ché ng ré n yá zh not u yá n 2 English reference
*** periodontitis 3 overview
adult periodontitis (* * * Periodontitis (AP), also known as chronic adult periodontitis (CAP), is the most common type of periodontitis, accounting for about 95% of periodontitis patients. It is caused by the long-standing chronic gingivitis spreading to deep periodontal tissue. The older you get, the higher the prevalence rate and the more serious your illness is. More common in adults, the process is slow, which can last for ten or decades. The amount of plaque and tartar is consistent with the severity of periodontal tissue damage. The gums are congested, swollen, soft and prone to bleeding. Attachment loss, periodontal pocket formation, and even pus overflow. Alveolar bone absorption is mainly horizontal absorption, and vertical absorption can occur when accompanied by biting trauma. Chewing weakness, tooth displacement and loosening. Bad breath, retrograde pulpitis and other manifestations. Although there are clear pathological differences between gingivitis and periodontitis, they are gradually transitional in clinic, and early detection and diagnosis of periodontitis should be emphasized. 4 disease name < P > Adult periodontitis 5 English name < P > * * Periodontitis < P > 6 alias of adult periodontitis < P > Chronic periodontitis * * Periodontitis 7 classification < P > Stomatology >: Periodontal disease > Periodontitis No.8 ICD
K5.5 9 Epidemiology < P > The prevalence of periodontitis increased significantly after the age of 35, and its severity also increased with age. 1 Etiology < P > Periodontal disease is a multifactorial disease, and its etiology is traditionally divided into local factors and systemic factors. Among the local factors, plaque bacteria and their products are the main causes of periodontal disease, and dental calculus, food impaction and poor restorations aggravate the retention of plaque. Plaque bacteria is an essential initial factor to cause periodontal disease, but it is influenced by other local factors and regulated by systemic factors. Systemic factors can change the host's response to local factors, and the host's response is also an important factor. Various factors in multi-factors are interrelated, influencing each other, or synergistic and antagonistic to each other. 11 Pathogenesis < P > When the dynamic equilibrium is maintained between bacterial invasion and host defense, the pathogenic effect of a small amount of plaque can be controlled by the host defense function, and the periodontal tissue can still be kept healthy. Whether periodontal infection can be established is actually determined by bacteria, host and environment. Some local promoting factors that affect dynamic balance, such as dental calculus, food impaction, trauma, some local anatomical factors, bad habits and bad prostheses, can enhance bacterial invasion, while some systemic promoting factors, such as endocrine disorders, smoking, mental stress, immunodeficiency, genetic factors and malnutrition, can reduce the host's defense. When the normal flora loses mutual restraint, or the periodontal microorganisms lose balance with the host, it turns into ecological imbalance and periodontal disease occurs. From another point of view, it is difficult and unnecessary to eliminate all bacteria in periodontal disease. The prevention and treatment of periodontal disease can rebuild the microecosystem beneficial to periodontal health by weakening the invasion of bacteria or enhancing the defense of the host, which is the ecological adjustment therapy involved in periodontal disease prevention and treatment. Page and Komman proposed the interaction of the pathogenic factors of periodontitis (Figure 1).
when the number and mutuality of microorganisms increase, or the body's defense ability is weakened, due to the characteristics of subgingival microecological environment and the nutrients provided by inflammatory products to microorganisms, a large number of periodontal pathogens such as Porphyromonas gingivalis, Pulenula intermedia, Actinobacillus Actinobacillus, Bacteroides Forsythiae, Fusobacterium nucleatum and spirochete breed in subgingival plaque, which aggravates and prolongs the inflammation of gingiva, leading to the destruction of collagen, the proliferation of combined epithelium to the root, the formation of dental pouches and alveoli. The clinical manifestations of adult periodontitis < P > generally invade most teeth in the whole mouth, and a few mouthfuls only occur in a group of teeth (such as front teeth) or individual teeth. The disease can begin in youth, and the active period and the static period alternate, and the course of the disease lasts for more than ten years or even decades. There are often a lot of tartar and plaque on the tooth surface. Gingiva presents chronic inflammation in different degrees, with dark red or bright red color, soft texture, disappearing stippling, gingival edema and blunt edges. There is bleeding and pus overflow on the inner wall of the probe bag. There was periodontal pocket and alveolar bone absorption in the early stage, but the teeth were not loose because of the light degree. The severity of periodontal tissue destruction was determined by the degree of attachment loss of connective tissue and alveolar bone absorption in the late stage:
① Mild: gingivitis and bleeding during probing, periodontal pocket ≤4mm, attachment loss of 12mm；; X-ray film shows that the alveolar bone absorption does not exceed 1/3 of the root length.
