Periodontitis: etiology, pathogenesis, classification

17. Apical periodontitis: etiology, pathogenesis, classification. Acute apical periodontitis: etiology, pathogenesis, clinic, diagnostics, differential diagnostics

Periodontium– the formation of connective tissue that fills the space between the root and the inner wall of the alveoli and connecting the teeth of the jaw bone. The width of this space – periodontalnoyi gap – from 0.15 to 0.4 mm with a significant narrowing in the middle third of the root. Periodontalna slit written in dense and loose connective tissue that provides holding of the tooth alveolar bone jaw.

The main structure is Periodontal bundles of dense fibrous tissue consisting of closely interwoven circles ¬ Genova fibers. They stretched between alveolar bone cement and the tooth root and have S-shaped line. In various parts of the cracks periodontalnoyi these beams have different chats ¬ governmental. Yes, around the edge of the dental alveoli are stretched almost horizontally and form a broadcast tooth (ligamentum circullare). Fibres of this relationship as different in size and orientation. These include tools gingival (tsementoyasenni), al-veoloyasenni, circular, zuboperiodontalni (tsementoperiostalni) and transseptalni group of fibers.

Broadcast provides attachment coronal edge of the connective tissue to the tooth, increases resistance to the free edge of the gums and periodontal protects against external irritants.

Basic Periodontal fiber cement roots start ¬ ing tooth cross periodontalnu crack in different directions and vkorinyuyutsya in alveolar bone in the form of fibers Sharpeya. Depending on their direction of such distinguished group of bundles of fibers: crestal, horizontal, oblique, apical, mizhkorenevi. Largest in periodontal fibers are oblique. They vkorinyuyutsya in alveolar bone close to the crown than the place of their attachment to the cement. Tooth as if suspended from the fibers of this group.

In addition to the core, collagen, fibers in the periodontal have a small number of randomly oriented thin, immature collagen fibers – reticular.

In small amounts in the walls of blood vessels are elastic periodontal fibers. Between the walls of blood vessels and underlying fibers in an oblique direction are oksytala-new fibers, which are also immature collagen fibers. They provide attachment of blood vessels and prevented ¬ yut their deformation during operation Periodontal.

Between the fibers are the main substance con ¬ meadow loose tissue, cells, blood, lymph vessels and nerves Periodontal.

The main substance Periodontal contains 70% water to the objective of transforming ¬ distribute masticatory pressure on the walls of al ¬ veoly. The most common cells in it is the fibroblasts that develop ¬ tashovani along the main direction of bundles of fibers, as involved in their formation. These cells produce elastin, glycoproteins, glycosaminoglycans.

In addition, there are periodontal epithelial cells, which are remnants of epithelial root sheath Hertviha. They form bands, strips, follicles that are closer to the cement, and are called islets Malyasse. Sometimes anastomozuyut epithelial strands together, permeating the entire Periodontal. These epithelial cells in the case of specific pathological conditions may participate in the formation of granulomas, kistohranu-Lema and navkolokorenevyh cysts.

An important cellular component of periodontal mesenchymal cells are malodyferentsiyovani. They are located around blood vessels and, if necessary, differentiate into fibroblasts, osteoblasts and tsementoblasty.

Throughout the periodontal, especially in a periapical ¬ tyni located reticuloendothelial cells and blood cells ¬ us who migrated from the vessels: erythrocytes, leukocytes, lymph ¬ tsyty, monocytes, at least – macrophages and plasma.

Blood supply is periodontal dental twig ¬ we are departing from the main arteries – Aa. dentalis, interradicularis, interdentalis. They branch out and closely anastomozuyut, ¬ ryuyuchy formed a dense vascular network Periodontal.

Venous vessels are parallel to the arterial. They have a greater diameter than the arterial, and receive blood from kapi-addition to the core, collagen, periodontal fibers in a small number of randomly oriented thin, immature collagen fibers – reticular.

In small amounts in the walls of blood vessels periods of DonNTU is elastic fibers. Between the walls of blood vessels and underlying fibers in an oblique direction are oksytala-new fibers, which are also immature collagen fibers. They provide attachment of blood vessels and prevented ¬ yut their deformation during operation Periodontal.

Between the fibers are the main substance con ¬ meadow loose tissue, cells, blood, lymph vessels and nerves Periodontal.

The main substance Periodontal contains 70% water to the objective of transforming ¬ distribute masticatory pressure on the walls of al ¬ veoly. The most common cells in it is the fibroblasts that develop ¬ tashovani along the main direction of bundles of fibers, as involved in their formation. These cells produce elastin, glycoproteins, glycosaminoglycans.

In addition, there are periodontal epithelial cells, which are remnants of epithelial root sheath Hertviha. They form bands, strips, follicles that are closer to the cement, and are called islets Malyasse. Sometimes anastomozuyut epithelial strands together, permeating the entire Periodontal. These epithelial cells in the case of specific pathological conditions may participate in the formation of granulomas, kistohranu-Lema and navkolokorenevyh cysts.

An important cellular component of periodontal mesenchymal cells are malodyferentsiyovani. They are located around blood vessels and, if necessary, differentiate into fibroblasts, osteoblasts and tsementoblasty.

Throughout the periodontal, especially in a periapical ¬ tyni located reticuloendothelial cells and blood cells ¬ us who migrated from the vessels: erythrocytes, leukocytes, lymph ¬ tsyty, monocytes, at least – macrophages and plasma.

Blood supply is periodontal dental twig ¬ we are departing from the main arteries – Aa. dentalis, interradicularis, interdentalis. They branch out and closely anastomozuyut, ¬ ryuyuchy formed a dense vascular network Periodontal.

Venous vessels are parallel to the arterial. They have a greater diameter than the arterial, and receive blood from capillaries

The most important feature is the periodontal attachment of teeth in the jaw bone. It is provided bundles of collagen fibers – their tortuous course provides physiological mobility teeth.

1. Barrier function. Periodontal, especially broadcast tooth, protects the body from penetration of microorganisms, toxins and other harmful agents.

2. amortization function. The presence of up to 70% of fluid in periodontal, a significant amount of vascular and fibrous structures provide Periodontal opportunity not only to withstand chewing pressure, and evenly distribute it on all sides periodontalnoyi cracks.

3. Trophic function. Dense network of blood vessels provides Periodontal trophic function of hard tissues. This even depulpovani teeth for a long time successfully running.

4. Plastic function. Periodontal cells, forming a secondary cement and bone, give him a plastic function, which is especially important when you move the teeth.

5. Sensory function due to the rich innervation of periodontal, so it is as if the body senses a tooth. This function zaNayvazhlyvishoyu periodontal attachment of teeth in a jaw bone. It is provided bundles of collagen fibers – their tortuous course provides physiological mobility teeth.

6. Barrier function. Periodontal, especially broadcast tooth, protects the body from penetration of microorganisms, toxins and other harmful agents.

7. Amortyzyvna function. The presence of up to 70% of fluid in periodontal, a significant amount of vascular and fibrous structures provide Periodontal opportunity not only to withstand chewing pressure, and evenly distribute it on all sides periodontalnoyi cracks.

8. Trophic function. Dense network of blood vessels provides Periodontal trophic function of hard tissues. This even depulpovani teeth for a long time successfully running.

9. Plastic function. Periodontal cells, forming a secondary cement and bone, give him a plastic function, which is especially important when you move the teeth.

Sensory function due to the rich innervation of periodontal, so it is as if the body senses a tooth. This is for in diffuse forms of inflammation of the pulp – in acute purulent pulpitis, chronic gangrenous pulpitis. Bacteria and their current ¬ sons periodontalnyy get into space and cause periodontal inflammatory response.

