially. The granulating P. — the most active form on a current hron. P. It can proceed asymptomatically, but quite often there is a morbidity at a nakusyvaniye on a painful tooth, sometimes in the field of a top of a fang the fistular course with purulent separated and the eminating expanded granulyatsionny fabric periodically opens. The hyperemia and puffiness of a mucous membrane of a gingiva about a painful tooth is noted. A palpation of a gingiva in the field of a top of a fang and percussion of tooth are painful. The granulating P. proceeds with the expressed resorption of a bone tissue of a tooth socket, cement and dentine of a fang, especially in sites of growth of granulyatsionny fabric.
Morfol, granulematozny P.'s forms (a tooth granuloma simple, difficult, a kistogranulema) are clinically indiscernible. A current them more often asymptomatic, less often patients complain of the unpleasant aching pain and insignificant morbidity at a nakusyvaniye. Tooth can have a crown of the changed color, poor sealed up channels or a carious cavity with disintegration of a pulp in channels of fangs. Percussion of tooth is more often painless, at a palpation of a gingiva small painful protrusion of a bone wall of a tooth socket from a vestibular surface, according to localization of a tooth granuloma can be noted.
Fibrous P. belongs to forms, optimum on a current, hron. P. Obychno it proceeds asymptomatically. The crown of tooth can be intact, discoloration of tooth or a deep carious cavity which sounding without serious consequences is sometimes observed. The carious cavity and channels of fangs can be sealed up. Percussion of tooth is more often painless, reaction to cold and heat is absent.
Aggravated hron. The item develops against the background of already available considerable destructive changes in a periodontium and a wall of a tooth socket therefore proceeds heavier. Aggravations can arise under the influence of the various reasons: overcoolings, the postponed diseases, an injury of a periodontium during treatment etc. Clinically it has much in common with acute P.: a constant acute pain, hypostasis of surrounding soft tissues, an indisposition, a headache, fervescence to 38 — 39 °, increase regional limf, nodes is frequent. Often in tooth there is a deep carious cavity, painless during the sounding. Tooth is mobile, its color is quite often changed. However tooth can be not injured by carious process or to be sealed up. At survey note otechnost a hyperemia of a mucous membrane of a gingiva and quite often face skin, the transitional fold is maleficiated, at a palpation is painful. Sharp pain at vertical percussion is noted, to a lesser extent — at horizontal. Reaction of a pulp to temperature and electric irritants is absent. In blood the leukocytosis, acceleration of ROE is observed.
The regional periodontium and t is observed much less often than apical. Emergence of pains, hypostasis and a hyperemia of gingival edge in one or several teeth is characteristic of acute regional P. The palpation of a gingiva and horizontal percussion of tooth are painful. Electroexcitability of a pulp of tooth within norm, however regional P.'s manifestations can be noted around depul-iirovanny teeth. The most frequent outcome of acute regional P. without treatment — transition to the chronic Item.
At hron. The item is noted an atrophy of gingival edge, formation of Paro-dontalnogo of a pocket, a subdingival dental calculus, an exposure of a neck of tooth and emergence of a hyperesthesia.
the Diagnosis is made on the basis a wedge, pictures, and also by means of a X-ray analysis. Rentgenol, a method takes the leading place in diagnosis, assessment a wedge. a current and results of treatment of P. Chashche use an intra oral contact X-ray analysis. At the raised emetic reflex, a lockjaw, and also in children's practice resort to an intra oral X-ray analysis vprikus. At impossibility of performance of an intra oral X-ray analysis use an extraoral X-ray analysis or pan-tomography (see).
Rentgenol, a picture P. is characterized by the following signs: increase in width and deformation of a periodontal crack, destruction or sclerosis of compact substance of a wall of a tooth socket, structural change of a bone tissue of a tooth socket, roughness of contours and hypercementosis of a fang.
Acute apical P., despite the expressed wedge, a picture, is poor rentgenol, signs. Only in certain cases at considerable accumulation of exudate in a periodontal crack on the roentgenogram its expansion in the field of a top of a fang is noticeable.
Hron, idiosyncrasies rentgenol, pictures have apical P.'s forms. The granulating P. radiological is shown as the center of destruction of a bone tissue at a top of a fang (fig. 5, a). Compact substance of a wall of a tooth socket in this place is destroyed. Contours of the center uneven, indistinct. As a result of a resorption of cement and dentine of a top of a fang its contours become uneven. At granulematozny P. (a tooth granuloma) in okoloverkhu-shechny area the roundish center of an enlightenment decides on the equal, accurate, sometimes sclerosed contours (fig. 5, b). At children and teenagers the tooth granuloma should not be mixed with the region of growth of tooth in the field of a top ^сформировавшегося a root (in a rostkovy zone the periodontal crack keeps uniform width, compact substance of a wall of a tooth socket is kept, the wide root channel has a grudge).