② moderate: dentity: inflammation, bleeding and pus in the gums, periodontal pocket ≤6mm, and attachment loss of 35mm；; X-ray film shows that the horizontal or angular absorption of alveolar bone exceeds 1/3 of the root length, but does not exceed 1/2 of the root length. There may be slight loosening of teeth, and there may be slight lesions in the root furcation area of many teeth.
③ severity: gingival inflammation is obvious or periodontal abscess occurs, and periodontal pocket >: 6mm, loss of adhesion > 5mm； X-ray film showed that alveolar bone absorbed more than 1/2 of root length, many teeth had furcation lesions, and many teeth were loose. In the late stage of periodontitis, besides the four characteristics of periodontal pocket formation, gingival inflammation, alveolar bone absorption and tooth loosening, other accompanying symptoms often occur, such as:
① tooth displacement;
② food impaction;
③ secondary occlusal trauma;
④ root exposure, temperature sensitivity or root gingival;
⑤ acute periodontal abscess;
⑥ retrograde pulpitis;
⑦ bad breath.
During the occurrence and development of adult periodontitis, there are often the following clinical manifestations: 12.1 Expression of gingival inflammation
As an important part of periodontal tissue, gingiva shows some changes in the early stage of adult periodontitis, mainly gingival inflammation and bleeding.
(1) Changes in color, shape and quality of gingiva: Normal gingiva is pink, and its edge is thin like a knife, and it clings to the tooth neck; Attaching gum is a bit colorful. Healthy gums are dense, tough and elastic. When suffering from adult periodontitis, the gingival tissue can show inflammation, and the wandering gingiva and gingival * * * can be bright red or dark red. In severe cases, the scope of inflammation can spread to the attached gingiva, corresponding to the scope of periodontal pocket. At the same time, due to the swelling of tissue during inflammation, the gingival margin becomes thicker, and the gingiva becomes round and blunt, and it is no longer close to the tooth surface; The surface of gingival tissue is bright, and the stippling disappears because of the edema of the tissue. Due to inflammatory infiltration and the destruction of collagen fibers, the texture of gingival tissue becomes soft and fragile and loses elasticity. In the case of chronic inflammation, epithelium can proliferate and thicken, collagen fibers proliferate, and gums can become tough and hypertrophy.
(2) Bleeding tendency of gingival tissue: Healthy gums will not cause bleeding even if brushing teeth or probing gingival sulcus lightly. Gum bleeding is often the main symptom of adult periodontitis; Generally, it happens when brushing teeth and biting hard objects, and occasionally there may be spontaneous bleeding. 12.2 formation of periodontal pocket
periodontal pocket is a pathological deepening gingival sulcus, which is one of the most important pathological changes and clinical features of adult periodontitis. Generally speaking, the periodontal pocket consists of soft tissue wall and root wall, and there are a lot of bacteria, food residue, saliva mucin, exfoliated epithelial cells and white blood cells in the pocket. The epithelium on the inner wall of the soft tissue wall of the periodontal pocket is often edematous and degenerated, and ulcers can form. After probing the periodontal pocket, it can bleed, and there are a large number of inflammatory cells infiltrating into the connective tissue under the epidermis. After the leukocytes die, pus will overflow from the pocket, which is clinically manifested as pus overflowing from the periodontal pocket. The root wall of periodontal pocket is usually covered with plaque and tartar. Due to the effect of plaque and its products, the cementum on the root surface can be demineralized and softened. The root wall of periodontal pocket is not smooth when probing. 12.3 attachment loss
healthy periodontal tissue, the depth of gingival sulcus is less than 2mm, and the combined epithelium is located at the enamel cementum boundary, forming epithelial attachment and sealing the gingival sulcus bottom. In adult periodontitis, the combined epithelium proliferates to the root, and the crown is separated from the tooth surface, forming a periodontal pocket. At this time, the attachment position of the epithelium has moved to the root of the enamel cementum, that is, attachment loss has occurred. Whether there is attachment loss is the key to distinguish gingivitis from periodontitis. The amount of attachment loss is expressed by subtracting the distance between gingival margin and enamel boundary from the distance between gingival margin and periodontal pocket bottom, and adding the distance between gingival margin and pocket bottom and enamel boundary to gingival margin when gingiva retreats. 12.4 alveolar bone absorption
alveolar bone absorption is an important clinical manifestation of adult periodontitis. The absorption of alveolar bone can often be expressed in the following forms:
(1) Horizontal absorption: this is the most common absorption form of alveolar bone. It is absorbed horizontally from the top edge of alveolar ridge to the root, which reduces the height of alveolar bone and forms an supraosseous pocket.