Table 18 etiology of periodontitis

 

2. Marginal way. Often it is implemented in patients with periodontal disease. In the case of generalized or localized periodontitis broadcast broken tooth plate cortical alveolus, periodontal pocket is formed, from which the infection enters the periodontalnyy space and it causes inflammation of tissues.

3. Contact way. In patients with osteomyelitis or sinusitis infection with pathological focus moves to the contact teeth are located.

4. Hematogenous or lymphogenous way. In this way the infection gets in periodontal patients with infectious for ¬ sickness.

To be infectious and so-called periods of perifocal dontyt, which was described IG Lukomski yet in 1955 he develops in patients with acute and chronic pulpitis, pulp gangrene and other diseases when infection is at the root canal tooth and there is focus – focus of the pathological process. With this focus in the periapical space penetrated ¬ yut individual bacteria and their toxins, causing an inflammatory re ¬ action Periodontal. After removal of the fire (eg removed ¬ ing infected pulp canal sterilization) inflammation periodically ¬ DonNTU disappears. This inflammatory reaction periodontalnyh tissues in the tooth root apex area serves as a barrier that obstacles ¬ zhaye further penetration of the infection.

Noninfectious periodontitis caused by the influence of periodic ¬ DonNTU various local and general factors.

1. The most common cause of periodontitis is a traumatic factors, mainly mechanical trauma – acute or chronic.

2. The second large group is chemical-toxic periodontitis.

3. Inflammation of Periodontal may cause allergic factors.

As noted, the traumatic factors that cause periodontitis include various injuries. Thus, acute trauma (shock, drop, etc..) Causing an acute traumatic injury. In such cases often suffer front teeth. Pathological changes vary depending on the strength and direction of the traumatic factor. In the case of small injuries may be breaks apical periodontal tissues, causing inflammatory reaction, and later it can pass and the pulp is alive.

Severe periodontal damage may result iot only the development of periodontitis, but also damage the pulp. Wang ¬ infected pulp complicates inflammation in periodontal.

Chronic trauma. With a weak, but the Permanent injury (eg, patients with abnormality of the bite, an artificial crown, denture or mostopodibnym seal that overstates the bite) forces traumatic focus in the area of ​​the root apex. This injury causes gradual resorption of alveolar bone and the body also gradually compensates by its produkuvan ¬ tion of granulation or fibrous tissue in the region of injury.

In addition, periodontitis may occur in smokers, smoking his pipe, in the musicians that played on wind instruments, in individuals who have bad habits teeth bite off the end ¬ us talk, biting a pencil and generally in all cases, when you create a constant pressure on land top of the tooth root. In this case the crown of the tooth can remain intact, although for a long ¬ fuel in the process can lead to periodontal destruction pulpovoyi tissue.

Traumatic periodontitis can lead to action dentist who carried out the treatment of inflamed pulp methyl ¬ dykamentozne and instrument processing channel root. Thus, while deep hysterectomy pulp may occur periodically break-dontalnoyi tissue, and eventually – Periodontal damage in the event of an incorrect definition of the length of the channel work file or rymerom’takozh can lead to periodontal damage.

Toxic-chemical periodontitis occurs mainly after dental manipulation. In most cases, is associated with the use of arsenious paste, whose action extends also to the periapical tissues in case of violation of terms of action or dose.

Strong antiseptic agents (formalin, phenol, ferezol et al.) Process which feeds the roots may also cause irritation and inflammation of periodontal.

Allergic periodontitis develops in patients with enhancement ¬ schenoyu sensitivity to drugs that are used for treating and filling root canals. Quite often, allergic reactions occur after the use of iodine and iodide compounds (yodoformu), especially when entering them into the paste for filling root canals.

Etiologic factors in many cases can act su ¬ Unto. For example, a tooth with necrotic infected pulp altered and may further injure; medication periodically ¬ dontyt may occur after treatment of infected root canal, when medication is combined with the infectious factor. All this complicates the treatment and needs of dentists to respect ¬ tion analysis of subjective and objective data to determine the main etiological factor responsible for the disease.

 Marginal periodontitis – an inflammation of the regional periodic-DonNTU – can also cause traumatic, chemical and infectious factors. Marginal periodontitis is always accompanied ¬ vodzhuye periodontitis and treated in the “periodontal disease”.

Periodontal pathogenesis

The major changes in the case of periodontal disease is inflammation of various forms of manifestations of alteration, exudation and prolife ¬ wrong. No matter how etiological factor caused nena ¬ inflammatory reaction – effect of infectious and toxic agents as a result of traumatic or chemical lesions, inflammation pochy ¬ nayetsya alteration of cells or tissues Periodontal.

In the area of damage accumulate lit ¬ tion mediators (histamine, serotonin, acetylcholine, etc.) and the fabric of ¬ teolitychni enzymes, which along with other alternative ¬ change we automatically trigger inflammatory response. As a result, changes occur in the vascular wall, circulation disorders, there is a withdrawal of blood plasma proteins and fluid forms. In parallel with the changes that come with the alteration and exudation, early inflammatory response exhibit proliferative processes inherent in acute, subacute and chronic zapa ¬ tion. The process ends with the formation of granule cell proliferation ¬ vation of tissue, which further transforms into fibrous, scar tissue ¬ tion.

The nature of the flow in the periodontal inflammatory process depends on the intensity and duration of the etiological factor, especially ¬ plots reflect the characteristics of lesions, as well as the state of body defenses. Inflammatory processes of the degree of pathological manifestations and nature of the clinical course can be divided into 2 groups oc ¬ mental objectives: 1) acute inflammation – characterized advantage of Alternative-exudative changes, less time-consuming and intensive course, a more severe clinical picture, 2) chronic inflammation – characterized advantage liferatively-regenerative processes, longer course and less severe clinical symptoms.

Pathogenesis of acute periodontitis

In the case of high body defenses and low intensity pathogenic etiological factor arises acute serous periodontitis. This form can be developed unas ¬ lidok root canal treatment of necrotic tissue pulpovoyi when the canal through the apical hole gets infection ¬ tion with severe virulence, or when the effect of injury or chemical agent is negligible.

Acute serous inflammation of periodontal early characters ¬ binds hyperemia. There have filling vessels and upovil ¬ nennya blood flow. Leukocytes are shifted to the vascular wall and reached stasis. Because vascular wall begin to penetrate the liquid part of blood protein, in a state of colloid, and neve ¬ lykiy number of neutrophilic leukocytes, lymphocytes and monocytes. Fluid loosens the connective tissue components and collagen fibrils Periodontal. At this stage, the inflammatory process spreads to bone tissue, which reacts very quickly because of its close association with periodontal. In the adjacent periodontal bone marrow spaces filled sponge possible expansion Cro ¬ vonosnyh vessels and stagnation.

Depending on the reactive capacity of the organism and timely therapeutic intervention ¬ tion process may stop or move to intensify and purulent inflammation.

Acute purulent periodontitis develops if the infection that got into periodontal, high virulence, damaged factor is quite aggressive and defensive reactions to a low level.

In connection with increased insight vessels due to activations of enzymes such as leykotoksyn, trypsin, penetrate through the vascular wall in a large number of leukocytes, lymphocytes and monocytes. Neutrophilic leukocytes phage bacteria and then die. their destruction is accompanied by release of enzymes – protease, cathepsin, chymotrypsin, alkaline phosphatase and others. and ¬ and each specific antigens that are necessary for the subsequent formation of antibodies ¬ ation. Decomposition of tissues with the formation of pus. Under hiperatsydozu tissue section showing active inflammation lymphocytes and monocytes Blood, and sedentary makrofahotsyty. Macrophages clean the area of ​​inflammation from dead cells and large unorganized

A                      B                   C                      D

Fig. 1. Four phases of acute purulent periodontitis:

A – periodontalna B – endosteal; C – subperiostalnyy abscess, D – submucous abscess

particles which lysis and complete destruction them.

