Classification of Periodontitis

On the clinical course of isolated acute and chronic periodontitis.

Acute periodontitis (periodontitis acuta) depending on the nature of fluid shared by many authors in acute serous and acute purulent. I should say that such a distinction on the basis of a subjective data is not always possible. In addition, the transition form serous purulent inflammation is very fast and depends on several conditions, primarily on the condition of the patient.

Chronic periodontitis is divided based on the nature and extent of damage to periodontal tissues. Distinguish chronic fibrotic periodontitis (periodontitis chronica fibrosa), chronic granulating (periodontitis chronica granulans) and chronic granulomatous periodontitis, or granuloma (periodontitis chronica granulomatosa s. granuloma).

Chronic periodontitis in response to various adverse conditions (influenza, chill, etc.) may exacerbate the inflammatory process. The clinical course of the aggravated chronic periodontitis although it has many features in common with acute periodontitis, but also possesses its distinctive features. This form of asplenia has not only the elimination of acute inflammatory events, such as acute periodontitis, but also those destructive disturbances that are characteristic of some form of chronic periodontitis. On this basis, should be distinguished in the classification and chronic periodontitis in the acute stage (periodontitis chronica exacerbata).

Etiology of Periodontitis

Differentiated by origin periodontal infection, traumatic and medical. Given that the pathogenetic therapy of the expected maximum effect, the modern classification of periodontitis should reflect the nature of the pathological process in the periodontium and to take into account the causal factors: infection, sensitization periodontal tissue, impaired trophic, injury potent drugs.

Infectious periodontitis. The main role in the development of periodontitis are infectious microbes, mainly streptococci, nonhemolytic streptococci among which is 62%, zelenyaschy - 26%, hemolytic - 12%. Coccal flora usually sow together with other microorganisms - veylonellami, lactobacilli, yeast fungi. Toxins of microorganisms and decay products of the pulp penetrate through the root canal, periodontal and gingival pocket. There is, though more rarely, hematogenous and also lymphogenous way of an infectious periodontitis (influenza, typhoid and other infections). According to the literature, the contents of root canals with untreated apical periodontitis determined by microbial associations, consisting of 2-5 species, and rarely, pure cultures of microorganisms.

Thus, by way of penetration of bacterial infection, periodontitis. Go to last and can be classified as infectious periodontitis, which develops as a result of the inflammatory process of transition from the surrounding tissue (osteomyelitis, osteitis, sinusitis, etc.).

Traumatic periodontitis. Is the result of the impact on the periodontium as a single significant injury (bruise, a blow or hit in the tooth hard object in the form of a pebble, stone), and less strong, but repetitive microtrauma repeatedly as a result of incorrect (high) sealing, "direct" the bite, with regular pressure on certain teeth mouthpiece a pipe or a musical instrument, as well as bad habits (snacking threads, pressure on the tooth with a pencil, etc.).

In acute trauma, periodontitis develops rapidly with acute events, bleeding. In chronic injury changes in periodontal grow gradually: first the periodontium as it adapts to overload. Then, with the weakening of adaptive mechanisms of periodontal trauma causes a constant flowing chronically inflammatory process. With traumatic stress can occur lacunar resorption compact disc alveoli in the apex of the root.

Medical periodontitis. Develops most often as a result of incorrect treatment of pulpitis, when released into the periodontium of potent chemicals or drugs, such as arsenical paste, formalin, formalin-trikrezol, phenol, and others. Penetration of these drugs in the periodontium, as well as its infection occurs through the root canal. This will include periodontitis, which develops in response to the removal of the periodontium in the treatment of pulpitis phosphate cement paratsina, resorcinol-formalin paste, pins and other filling materials. To include medical periodontitis and periodontitis, which has developed as a manifestation of allergy as a result of the use of drugs that can cause a local immune reaction (antibiotics, eugenol, etc.).

Information on Periodontitis

Taking into account the difference in the direction and organization of bundles of collagen fibers, they should be classified as follows: transseptal fibers loose fibers gums (leading from the neck of the tooth and are woven into the connective tissue of the gums), the circular fibers (covering the neck of the tooth), alveolar pectinate fibers (passing from the top of the alveolar crest to the neck of the tooth cement), oblique fibers; group; apical fibers.