Fibrous P. is distinguished on expansion of a periodontal crack at a top of a fang. Compact substance of a wall of a tooth socket is kept, its sclerosis is sometimes noted.
The top of a fang owing to a giiyertsementoz is thickened (fig. 5, a). At chronic P.'s aggravation the X-ray pattern significantly does not change.
Rentgenol. acute regional P.'s manifestations usually are absent. Hron, regional P. on roentgenograms is shown by osteoporosis of top of an interalveolar partition which in the subsequent turns into its gradual destruction with partial or its almost total disappearance.
apical P.'s Treatment includes endodontichesky (intra channel), physiotherapeutic and operational methods.
Tool processing of the channel of endodontiche-Skye of a fang (its expansion, removal of the broken-up fabrics) is an important stage of treatment. For the purpose of impact on microflora of the channel of a fang antimicrobic processing is carried out it. For this purpose apply Dekaminum, decamethoxynum, Iodinolum, chloroamine, hydrogen peroxide, a gastric juice, drugs of a nitrofuran row (Furacilin, furagn, etc.), Bactrimum, Dimexidum.
Sealing of the channel of a fang is regarded as the most important stage of treatment of the Item. Choice sealing material (see) depends on a form P., features of a structure of the channel of a fang, age of the patient. At the same time pins are widely used.
Giposensibnliziruyushchy therapy at P. provides transchannel introduction of glucocorticoids (an emulsion of a hydrocortisone) or appointment in antihistamines.
Acute serous P.'s treatment consists seals or trepanations of a crown of tooth, bystry evacuation of necrotic masses from the channel of a fang at a distance. In cases of toxic damage of a periodontium apply antidotes (e.g., Unithiolum, Iodinolum), use the means possessing anti-exudative action (solution of Furazolinum, an emulsion of a hydrocortisone, etc.). All specified means enter in the channel of a fang. Then make sealing of the channel within an apical foramen hardening a pass tamn.
At treatment acute purulent and aggravated hron. The item needs to create conditions for outflow of purulent exudate via the channel of a fang, in the absence of such opportunity resort to a section of a gingiva on a transitional fold or an odontectomy. The channel of a fang remains open within 7 — 10 days. Inside appoint the streptocides, antibiotics, anesthetics hyposensibilizing means, conduct a course of physical therapy. All manipulations on tooth at acute and aggravated hron. Items carry out under local anesthesia. After subsiding of the inflammatory phenomena medicamentous and tool en-dodontichesky processing of the channel of a fang, sealing by its hardening pastes (is carried out at acute purulent P.), cements (at an aggravation hron. Item). Use of gutta-percha or silver pins is reasonable.
Hron. it is better to liquidate the infectious centers in single-root teeth in the operational way. For operational treatment of P. several methods are offered: radectomy (apiectomy), replantation of tooth, hemisection, amputation of a fang, koronoradiku-lyarny separation. Multi-rooted teeth with hron, granulematozny forms P. it is necessary to delete.
The radectomy is shown in the presence is long the existing fistulas, a nedoplombiro-vaniya of the channel of a fang, breakdown of the tool in the channel, excess removal of a pin and sealing material for a top of a fang, a kistogranulema, and also in all cases when transchannel endodontichesky treatment of P. is impossible (an obliteration, a curvature of the channel of a fang). Operation is performed under local infiltration or conduction anesthesia with performance of the following stages: a section (the arc-shaped or trapezoid), formation of a mucous and periosteal rag, trepanation of a wall of a tooth socket or expansion of defect at its existence for the purpose of an exposure of a top of a fang, a resection of a fang, removal of granulyatsionny fabric and an epithelium, formation of a cavity in a fang (expansion of a gleam of the channel of a fang obratnokonusovidny boron) and sealing by its amalgam, suture (fig. 6).
Replantation of tooth (see. Replantation ) it is carried out under local anesthesia, at the same time channels of roots of the extracted tooth are sealed up by amalgam or cement (quite often retrogradno). After such processing tooth is placed in physiological solution, carefully process a tooth socket the curette, wash out it warm physiological solution and enter into it tooth then impose the tire. Engraftment of tooth depends on type of an union of replantirovanny tooth with fabrics, and terms of its preservation, according to V. A. Kozlov (1974), vary ranging from 4 up to 12 years.
Hemisection and amputation kornyag tooth are shown in the presence of deep bone pockets, an exposure of a fang, caries of cement and dentine of one of roots, perforation of a fang, impassability of the channel of a fang, the progressing inflammatory and destructive process at a top of a fang. Hemisection — removal of one of roots (is more often than a medial root of the lower painters) and a crown of tooth with use of the second half of tooth under a bridge-like prosthesis — is carried out with formation or without formation of a mucous and periosteal rag. After sealing of the channel of a fang and a carious cavity tooth under local anesthesia is cut and a half it is deleted. The rest of tooth serves as a support for a bridge-like prosthesis.