Often, the inflammatory process in periodontal cover at ¬ lehlu jaw bone tissue. In bone develops purulent process – manure gets into bone tissue by haversovyh and folk manivskyh channels and accumulates in the periosteum. In the course of sp ¬ troho purulent periodontitis can distinguish four successive phases (Fig. 1).

1. Periodontalna phase – limited periodontal abscess process. Reactive inflammation of the alveolar bone.

2. Endosteal phase – purulent fluid enters the alveolar bone tissue paths with the least resistance and infiltruye kistkovomozkovi intervals sponge.

3. Subperiodontalna phase – purulent exudate accumulates under the periosteum, forming subperiostalnyy abscess.

4. Submucous phase – due to destruction periostu purulent exudate enters the soft tissue, forming a submucous abscess.

Definition phase of purulent periodontitis is essential locat ¬ ed for choice of treatments, because each of them take the ¬ phase requires specific measures. With the leveling forces of the damaging factor and body defenses are beginning to emerge proliferation processes. Granulation tissue that develop ¬ vyvayetsya directly over the processes of alteration and exudation, restores damaged in periodontal and alveolar bone. In the future it may serve as a protective barrier that neutralizes bacteria, toxins and other irritants.

CLASSIFICATION OF PERIODONTITIS

Acute and chronic periodontitis is one of the main causes of premature loss of teeth. Among those seeking dentist ¬ logical means, patients with different forms of periodontitis hundred ¬ novlyat from 15 to 30%. This high percentage of this type of pathology, from our point of view, because in 20% of teeth treated with pulp by about diseases prev ¬ noyi ITS devitalizatsiyi preparations of arsenic, the first year after treatment of clinically developing one or another form ¬ dontytu periodically. During X-ray examination of teeth in periodontal changes are 2 times more often (40 – 45%) than treated with other methods.

Often observed in periodontitis villagers, as well as persons who for various reasons not timely provided stomatolo ¬ hichna help.

The relatively high incidence of periodontitis and the considerable difficulties of its diagnosis and treatment is particularly necessary to develop a single classification.

Back in the XIX century. proposed classification of periodontal ¬ the one based primarily on clinical features. In 1891 O.K. Limberh systematized clinical signs of inflammation periodically ¬ DonNTU and suggested their classification.

Later appeared the classification in which urahovuvaly not only clinical symptoms but also data pathoanatomical maps us. These include classification of BI Mohylnytskoho and OI Evdokimova. In 1924, YM Hofunh proposed clinical-anatomical classification, which was reflected as lokaliza ¬ tion and pathological changes in periodontal inflammation. The author divided the processes involved in periodontal, on acute and chronic.

I. Acute periodontitis.

1. Acute marginal periodontitis.

2. Acute apical periodontitis.

3. Acute diffuse periodontitis.

II. Chronic periodontitis.

1. Chronic fibrous periodontitis.

2. Chronic granulomatous periodontitis.

However, proposed in the early XX century. classification does not completely re ¬ but revealed the clinical manifestations that are not always allowed Use ¬ stovuvaty them. IG Lukomsky (1955) investigated patofizio ¬ logical and pathomorphological changes in the periodontal condition of his zapa ¬ tion and proposed a classification that now common in clinical practice. It allows more directed diagnosed ¬ wool periodontitis and differential therapeutic exercise on gait ¬. According to this classification, periodontitis is divided into three main groups.

I. Acute periodontitis (periodontitis acuta).

1. Acute serous periodontitis (periodontitis acuta serosa).

2. Acute purulent periodontitis (periodontitis acuta purulenta).

I. Chronic periodontitis (periodontitis chronica).

1. Chronic fibrous periodontitis (periodontitis chronica fibrosa).

2. Chronic granulomatous periodontitis (periodontitis chronica granulomatosa).

3. Chronic granulating periodontitis (periodontitis chronica granulans).

III. Execerbated chronic periodontitis.

CLINIC, DIAGNOSTICS, DIFFERENTIAL DIAGNOSIS OF APICAL PERIODONTITIS

ACUTE PERIODONTITIS

Acute serous periodontitis (periodontitis acuta serosa).

In clinical practice most often occurs periodontitis, which occurs under the influence of infection and usually develops as UIC ¬ ladnennya pulp inflammation or due to errors that were to ¬ commercialized during endodontic therapy.

Symptoms. The complaints of the patient so characteristic that it happens often enough to install almost directly ¬ mylkovoho diagnosis. Initially, the patient feels heaviness and stress in the tooth ¬ its provisions, which became as if higher, longer than others. Progress ¬ PA occurs very severe pain of spontaneous origin. The pain is constant, localized, not radiating, nighttime and almost the same ¬ not inhibited conventional analgesics. Because of ¬ process is constantly evolving, the intensity of pain increases.

In addition, the characteristic may occur provoked pain. All that can increase the blood supply in the area of ​​the tooth and changes its mobility ¬ you, provokes attacks of pain. Yes, there is stronger ¬ tion pain during eating. In the initial stage, however, balanced, ¬ for free, long-pressing reduces pain associated with the outflow of fluid from periodontal, decrease congestion and styskan ¬ tion of nerve endings. Therefore, pressing the tooth in the alveoli, patients temporarily improve their condition. Pain when you press on the tooth may occur by heat when periodontitis is a complication of gangrene of the pulp of the tooth cavity closed. The temperature difference can cause pain if the change occurs suddenly. In the case of a gradual increase in tempera ¬ tours and long-acting sedative effect of heat is achieved due to sustained vasodilation, which promotes krovovidtoku of areas of inflammation.

Objectively. The patient’s tooth may be intact, not you ¬ klyuchaye presence of injury (eg in case of use of orthodontic devices). Often, however, it is carious, devitalizovanym, with an open cavity filled with large teeth or seal. Enamel loses its characteristic luster, becomes gray. Clear leadership in the area often hiiperemiyovani and swollen, sometimes hyperemia present in adjacent areas of the gums. Vertical percussion painful. The reason for this reaction is to increase the sensitivity of nerve retsephoriv in the field of periapical inflammation.

Palpation of the ash in the field of top teeth (especially front) painful, because of the proximity of the root to the periosteum.

Regional lymph nodes enlarge, becoming painful ¬ we during palpation. Depending on the top “that limfatychini inflamed sites, in diagnostically difficult cases can dyferentsiyu ¬ wool aching tooth. Thus, periodontitis lower front teeth accompanied ¬ vodzhuyetsya inflammation submentalnyh litsfatychnyh nodes periodically ¬ dontyt upper incisors and upper and lower canines and premolars – front submandybulyarnoho lymph node corresponding side, and periodontitis molars of both jaws – middle and rear submandybulyarnyh lymph nodes.

Elektrozbudlyvist – higher than 100 mi-A, except in cases of traumatic injury period when kept alive and pulp response to direct current is connected with its reaction.

Radiographic changes are usually not detected only in the later stages of development may be a slight extension of detailed pieriodon cracks.

Depending on the etiology of the clinical picture of acute serous periodontitis may have its own specifics that should be considered during differential diagnosis-nostyky.

In patients with traumatic periodontitis clinical picture significantly ¬ extent depends on the pulp, which has suffered of ‘acute injury. If the pulp alive during the process gets easier form ¬ we forecast favorable treatment. In case of septic necrosis of the pulp is always attached periodontal infection and there is clinical picture of infectious periodonhytu.