Periodontitis polozhenie periodontal fibers in the longitudinal sawing tooth (left)

Location periodontal fibers in transverse sawing tooth (right)

While the above groups of fibers can be traced to teriodonte all teeth, however different in the periodontium of teeth functionally different in structure. Thus, for anterior teeth (incisors, canines) is characteristic that bundles of fibers that make up the fabric of periodontal relatively thin. This particularly applies to circular group covering the neck of the tooth. Group oblique fibers is divided into separate fragments triangular spaces filled with loose connective tissue. The angle of these fibers is about 40-45 ° in the vestibular division and periodontal ligament 35 ° - in the oral department. It should be noted that the angle of the fibers also varies in different parts of the periodontal ligament. On the site of periodontal immediately below the neck of the tooth, the slope of the fibers varied - 25-35 °. Below this level, the slope of the fiber increases up to 45-50 °. And finally, in periapikal-term part of bundles of fibers, as noted above, takes an almost vertical direction. It should be noted that the group of the underlying tissue in anterior teeth is relatively small. Here you can observe rather dense plexus of argyrophilic fibers.

In periodontal premolar teeth (premolars group) bundles of collagen fibers thickened. This applies to both circular and to transseptal group. More clearly expressed here nolokna going in bucco-lingual direction. The angle of oblique fibers of 20-25 ° was in the cervical area, then increasing to 50-60 °. In the group of fibers underlying the tip of the root, good stands crosswise weave. For periodontal molars are characterized by strong trans-septal and circular fibers and thick bundles in the apical part of periodontal, which seemed to create a mat for the top of the root. Pay attention as well-developed bundles of fibers running in the horizontal direction and connecting the alveolar crest with the root canal with cement.

The angle of the fibers arranged obliquely, also increased more gradually from 20 ° in the cervical area to 40 ° in the middle sections of root length. Notably the fiber at the bifurcation of multi teeth. The upper portion of the fibers connecting the crest of the alveolar walls with cement at the bifurcation of the roots, the arrangement resembles alveolar pectinate fibers. In addition, over the top of the alveolar walls observed fibers coming from the horizontal direction and how to connect the roots of the teeth. These fibers form a particularly complex weave-in the teeth with three roots. Below these fibers followed by oblique fibers, basically repeating the opposite direction of the fibers department periodontal ligament.

In periodontal tooth contains elastic fibers, but their number is small. This is mainly fine fibrils, which are located between bundles of collagen fibers of the periodontal ligament. It should be noted that these elastic elements are often found in the periodontium of incisors and canines fibers cervical group.

One of the features is the presence of periodontal significant amount oxytalan  fibers, so named for their resistance to acids. They are a permanent component of periodontal connective tissue. Their distribution is also uneven, they are more often found in the fibers of the cervical group, and in the periapical area.

Oksitalanovye periodontal fibers are a kind of elastic fibers. Contents oxytalan  fibers and their thickness increased in periodontal tooth experiencing increased functional load.

Oxytalan  fibrils form a dense network, which weaves between the collagen fibers. Oxytalan  fiber, connecting with the periodontal blood vessels to form oxy-Talanova-vascular structures. It is established that, along with the plastic function oksitalanovaya system is part of the tor receptor mechanism of periodontal performing vascular control.

In periodontal teeth, especially of multi there Argyro-hydrophilic fibers, which are morphologically very similar to argyrophilic fibers of the reticulum. These fibers are most often detected in periodontal sites, communicating with the bone marrow spaces of the jaw.

Between the connective tissue in periodontal cellular elements are - fibroblasts with an oval nucleus and pale cytoplasm, in the loose connective tissue - fat cells and histiocytes (wandering cells) with a brightly colored small nucleus and granular cytoplasm. Near blood vessels and capillaries are found periodontal perivascular adisntitsialnye histiocytes and mast cells.

Mast cells have a round or elongated. Established that the grain of the mast cells are heparin and histamine involved in the regulation of permeability of the basic substance of connective tissue of periodontal.

Plasma cells are mainly localized in prisheech-connected domain. Have a rounded shape with very basophilic cytoplasm, round nucleus and a characteristic arrangement of chromatic new clumps.
In periodontal sites adjacent to the cement of the root are cementocytes - cells having cosmetic function and the construction of a secondary (cell), cement, and in areas adjacent to the alveoli, are osteoblasts - bone builders alveoli.