Amputation of a fang consists one or two fangs with preservation or rearrangement of a crown at a distance, i.e. removal by boron of that part of a crown which corresponds amputated korvyu. Amputation is performed on big molars (painters) of an upper jaw, and one can be removed or two buccal or only a palatal fang. It is better to perform operation without cutting out of a mucous and periosteal rag, at the same time boron carries out wedge-shaped excision of a small part of a crown of tooth and thus the area of an otkhozhdeniye of the fang which is subject to removal is bared. After a section of a zone of bifurcation the root easily is removed an elevator or nippers.
Koronoradikulyarny separation consists in a section of tooth on a part with the subsequent connection of fangs under one general crown. Operation is shown in the presence of perforation of a bottom of a pulp cavity, destructive changes, an idiopathic resorption in the field of bifurcation of roots of the lower painters. Under local anesthesia diamond boron tooth is cut on two half, delete canopies, carry out a curettage (scraping) in the field of bifurcation. In the subsequent on each of roots make the soldered crowns.
Complications at treatment: burn of a periodontium at diathermocoagulation, removal of excess amount of cement or a pin for a top of a fang, perforation of a bottom of a pulp cavity or wall of the channel of a fang, a nedoplombirovaniye of the channel of a fang, breakdown of the tool in the channel.
The long-term results of endodontichesky treatment of apical P. depend on sterilization and tool processing of the channel of a fang, character of sealing material, a wedge, forms P., the size of the center of destruction, adequacy of sealing of the channel of a fang (fig. 7, and, b).
Regional P.'s treatment provides elimination of action etiol, a factor (correction of a crown or seal, removal of a dental calculus and excess of sealing material from an interdental space). Good results are yielded by processing of edge of a gum antiseptic agents (hydrogen peroxide, podinol, etc.), derivatives of nitrofuran (Furacilin, faugh-ragnn), the enzymes combined by pharmaceuticals (ingaligkht, Bactrimum). Treatment hron, regional P. comes down to carrying out a curettage (scraping) parodon-talyyugo a pocket under infiltration (1 — 2% solution of novocaine, Trimecainum, lidocaine) or application anesthesia (using an emulsion of lidocaine, pirome-kalnovy ointment with collagen).
Forecast at timely treatment of P. favorable; teeth in most cases manage to be kept.
belongs timely treatment of carious teeth, careful imposing of protective laying during the sealing of teeth for the purpose of the prevention of toxic damage of a periodontium To preventive actions.
Features of periodontitis at children
P. at children is shown preferential in the form of primary hron granulating P. of milk and second teeth. The most frequent localization hron, the granulating P. of multi-rooted milk teeth is the field of bifurcation of fangs. Inflammatory process can extend to a rudiment of a second tooth, at the same time covers of a follicle of a second tooth collapse, the epithelium of tooth body burgeons in granulation of the inflammatory center and hron, the granulating P. gains character of an epithelial granuloma. In process of distribution of inflammatory process of a periodontium to a bone of a jaw, on a rudiment of a second tooth and on roots nearby of the standing teeth forms hron, the granulating osteitis which can cause a local hypoplasia of tissues of the forming second tooth or even death of its rudiment, premature eruption ^сформированного a second tooth, patol, a resorption of roots nearby of the standing milk tooth, formation of a follicular cyst, etc.
P. of second teeth at ^сформированных roots preferential develop as granulating. At tops of the created roots also fibrous and granulematozny Items develop.
At P.'s diagnosis milk teeth it must be kept in mind existence fiziol, resorptions of roots of milk teeth, to-ruyu it is necessary to distinguish from pathological. At fiziol, resorptions the bone of normal structure densely adjoins to rezorbirovanny roots of milk teeth.
For P.'s diagnosis second teeth at children matters rentgenol. a research since under influence patol, process the fabrics creating fangs and a periodontium collapse.
Children can have both conservative, and operational P.'s treatment. At conservative treatment of P. of milk teeth make endo-dontichesky processing of channels of a fang and sealing by their hardening pastes. Distribution patol, process on a rudiment of a second tooth is the indication to operational treatment.
Features of treatment of P. of second teeth at children exist only in cases when growth of fangs is not finished. For treatment of such teeth the endodontichesky processing of the channel of a fang providing the maximum removal from its walls of the infected not calciphied fabric and sealing of the channel antiseptic pastes is recommended. Children to whom P.'s treatment second teeth with not created root is carried out shall be under observation of the doctor. If in 6 — 8 months in the field of roots of such teeth there are no reparative processes that is established radiological, the radectomy, hemisection, amputation of a fang, koronoradikulyarny separation of a pla an odontectomy are recommended.
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B. S. Ivanov; T. F. Vinogradova (ped.), Yu. I. Vorobyov (rents.), V. V. Panikarovsky (stalemate. An.).