Often, inflammation may be caused by medication ¬ we have drugs that were used in the treatment of pulpitis (for example ¬ arsenious paste trykrezol (formalin), or filling materials that have a necrotizing effect on periodontalni tissue. Periodontitis For this group, typical sustained flow and resistance to therapy.

In practice, often become allergic to meet periodon ¬ Titus, which is associated with sensitization of patients to zastosovuva ¬ these drugs. Serous overall process in this form of periodontitis is accompanied by such manifestations of allergy, as vysy ¬ panels on the skin, swelling of the face and oral mucosa, pharynx under ¬ raznennya with characteristic pidkashlyuvannyam etc., that contribute to clarifying ¬ yayut nature of the disease. Detecting a history of predisposition to allergic reactions and positive results of allergic tests help clarify the diagnosis and determine treatment methods.

The differential diagnosis of acute serous periodically ¬ dontytu should be done with acute diffuse pulpitis. Charac ¬ turn to irradiation pulpitis pain, acute onset, remission and in the course intermisiyi sharply distinguish it from periodontitis. Pain in patients with periodontitis is tupishym not so sp ¬ Triple as in pulpitis. Lymph nodes in patients with pulpitis not affected.

The differential diagnosis between serous and purulent periodon-Titus in AD based on the severity of the patient and the nature of pain, and general clinical picture. In patients with serous ne ¬ riodontyt pain is less pronounced, not as intense, strictly localized. Changes in the mucous membrane in the area of ​​the top co ¬ renya minor, often in the form of light congestion. Tooth barely moving only in the transverse direction. The general condition of the patient does not suffer.

Acute purulent periodontitis (periodontitis acuta purulenta) usually develops after serous. But often it can start without permission in case of massive penetration of virulent ¬ tion in periodontal infection and reduction of reactivity dis ¬ sick. The clinical picture of the periodontitis is not unique. Compared with serous form of his more rapid progress, expressed common manifestations. Formed in periodontalnomu ¬ Story of purulent exudate, which looks out, often breaks out, destroying the periodontal tissues.

Patients complain of acute spontaneous continuous pain pulsivnoho character. At the beginning of the pain is lokalizo ¬ vanym. But soon it becomes diffuse, radiating from the teeth of the mandible in the ear, and on top – in the temporal area. The patient always points to the aching tooth, he feels as “higher” very painful when pressed, contact antahonis ¬ tamy or even if touched his tongue while talking. Pain enhance existing ¬ lyuyetsya by heat, while cold, by contrast, operates ¬ lyvo rest. Any physical effort leading to increased pain.

Objectively. The patient’s tooth may be intact, although its color is changed, sometimes significantly carious defects or filling. Pulpova cavity in most cases closed, but may be open. Elektrozbudlyvist – 120-150 mA, which determines not ¬ Crozet pulp. In channels during sensing observed Ganges ¬ renoznyy decay, often under pressure goes manure. Horizontal and vertical ¬ on percussion tooth is very painful. Tooth movement in meziodystalnomu direction and towards the longitudinal axis. Mobility is particularly significant if the manure reaches broadcast and looking out in the area of gingival pockets. In such cases ¬ ku tooth as if floating in the accumulation of pus. Tooth like raised, not only subjectively feels sick, but determined during ohlya ¬ ing, as it really is somewhat squeezed out of the alveoli accumulation chenym uhlybyni inflammatory exudate. Mucosa in the area of top hiperemiyovana and edematous. Transitional fold smooth out ¬ weighted due to the accumulation of inflammatory infiltrate, very bolis ¬ on during palpation. Depending on the stage of purulent periods of dontytu palpation can be detected by extremely painful ¬ curing the periosteum in the case of forming subperiostalnoho abscess.

In the case of submucous abscess during palpation q. ¬ yut not only pain but also the phenomenon of fluctuations, changes have collateral in the form of soft tissue swelling of the face, the size of which does not always correspond to severity of injury. In ¬ bryak can lead to significant asymmetry and deformation at ¬ lychchya, especially in pastoznosti tissues. If the circle ¬ Real edema should always carry the differential diagnosis of phlegmon ¬ nostyku, but phlegmon characteristic expressed pain and tension and elegance shinning skin. Promotion of purulent fluid and abscess localization depends on the location root that is the source of infection, and anatomyhystologic features jaw area.

In some cases, pus, which met in Periodontal may Forks ¬ tooth that can be used through the channel (Fig. 2). This is the most favorable option evacuation of pus, but it is only possible in cases, when the channel is open and passable.

Often in the case of lesions of the lower molars cattle manure flows ¬ nally through the gingival pocket, what happens after the melt heating circuit pumps ¬ ties kulyarnoyi Periodontal. Such an adverse way, so that subsequently melted cortical plate and bone pocket appeared.

Fig.2. Ways

evacuation of purulent exudate in acute or pointed chronic periodontitis:

1 – root canal;

2 – gingival pocket;

C – sponge bone (pidokistya)

Chronic periodontitis: etiology, pathogenesis, symptoms, diagnosis, differential diagnosis. X-ray photography diagnosis of periodontitis.

Periodontium is a connective tissue formation, which fills the space between a root and an inner side of alveoli, and connects teeth with jaw bones. The width of this space (periodontal gap) varies from 0.15 mm to 0.4 mm with a significant narrowing in the middle of a root. Periodontal gap is filled with a dense, soft connective tissue, which provides retention of a tooth in a socket of an alveolar bone of a jaw.

The main structure of periodontium is presented by bundles of a dense fibrous tissue consisting of tightly interwoven collagen fibers

а – epithelial islands Malyasse б – blood vessels, в – nerve fibers, г – osteoclast д – cement е – tsementoblast; ж – bundles of collagen з -fibers with – fibroblasts, и – osteoblasts к – dental alveolus

They are stretched between the alveolar bone and the tooth root cement, and are S-shaped. In various parts of the periodontal gap these bundles have different positions. They are stretched almost horizontally, forming a circular ligament of a tooth (ligamentum circullare) around the edge of the dental alveoli. Fibers of the ligament differ both in size and in orientation. They include dentogingival (cement gingival), alveolar gingival, circular, tooth periodontal (cement periodontal) and transseptal fiber groups.

                               1 – collagen fibers, 2 – elastic fibers, 3-cell, 4-core.

Circular ligament provides attachment of the coronal edge of connective tissue to the tooth, increases resistance of the free gingival edge and protects periodontium from the external irritants.

Major periodontium fibers start from the root cement of a tooth crossing the periodontal gap in different directions and rooting themselves into the alveolar bone in the form of Sharpey fibers. According to their directions the following groups of fibers bundles are distinguished: alveolar crest fibers, horizontal fibers, oblique fibers, apical fibers and interroot fibers. The major part of periodontium consists of oblique fibers. They are rooted in the alveolar bone close to the tooth crown than to the place of their attachment to the cement. A tooth seems to be suspended on the fibers of this group.

1 – enamel, 2-dentin 3 – pulp 4 – bone alveoli, 5 – periodontal gap; 6 – gums 7 – cement, 8 – connection between teeth, 9 – extragingival fibers; 10 – teethperiosteal fiber, 11 – teethcrest fibers; 12 – Spit teethalveolar fiber, 13 – apical fibers;

2-dentin3pulp;4-bonealveoli,5-periodontalgap;7-cement,14-tangentiafibers;15 radial fibers

In small amounts in the walls of blood vessels of periodont is elastic fibers. Between the walls of blood vessels and the main fibers in an oblique direction are periosteum fibers, which are also immature collagen fibers. They provide attachment of blood vessels and They provide attachment of blood vessels and prevents ¬ tion of deformation during operation periodontium. Between the fibers are the main ingredient loose connective tissues, cells, blood, lymph vessels and nerves periodontium.