(2) vertical absorption: refers to the vertical or oblique absorption of alveolar bone, forming an angular bone defect between the alveolar bone and the root surface, and the height of alveolar ridge is not obviously reduced. Vertical bone resorption mostly forms a subchondral pocket.
(3) Other forms of alveolar bone absorption: Pit-like absorption is also a common form of alveolar bone absorption, which often occurs in the alveolar septum, and its central part is destroyed rapidly, while the buccal and lingual bone remains, forming crater-like or crater-like defects. 12.5 Tooth looseness and displacement < P > Healthy teeth have certain physiological mobility, but the mobility range is very small; When suffering from adult periodontitis, the mobility of teeth exceeds the physiological range, which is called tooth loosening. This is due to the absorption of alveolar bone and the loss of periodontal supporting tissue during periodontitis. Tooth loosening is also one of the main clinical manifestations of periodontitis. When alveolar bone absorption and periodontal supporting tissue loss reach a certain amount, the teeth with periodontitis can be displaced from their normal positions under the force, which is also a common clinical manifestation of adult periodontitis. Causes of tooth loosening and displacement:
(1) Absorption of alveolar bone: Periodontitis causes the absorption of alveolar bone, which reduces the amount of periodontal supporting tissue. When it reaches a certain level, the teeth become loose, and with the action of force, the teeth can be displaced. Therefore, in the early stage of adult periodontitis, the teeth are not loose, and only when the disease develops to a certain extent will the teeth become loose and displaced.
(2) bite injury: excessive bite force can cause alveolar bone absorption, periodontal ligament space widening, teeth loosening and displacement.
(3) Others: Acute inflammation of periodontal ligament makes periodontal fibers hyperemia and edema, which can lead to tooth loosening and displacement, periodontal surgery trauma, tissue edema and increased tooth mobility. 12.6 secondary trauma
in periodontitis, the supporting force of periodontal tissue is obviously weakened due to the absorption of alveolar bone and the destruction of periodontal supporting tissue, which can not adapt to the original physiological biting force, resulting in secondary trauma and more serious destruction of periodontal tissue. 12.7 Periodontal atrophy < P > Periodontal atrophy refers to the simultaneous destruction and loss of alveolar bone, periodontal fiber and gingival tissue caused by chronic inflammation for a long time, which eventually leads to root exposure. Periodontal atrophy is a common clinical manifestation of adult periodontitis. With the growth of adult periodontitis patients' age and the long-term existence of local factors, the destruction of periodontal tissue is gradually aggravated, and the number of teeth with periodontal atrophy is gradually increasing. Because of periodontal atrophy and root exposure, teeth often have allergic symptoms, and because root cementum is directly exposed to oral environment, root caries is also prone to occur. Periodontal tissue in the adjacent area shrinks, resulting in food impaction, which can aggravate the inflammation and destruction of periodontal tissue. Tooth root exposure caused by periodontal atrophy in the upper anterior teeth area affects aesthetics. 12.8 Periodontal abscess < P > Periodontal abscess is also a common clinical manifestation of adult periodontitis; Especially in the late stage of periodontitis, deep periodontal pockets appear in the affected teeth. When suppurative inflammation occurs in the periodontal pockets and the drainage is not smooth, it is easy to form periodontal abscess.
Periodontal abscess is generally an acute process with an acute onset, and a hemispherical swelling process is formed in the gum of the affected tooth. The local gingival tissue is edema, redness and brightness, and the pain is obvious in the early stage of abscess formation. The affected teeth may feel floating, loose and painful. After the abscess is localized, the pain is relieved and the feeling of fluctuation can be felt locally. Sometimes the abscess can burst by itself, and the sinus is formed on the gum surface to discharge pus, which becomes a chronic periodontal abscess. 12.9 retrograde pulpitis
when periodontal disease develops to a certain extent, it can cause pulp tissue lesions. In adult periodontitis patients, bacteria and toxins in deep periodontal pockets can enter the pulp through apical foramen or lateral branch root canals, causing pulp inflammation in the corresponding parts, which is called retrograde pulpitis. Clinically, the teeth with retrograde pulpitis can show typical acute pulpitis and sometimes chronic pulpitis. 12.1 Clinical judgment of the active stage of periodontitis < P > For a long time, people have traditionally thought that periodontal disease is a chronic and continuous progressive disease, and the destruction of periodontal tissue is a progressive destruction process. Until the mid-198s, scholars put forward on the basis of a lot of research that the progress of periodontitis is not a chronic, persistent and progressive destruction, but a periodic feature, that is, the disease is