However, the set of cellular elements in different parts of the periodontal different. More young malodifferentsironainyh cells characteristic of the periapical and periodontal cervical area, while the multi-rooted teeth in such a plot, moreover, is the periodontium at the bifurcation of the roots. In the middle parts of the periodontal ligament space is dominated by more mature forms of the fibroblasts. Characteristically, the same is subject to fluctuations in the number of plasma and mast cells.

In addition to these cells in connective origin, closer to the cement arranged epithelial formation - the so-called epithelial remnants (relictum epitheliale). The conventional wisdom is that these are remnants of the epithelial formation zuboobrazovatelnogo epithelium, which is stored in the periodontium of teeth throughout life. Domestic authors proved the heterogeneity of the epithelial origin of these elements in okoloverhushechnoy part of the tooth root, they are the remnants of (islands, nests) juxtahilar epithelial sheath, and in the neck of the tooth - the remnants of dental lamina.

Places the greatest localization of the epithelial cells are part of the Cervical and periapical periodontium. Here are allocated the largest complexes of these cells. Shapes and sizes of clusters of epithelial cells are different. In some cases they form small groups of cells in the other - the kind of short strands. It is significant that the content of these epithelial Residues exposed to pronounced age variations. The largest number of residues found in the epithelial periodontal people aged 10-20 years. A significant number of these cells found in periodontal people 21-30 years of age. At the same time in the periodontium to persons aged 50 years, their number is markedly reduced. This changes and the morphological structure itself remains.

The content of the epithelial nests in reduced periodontal tooth bearing functionally increased load.
Many authors argue that the epithelium of these nests, under certain conditions can cause both benign (kistogranulemy, cysts) and malignant (cancerous) tumors.

Periodontal vascular network is well developed. Perfusion of the apical part of periodontal longitudinally spaced by 8.7 dental branches (rami dentales), extending from the main arterial trunks (a. alveolaris superior, posterior et anterior maxillary and a. alveolaris inferior to the mandible). These branches ramify, connected by thin anastomosis and form a dense network surrounding on all sides of the tooth root. Perfusion medium and periodontal prisheechnoi parts is made by interalveolar arterial branches (rami interalveolares), penetrating along the veins in the periodontium through numerous holes in the walls of the alveoli. Interalveolar vascular trunks that penetrate into the periodontium, dental anastomose with branches.

In prisheechnoi of periodontal vascular location-less correct. Dense plexus in the circular bundles formed capillary loops, ranging in form glomeruli. Vascular glomeruli are periodontal arteriovenous anastomoses, which consist of clusters of epithelioid cells and capillaries. Part of the tiny capillaries located in the collapsed state and is not functioning. As suggested to function in iklyucheniya they are not subject to hardening of the pathological process that is important for the regeneration of periodontal tissue.

Thus, the primary role in periodontal blood supply vessels are coming out of the interalveolar septa. Less important are the ramifications of the vessels that penetrate into the pulp, blood vessels and their anastomoses gums.

Blood vessels form several periodontal plexus. Outdoor (closer to the hole) plexus is composed of longitudinally arranged larger blood vessels, the average - of smaller caliber vessels. Next to the cement of the root is located capillary plexus. There is a close relationship with blood vessels periodontal nerve structures and blood vessels to the pulp, which accounts for the effect of periodontal disease and slurry on each other.
Lymphatic vessels periodontal located mainly longitudinally, like blood vessels. Lacunary extension of lymphatic vessels depart plexus in the form of glomeruli. Recent located more deeply under the plexus of capillaries. Lymphatic vessels are periodontal in connection with the lymphatic vessels of the pulp, bone alveoli and gums.

Lymph flowing from pulp and periodontium through the lymph vessels that pass into the interior of the bone along the neurovascular bundles. Together with the lymphatic vessels and surrounding periosteum jaw jaw tissue lymphatic vessels external and internal surface of the mandible body form krupnopetlistuyu lymphatic network. Vents vessels of the network flow into the chin, submandibular, parotid and medial retropharyngeal lymph nodes.

Innervation of periodontal carried out, as blood supply in two ways. In the apical third of root myelinated nerve fibers penetrate into the periodontium and embedded in the fibrous bundles, and a layer of loose connective tissue. Some of these fibers stretched in the form of longitudinal beams along the peri-odontalnoy gap. In the middle and prisheechnoi thirds of periodontal innervation by nerve fibers that penetrate the walls of the alveoli of the bone.