The main substance Periodontal contains 70% water which allows to distribute the pressure of chewing on the walls of alveolus The most common cells it contains fibroblasts, which located along the main direction of bundles of fibers as involved in their formation. These cells produce elastin, glycoproteins.

In addition, there periodontal epithelial cells, which are the remnants of the epithelial root sheath Hertviha. They form bands, stripes, follicles that are closer to the cement, and are called islands Malyasse. Sometimes anastomosing epithelial strands together, permeating the entire periodontium. These epithelial cells in the case of specific pathological conditions may participate in the formation of granulomas, cystogranulomas and around root cysts. An important component of cellular Periodontal mesenchymal cells are poorly differentiated. They are located around blood vessels and, if necessary, differentiate into fibroblasts, osteoblasts and cementoblasty Throughout Periodontal especially in periapical part located reticuloendothelial cells and blood cells who migrated from the vessels: erythrocytes, leukocytes, lymphocytes, monocytes, at least – macrophages and plasmocytes.

1-transseptal 2-cementoperiosteal;
3-Horizonta l4-oblique, 5-apical;
6 – betweenroot

Periodontal Blood supply by dental branchlet departing from the main arteries – dentalis, interradicularis, interdentalis. They branch out and closely anastomosing making dense vascular network periodontium.

Venous vessels are parallel to the artery. They have a larger diameter than the blood, and receive blood from the capillaries.

The most important function is Periodontal fixing teeth in the jaw bone. It provides bundles of collagen fibers – their tortuous course provides physiological mobility of the teeth.

1.           Barrier function. Periodontal especially circular ligament tooth protects the body from the penetration of microorganisms, toxins and other harmful agents.

2.            dumper function. The presence of up to 70% of fluid in periodontal disease and a significant amount of fibrous structures provide periodontal to not only withstand considerable chewing pressure, and evenly distribute it on all the walls of fissure periodontitis.

3. Trophic function. A dense network of blood vessels provides periodontal trophic function of the hard tissues. This even teeth without pulp for a long time successfully operate.

4. Plastic function. Periodontal cells, forming secondary cement and bone, giving it plastic features, which is especially important when you move your teeth.

5. Sensory function due to the rich innervation Periodontal, so it is as if the body senses tooth. It is a most important function is Periodontal fixing teeth in the jaw bone. It provides bundles of collagen fibers – their tortuous course provides physiological mobility of the teeth.

6. Barrier function. Periodontal especially circular ligament tooth protects the body from the penetration of microorganisms, toxins and other harmful agents.

7. Dumper function. The presence of up to 70% of fluid in periodontal disease and a significant amount of fibrous structures provide periodontal to not only withstand considerable chewing pressure, and evenly distribute it on all the walls of fissure periodontitis.

8. Trophic function. A dense network of blood vessels provides periodontal trophic function of the hard tissues. This even teeth without pulp for a long time successfully operate.

9. Plastic function. Periodontal cells, forming secondary cement and bone, giving it plastic features, which is especially important when you move your teeth.

                                                

Sensory function due to the rich innervation Periodontal, so it is as if the body senses tooth. It is a form in diffuse inflammation of the pulp – acute purulent pulpitis, chronic gangrenous pulpitis. Bacteria and toxins get into periodontal space and cause an inflammatory reaction periodontium.

 

 

The etiology of periodontitis

 

 

2. Marginal Way. It is most commonly sold in patients with periodontal disease. In the case of generalized or collapse localized periodontal ligament circular tooth cortical plate alveoli formed periodontal pocket, the infection of which falls into the periodontal space and causes inflammation of his tissues.

3. Contact way. In patients with osteomyelitis or sinusitis infection with pathological focus moves to contact each tooth.

4. Hematogenous or lymphogenous way. In this way the infection gets in periodontal patients with infectious disease.

To be infectious and so-called perifocal peridontyt, which was described IG Lukomski yet in 1955 he develops in patients with acute and chronic pulpitis, pulp gangrene or other diseases when the infection is in the canal of the tooth root and there is the pathological process. With this focus in periapical space penetrated tion some bacteria and their toxins, causing an inflammatory re action periodontium. After removal of fire (eg removed ing infected pulp canal sterilization) inflammation years be disappears. This inflammatory reaction periodontal tissues in the area of the tooth root apex acts as a barrier that obstacles further penetration of infection.

Noncommunicable periodontitis caused by the action on periodont various local and general factors.

1. The most common cause of periodontitis is a traumatic factors, mainly mechanical trauma – acute or chronic.

2. The second large group owned chemical toxic periodontitis.

3. Zapalennya Periodontal may cause allergic factors.

As noted, the traumatic factors that cause periodontitis, are various injuries. Thus, acute trauma (a blow, fall, etc.). Causes acute traumatic injury. In such cases, often suffer front teeth. Pathological changes vary depending on the strength and direction of the traumatic factor. In the case of small injuries may be gaps apical periodontal tissue, causing an inflammatory reaction, later she can pass and pulp remains alive.

Severe periodontal damage can cause not only the development of periodontitis, but also damage the pulp. infected pulp complicating inflammatory process in periodontium.

Chronic trauma. With a weak, but the permanent injury (eg, patients with malocclusions, artificial crowns, dental bridges or seal that overstates the bite) force traumatic concentrated in the region of the root apex. This injury causes a gradual resorption of alveolar bone, and the body also gradually compensates it by produсtion of granulation or fibrous tissue in the area of ​​injury.

Furthermore, periodontitis may occur in smokers who smoke a pipe in musicians who play wind instruments, in individuals who have bad habits bite teeth end of thread , chew pencil and generally in all cases creates constant pressure on land apex of the tooth root. In this case the crown of the tooth may remain intact, although for a long inflammatory process in the periodontium may lead to loss of pulp tissue.

Traumatic periodontitis can cause of a dentist who conducted the treatment of inflamed pulp – medicament and instrumental treatment of a root canal. Thus, during the deep hysterectomy pulp separation can occur periodontal tissue, and eventually – Periodontal damage in the event of an incorrect definition canal length work file or rymer can damage the periodontium.

Toxic-chemical periodontitis occurs mostly after dental procedures. In most cases it is associated with the use of arsenious shepherd, whose action extends also to the periapical tissue in case of violation of the terms of its action or dose.
Strong antiseptic agents (formaldehyde, phenol, ferezol et al.), Which is treated with a root canal can also cause irritation and inflammation of the periodontium.

Allergic periodontitis develops in patients with increased sensitivity to drugs that are used for treatment and root canals. Quite often allergic reactions occur after the use of iodine and iodine compounds (iodoform), especially when putting them in the paste for filling root canals. Etiologic factors in many cases can act together. For example, a tooth with infected necrotic pulp altered and may further injury, medication periodontitis may occur after treatment of an infected root canal when medication is combined with an infectious factor. All this complicates the treatment and needs of dentists to respect analysis of subjective and objective data to identify the main etiological factor responsible for the disease

Marginal periodontitis – inflammation of the marginal periodont – can also cause traumatic, chemical and infectious factors. Marginal periodontitis is always accompanied periodontitis and is seen in the “periodontal disease.”

 

 

Pathogenesis of periodontitis

The major changes in the case of periodontal disease include various forms of inflammatory manifestations of alteration, exudation and proliferation No matter how etiological factor caused by a inflammatory response – the action of infectious and toxic agents, as a result of traumatic or chemical injury, inflammation begins of alteration cells or tissues periodontium.

In the area of ​​damage accumulate inflamed mediators (histamine, serotonin, acetylcholine, etc.) as well as tissue proteolytic enzymes along with other alternative change begins we automatically trigger inflammatory reactions. As a result, there are changes in the vascular wall, circulation disorders, is the output of plasma proteins and fluid forms. Along with the changes that come with alteration and exudation, early inflammatory response showing proliferative processes inherent in the acute, subacute and chronic inflammation begins Lenny. The process ends with the formation of proliferation granulator tissue, which further transformed into fibrous, scaring tissue.

The nature of inflammation in periodontal depends on the intensity and duration of the etiological factor, reflect the characteristics destruction area and the state of the defenses. Inflammatory processes in the degree and nature of the pathological manifestations of the clinical course can be divided into two main groups: 1) acute inflammation – characterized advantage of alternative–exudative changes, less prolonged and intensive course, a more severe clinical picture, 2) chronic inflammation – characterized advantage liferatively–regenerative processes, longer course and less severe clinical symptoms.

 

Pathogenesis of acute periodontitis

If high levels of defenses and low intensity pathogenic etiological factor arises acure serous periodontitis. This form can be developed by root canal treatment of necrotic pulp tissue when the canal through apical hole gets infectious with severe virulence or when the effect of trauma or chemical agent is negligible. Аcute serous inflammation Periodontal early characterized hyperemia. There have been filling vessels and slow down of blood flow. Leukocytes are shifted to the vascular wall and reached stasis. Because vascular wall begin to penetrate the liquid part of blood proteins that are able colloid, and small of neutrophilic leukocytes, lymphocytes and monocytes. Fluid loosens the connective tissue elements and collagen fibrils periodontium. At this stage of the inflammatory process extends to the bone, which is very responsive thanks to its close association with periodontal. In the adjacent periodontal bone marrow-filled intervals spongy substance possible extension blood vessels and stagnation.

Depending on the reactive capacity of the organism and timely therapeutic intervention process may cease or intensify and move in purulent inflammation.
Acute suppurative periodontitis develops if the infection that got into Periodontal has high virulence, damaged factor very aggressive and protective reactions of the organism at a low level. Due to the high penetration of blood vessels due to activation such enzymes as leykotoksyn, trypsin, penetrate through the vascular wall in a large number of white blood cells, lymphocytes and monocytes. Neutrophilic leukocytes phage bacteria and then die. their destruction accompanied by the release of enzymes – protease, cathepsin, chymotrypsin, alkaline phosphatase and others., and also spe There is a breakdown of tissue with the formation of pus. In hyperacidosis tissue in the area of ​​inflammation are active lymphocytes monocytes blood, and settled macrophagocytes. Macrophages clean the area of inflammation from dead cells and large unorganizedcific antigens that are needed for the next formation Rennie antibodies.

Picture.1.Four phases of acute suppurative periodontitis:
A – periodontitis B – endosteal B – subperiosteal abscess, G – submucous abscess

particles are lysed and rechanged by them.
Often inflammation in periodontal extends to nearest bone of the jaw. In bone the purulent process – manure enters the bone in gaversovyh and folk manivskyh canals and accumulates under the periosteum. During the acure suppurative periodontitis can distinguish four successive phases (Fig. 1).

1. Periodontitis phase – limited Periodontal purulent process. Reactive inflammation of the alveolar bone.

2. Endosteal phase – purulent fluid enters the alveolar bone paths of least resistance and tissue infiltrating bone marrow intervals spongy substance.

3. Subperiodontalna phase – purulent exudate accumulates under the periosteum, forming a subperiosteal abscess.

4. Submucous phase – due to destruction of periosteum purulent exudate enters the soft tissue, forming submucous abscess.

 

Definition phase suppurative periodontitis is important to select treatments because each of these phases requires specific measures. With the leveling forces of damaging factors and the body’s defenses begin to manifest processes of proliferation. Granulation tissue that developed directly the processes of alteration and exudation, restores damaged in periodontal and alveolar bone. In the future it may serve as a protective barrier that neutralizes bacteria, toxins and other irritants.

 

CLASSIFICATION OF PERIODONTITIS

Acute and chronic periodontitis is one of the main causes of premature loss of teeth. Among those seeking dental care, patients with various forms of periodontitis ranged from 15 to 30%. This high percentage of this type of pathology, from our point of view, because in 20% of teeth treated about diseases of the pulp by her previous devitalization drugs arsenic during the first year after treatment clinically developing some form of years periodontitis. During the X-ray examination of the teeth changes in periodontal found in 2 times more likely (40 – 45%) than in patients treated by other methods

Often periodontitis seen in villagers, as well as persons who for various reasons is not timely dental care.

The relatively high incidence of periodontitis and serious difficulties of its diagnosis and treatment is especially necessary to develop a common classification.
Even in the XIX century. proposed classification of periodontitis, based mainly on clinical signs. In 1891 O.K. Limberg systematized clinical signs of inflammation periodont and proposed a classification.

Later appeared classification, which take into account not only clinical symptoms but also data cards pathoanatomical us. These include classification of BI Mohylnytskoho and AI Evdokimov. In 1924, JM Hofunh proposed clinical and anatomical classification, which was reflected as localization and pathological changes in periodontal inflammation. The author has divided the processes that occur in periodontal into acute and chronic.

I.Acute periodontitis.
1.acute marginal periodontitis.
2.Acute apical periodontitis.
3.Acute diffuse periodontitis.
II.Chronic periodontitis.
1.Chronic fibrotic periodontitis.
2. Chronic granulomatous periodontitis.

 

However, proposed in the early XX century. classification of incompletely revealed clinical features that are not always allowed to use them. IG Lukomski (1955) investigated the pathophysiological and pathomorphological changes in the state of periodontal inflammation and its proposed classification that now common in clinical practice. It allows more directed diagnose wool periodontitis and implement differential therapeutic measures. According to this classification, periodontitis is divided into 3 main groups

I.                  Acute periodontitis (periodontitis acuta).

1. Acute serous periodontitis (periodontitis acuta serosa).

2. Acute suppurative periodontitis (periodontitis acuta purulenta).

I. Chronic periodontitis (periodontitis chronica).

1. Chronic fibrotic periodontitis (periodontitis chronica fibrosa).
2. Chronic granulomatous periodontitis (periodontitis chronica granulomatosa).
3. Chronic granulating periodontitis (periodontitis chronica granulans).
III. Exacerbations of chronic periodontitis.

WHO Classification (ICD-X)

K04.4 Acute apical periodontitis pulp origin

K04.5 Chronic apical periodontitis apical granuloma

K04.6 periapical abscess with fistula

K04.60 What is communication (fistula) with maxillary bosom

K04.61 What is communication (fistula) with nasal cavity

K04.62 What is communication (fistula) with oral

K04.63 What is communication (fistula) with skin

K04.69 periapical abscess with fistula unspecified

K04.7 periapical abscess without fistula

K04.8 root cyst

K04.80 apical and lateral

K04.81 residual

K04.82 Inflammatory paradentalna

K04.89 root cyst unspecified

K04.9 Other and unspecified diseases of pulp and tissue periapical

 

 

Clinics, diagnosis of periodontitis

DIFFERENTIAL DIAGNOSIS of ACUTE PERIODONTITIS

 

Acute serous periodontitis (periodontitis acuta serosa).

In clinical practice is most common periodontitis, which occurs under the influence of infection and usually develops as a complication of inflammation of the pulp or because of mistakes that were made during endodontic therapy.

Symptoms. Complaints patient so characteristic that often their is sufficient to establish a virtually error-free diagnosis. Initially, the patient feels heaviness and tension in the tooth, which was like the big, longer than others. Gradually there is quite a lot of pain spontaneous nature. The pain is constant, localized, not radiating, worse at night and barely suppressed conventional analgesics. Since the process is constantly evolving, pain intensity grows.