Throughout the periodontal (from circular ligament to the tip of the tooth root) is scattered a large number of free sensory nerve endings, different in structure. However, more of these endings is determined and okoloverhushechnoy of periodontal and much less in beams with circular ligament of the tooth.

LI Falin pointed to the existence of two morphologically different types of free sensory nerve endings: 1) in a tree-branching shrub, 2) in the form of single and double glomeruli. Also detected the nerve terminal structure in the form of antennae, eyes are plaques, sticks and bottles.

Terminal branches of the nerve endings kustikovyh mostly oriented along the fiber bundles of fibrous periodontal and glomerular nerve endings located in the strata of loose connective tissue, across and between collagen bundles. Terminal twigs kustikovyh nerve endings that are in close contact with the fibrous bundles of fibers, regard recently as mechanoreceptors, by which power is regulated by reflex chewing pressure on the tooth. Kustikovye periodontal nerve endings, in turn, believe the initial link in the reflex path. Glomerular nerve endings is attributed to the ability to perceive tactile stimulation (sensory function).

Histochemical studies carried out revealed that the basic substance of the periodontal contained neutral and acid mucopolysaccharides. The amount of these substances varies in different parts of the periodontal ligament. The content of acid mucopolysaccharides in the cervical and larger periapical areas. The acid mucopolysaccharides play an important role in the formation and differentiation of periodontal collagen structures.

Neutral mucopolysaccharides are found in cells, amorphous material, fibrous structures, as well as in vascular walls.With age, collagen in the periodontal structures is a reduction of the content of hyaluronic acid, thus changing their properties. For periodontal cellular elements have a high level of metabolic processes. Differences in the activity of enzyme systems in cells that lie in different parts of the periodontal ligament. The highest activity of enzyme systems are characterized by cells that lie close to the bone cement and the alveoli. Interestingly, the cellular elements of these particular departments previously only respond to changes in the load of periodontal chewing.

Age-related changes in periodontal tissue are not only of great theoretical and practical interest. These specialized literature on this subject are scarce.

It is established that the structure of the periodontium is not constant, but undergoes a series of characteristic changes brought about by the age period. These changes occur in fibrous structures, and in the cellular elements.

Age-related changes in periodontal, three main periods.

For the period I (approximately 20 to 24 years of age) is characterized by the development and formation of the normal structure of periodontal final maturation of collagen fibers and the formation of their spatial orientation. II period (25 - 40 years of age) is characterized by stabilization of the structure of the periodontium. The structure of the periodontal changes very little. III period (over 40 years) differs destructive changes in the periodontium in the form of separate beams razvolokneniya collagen changes tinktorialnyh properties. In particular, the individual collagen fibers impregnated with silver starting in black, like the argyrophilic fibers.

Characteristically, to a greater extent the phenomenon of degradation of the fibrous structures occur in the cervical area of periodontal and to a lesser extent - in the fibers that connect the bone with cement, the alveoli of the root. However, in these fibers are also seen changes. With age, these areas are marked thickening sharpeevskih fibers woven into the alveolar bone.

In the elderly beams sharpeevskih fibers penetrate the wall of the alveoli surrounding the adjacent osteons, which is seen as a kind of compensatory reaction of periodontal. The composition of the cellular elements also varies with periodontal mozrastom. More young malodifferentsirovanpyh forms of periodontal fibroblasts is typical for young persons (20 years).

Maturation of the fibrous structures is accompanied by some reduction in young forms of the fibroblasts. These changes are reflected in the histochemical reactions. Higher activity of enzyme systems detected in the cells of the periodontal 20-year-olds, after which the enzyme activity is reduced. However, it should be noted that in people over 40 years back, there is some excitement of enzyme activity in the cells of the periodontium. Because in this period in fibrous structures have periodontal destructive changes, it is likely that a similar activation of cellular elements in the periodontium is compensatory in nature.

Options periodontal diverse: supporting-holding, distributing the pressure, the plastic, the trophic, sensory and protective. The main function - the tooth is strengthened in the hole with the periodontal fibers that act as ligaments. In fact, periodontal fibers are arranged so that they keep the tooth n different directions.