Also, can occur characteristic provoked pain. All that can increase blood flow in the area of ​​the tooth and change its mobility, provokes attacks of pain. Yes, there is pain during eating. In the initial stage, however, passive, slow, long-term pressing reduces the pain that is associated with the outflow of fluid from periodontal reducing congestion and compression of nerve endings. Therefore, clutching a tooth in the alveoli, patients temporarily improve their condition. Pain when touching the tooth can occur under the influence of heat, if periodontitis is a complication of gangrene of the pulp with a closed cavity of a tooth. The temperature difference can cause pain if the change is sudden. In the case of a gradual increase in temperature and prolonged exposure to heat achieved calming effect due to sustained vasodilation, which promotes blood flow areas of inflammation.

OBJECTIVE. Sick tooth may be intact, that does not exclude injury (such as when you use orthodontic appliances). Often, however, it is caries, devital, with an open cavity of a tooth filled or a great seal. Enamel loses its characteristic luster, is gray. It is clear in the area of ​​apex often hiperemic and swollen, sometimes existing congestion and adjacent areas gums. Vertical percussion painful. The reason for such a reaction is to increase the sensitivity of nerve receptors in the area of ​​periapical inflammation.
Palpation of the gums in the area of ​​the top teeth (especially front) painful, because of the proximity of the root to the periosteum.

Regional lymph nodes are enlarged, become painful during palpation. Depending on the top “that limphatic nodes swollen in diagnostically difficult cases can be differentiated tooth. Yes, periodontitis lower front teeth accompanied by inflammation limphatic Submental nodes periodontitis upper incisors and upper and lower canines and premolars – Front submandybulyar lymph node corresponding side and periodontitis molars of both jaws – middle and rear submandybulyar lymph nodes.
electrical conductivity – higher than 100 mi-A, except traumatic injury period when kept alive pulp and response to constant current associated with its response.

X-ray changes usually are not found only in the later stages of a possible slight expansion pieriodontal slit.
Depending on the etiology of the clinical picture of acute serous periodontitis can have its own specifics that should be considered during the differential diagnosis.
In patients with traumatic periodontitis clinical picture depends largely on the state of the pulp is exposed to ‘severe injury. If the pulp is alive, the course of the process becomes lighter forms, weather favorable treatment. In the case of septic necrosis of the pulp always joins periodontal infection and there is clinical picture of infectious periodontitis.

Often inflammation may be caused by medications, or used in the treatment of pulpitis (eg arsenious paste trykrezol (formalin) or filling materials that have a necrotizing effect on periodontal tissue. Periodontitis For this group, the typical steady nature of the flow and resistance to therapy .
In practice often become allergic meet periodontitis, which is associated with sensitization of patients to drugs used. Serous overall process in this form of periodontitis allergy accompany such as skin rash, swelling of the face and mucous membranes of the mouth, throat irritation with characteristic cough etc. that contribute clarifying the nature of the disease. Revealing a history of exposure to allergic reactions, as well as positive results allergy tests help clarify the diagnosis and identify therapies.

The differential diagnosis of acute serous periodontitis should be conducted with acute diffuse pulpitis. Characteristic for irradiation pulpitis pain, acute onset, remission and intermission in progress sharply distinguish it from periodontitis. Pain in patients with periodontitis is dumber, is not as sharp as with pulpitis. Lymph nodes in patients with pulpitis not affected.

Differential diagnosis between serous and purulent periodontitis based on the severity of the patient and the nature of pain and overall clinical picture. In patients with serous periodontitis pain less pronounced, not as intense, strictly localized. Changes in the mucosa in the area of ​​the root apex small, often in the form of mild hyperemia. Tooth barely moving only in the transverse direction. The general condition of the patient does not suffer.

Acute suppurative periodontitis (periodontitis acuta purulenta) usually develops after serous. But often it can begin spontaneously in the case of massive penetration of virulent infections in periodontal and reduced reactivity of the patient. The clinical picture of this fairly typical periodontitis. In comparison with serous form of his more rapid progress, expressed common manifestations. Founded in periodontal space purulent exudate, which looks out, often breaks out, destroying the periodontal tissue.

Patients complain of spontaneous acute continuous pain pulsating character. At the beginning of the pain is localized. However, he soon becomes diffuse, radiating from the teeth of the mandible in the ear, and the top – in the temporal area. Patient always indicates tooth that he feels like “higher” very painful when pressed, contact with antagonists or even if you touch your tongue while talking. Pain aggravated by heat, whereas cold, on the contrary, has a sedative effect. Any physical effort leading to increased pain.

OBJECTIVE. Sick tooth may be intact, although its color is changed, sometimes significantly carious defect or seal. Pulp cavity in most cases closed, but may be open. elektrosensitivity – 120-150 mA, which determines necrosis of the pulp. In canals during sensing there gangrenous decay, often under pressure turns manure. Horizontal and vertical percussion tooth is very painful. Tooth movement in moesia distal direction and in the direction of the longitudinal axis. Mobility is particularly significant, if manure reaches the circular connections and looking out in the area of gingival pockets. In this case, the tooth as if floating in the accumulation of manure

Tooth allegedly grew not only a subjective feeling sick, but determined during the review, because it really is somewhat supplanted with alveoli accumulated Indepth inflammatory exudate. Mucosa in the area of ​​the top bloodshots and edematous. Transitional fold smoothed due to the accumulation of inflammatory infiltrate, very painful during palpation. Depending upon the stage of suppurative periodontitis can be detected by palpation extremely painful hardening of the periosteum in the case of formation of subperiosteal abscess.

In the case of case of protruding abscess during palpation reveal not only the pain but also the phenomenon of fluctuations arise collateral changes, such as edema of the soft tissues of the face, the size of which does not always correspond to the severity of injury. Swelling can lead to significant asymmetry and deformation face, especially in pasty tissues. If collateral edema should always perform a differential diagnosis of cellulitis, phlegmon but for the expressed pain and tension and elegance skin. shine Promotion purulent exudate and abscess localization depend on the location of the root, which is the source of infection, and anatomic and histologic features section of the jaw.

In some cases, pus, which met in Periodontal could spill across the canal tooth (Fig. 2). This is the most favorable option evacuation of pus, but it is possible only when the canal is open and passable.
               Often in the case of lesions of the lower molars manure flows through the marginal gingival pocket that after melting circular links periodontium. This path is unfavorable because the cortical plate subsequently melted and formed bone pocket.

Fig.2. Ways evacuation of purulent exudate in acute exacerbations or chronic periodontitis:
1-root canal;
2-gingival pocket;
3 sponge bone (underperiosteum)

In these ways, manure ing fluid can break into sinus or adjacent alveoli penetrate the thick jawbone, the spongy substance. In such
growing conditions limited osteomyelitis. This is particularly unfavorable option spread manure, which leads to serious complications.
In case of suppurative periodontitis inflammatory response extends to regional and even cervical lymph nodes become enlarged and painful. Unlike serous purulent forms of periodontitis often accompanied by general symptoms. General disorders observed in the case of subperiosteal abscess formation when set against a high body temperature (38 – 39 ° C) occur unbearable pain, symptoms of intoxication, develops general exhaustion, changing the complexion appear typical shadows under the eyes. Abuse of analgesics aggravate the condition. Patients complain of headache, dizziness, weakness.

X-ray with purulent periodontitis within 24 – 48 hours is the eclipse structure of cancellous bone due to bone marrow infiltration. The outlines of compact plates are even and clear. When expressed collateral edema on images of bone structures piling light shade from infiltrated, swollen soft tissue. Periodontal gap expanded. Radiography in patients with acute suppurative periodontitis feasible mainly for the differential diagnosis of various forms of exacerbation of chronic periodontitis, when the picture revealed changes characteristic resorptive processes.

Differential diagnosis. Differential diagnosis between serous and purulent periodontitis is not difficult. Intense, unbearable pain radiating pulse character evidence in favor of suppurative periodontitis. The pain increases when you press on the tooth, or even if you touch it, the more pronounced mobility tooth mobility characteristic also in the longitudinal axis, in the case of circular melting relations tooth like floating in purulent exudate. The presence of an abscess, pus discharge and the general condition of the patient leave no doubt in the diagnosis.
Acute suppurative periodontitis, especially with severe general symptoms must be differentiated from osteomyelitis. In the event of unauthorized emerged osteomyelitis is quite severe general condition of the patient. In patients with purulent periodontitis general intoxication is less pronounced, local inflammatory changes apply only to one or the adjacent teeth, not a group of teeth or jaw half, as it happens with osteomyelitis. The final diagnosis will help to establish radiological examination.

Acute suppurative periodontitis should be differentiated as from exacerbations of chronic periodontitis (Table 19). A history that point to the primacy of the disease, the relatively slow development of abscess testify in favor of suppurative periodontitis. If patients with acute purulent periodontal abscess develops in 3 -4 days, in the case of heightened periodontal abscess occurs within one day or even several hours due to the presence of destructive changes in the bone tissue. During the clinical examination of patients with chronic inflammatory periodontitis, especially granulating, exhibit fistula or scars from them. No changes in the periapical area on radiograph confirms the diagnosis of acute suppurative periodontitis.

If periodontitis in section 654 456 teeth should be a differential diagnosis of sinusitis. Patients with sinusitis complain of spontaneous pain in the maksylyar sinus, radiating to the back offices; percussion few teeth, the roots of which are close to the bottom of the maxillary (maxillary) sinus painful. In addition, if a comparative study of both sinuses pain appears when you press over the affected sinus. Characteristic also leakage of purulent exudate from the nostrils, which is usually laid on the side of the affected maxillary sinus.

Acute suppurative periodontitis after drainage and drainage of purulent exudate becomes chronic.

TREATMENT OF PERIODONTITIS

The choice of periodontal treatment strategy depends on the etiology and course of the pathological process (acute, chronic, chronic recrudescence), anatomical and topographical features of tooth roots, the presence of periapical pathology, as well as the general state of health of a patient.

Existing treatments for periodontitis can be divided into 4 groups (Table 20):

1) conservative – aimed at preserving the anatomical and functional features ​​of the patient’s tooth;

2) conservative surgery – aimed at preserving the main functions of a tooth. It involves removal of the root or around root tissue destroyed by pathological process that cannot be treated;

3) surgery – removal of the patient’s tooth and pathologically altered alveolar bone;
           4) physical.

Conservative treatment of periodontitis is performed to eliminate seats of periodontal infection (abnormally altered pupl tissues, dentin, root canal microflora and microtubules) through careful instrumental, medical

Methods of periodontitis treatment

 

treatment of root canals and obturation, which creates conditions for the regeneration of periodontal tissues and periapical areas.

Indications for surgical and conservative surgical techniques is ineffectiveness or impossibility of conservative treatment or any contraindications to its implementation, among them:
– A Tooth disease causes acute septic conditions, chronic infection and intoxication;

– Total destruction of the tooth crown if its recovery is impossible;
– Considerable perforations of the root wall or the bottom of the tooth cavity

 

Conservative treatment of periodontitis

Treatment of acute exacerbations of chronic periodontitis. One of the main objectives of treatment of acute exacerbations of chronic periodontitis is the fastest elimination of inflammation of tissues   of periodontium, pain relief and prevention of inflammation.
           Treatment of periodontitis deals with the root canal, microtubules and periapical inflammation.

Doctor’s strategy depends on the etiology of periodontitis, the stage of the inflammatory process and the general conditions of the patient.

Treatment of acute infectious periodontitis. Acute infectious periodontitis has very short phase of intoxication, but strongly expressed exudation that develops very fast. Fluid formed in periapical space may move into surrounding tissue in various ways: through root canal, through alveolar jaw bone under the periosteum of the vestibular or tongue side and then under the mucous membrane on periodontal cleft to circular ties. The main objectives of the treatment of acute infectious periodontitis (both serous and purulent) are: pain relief, creating conditions for the outflow of fluid, carrying antimicrobial and anti-inflammatory treatment cessation prevalence of periodontal tissue inflammation, restoring of anatomic form and function of the tooth.

Methods of treatment of acute periodontitis consist of several stages and are performed through several visits. During the first visit the following stages of treatment are carried out:

1. Anesthesia. Taking into account the inflammatory changes in the soft tissues around the teeth of the patient, the presence of an abscess, and sometimes difficulty in opening the mouth, the anesthesia recommended.

2. Antiseptic treatment of the oral cavity. Patients with acute periodontitis, especially purulent, resulting in serious condition caot follow the oral hygiene and take only softened food because their teeth are covered with plaque infected by various microorganisms. Prior to treatment it is necessary to remove soft plaque using hydrogen peroxide and tincture of furacilin, herbal decoction.
            3. Dissection of carious cavity based on topographic and anatomical features of the patient’s tooth. The cavity of the tooth should be disclosed so that was free access to the root canal. In 2-3-root teeth after opening and expansion of the mouth cavity of the tooth root canal reveal through internal root boron like Gates Glidden.

Removing pulp of root canal. Quality  of further treatment depends on thorough removal of infected pulp tissue, residue filling material infected by softened dentin and other irritants.

Pulp tissues are removed by broach gradually, layer by layer, very carefully, not pushing the infected tissue in periapical hole, constantly processing canal with antiseptic solutions.

After removing of all pulp masses there is a chance of serous or purulent exudate allocation, which can contain blood. Exudation is removed be means of cotton turundas or paper pins.

5. Medical treatment of root canal. It is conducted by means of not aggressive and fast working (1% chlorhexidine solution, 1% sodium iodinolum, 3% solution of hydrogen peroxide, etc.) Treatment can be made using a syringe or a clean cotton turundas.

6. Disclosure of apical opening. If the exudation is not released into the canal, i.e. apical opening not disclosed, after careful medical treatment and drying of the root canal it is being disclosed. For the outflow of fluid through the root canal apical drainage hole is required. Apical hole reveals by means of root needle, file or reamer, gently rotating around an axis and pushing the tool to the apical part. This should be performed especially carefully in order not to injure or infect periodontal tissue again. Impassable canals, as well as in the case of obliteration of the apical opening, its disclosure and expansion of canals are carried out by means of manual and machine drill–reamers (reamers and files). After the outflow of exudation, the canal is washed and covered with turunda plentifully moistened with enzymes (trypsin, chymotrypsin) and antibiotics (streptomycin, lіncomycin) for 1-2 days under soft or hermetical bondage.

If under gums or under periosteum it lanced the abscess and drain.

Type headbands, and the nature of matter, which is administered depends on the general condition of the patient, the severity of the inflammatory process, the number and nature of the fluid that is released through the root canal. Acute suppurative periodontitis, which is usually accompanied by a violation of the general condition of the patient, severe collateral edema, a large number of purulent exudate treated by imposing a loose bandage.antibiotics (streptomycin, lincomycin) for 1-2 days under loose or tight bandage.

If undergums or under periosteum it lanced the abscess and drain.
Type headbands, and the nature of matter, which is administered depends on the general condition of the patient, the severity of the inflammatory process, the number and nature of the fluid that is released through the root canal. Acute suppurative periodontitis, which is usually accompanied by a violation of the general condition of the patient, severe collateral edema, a large number of purulent exudate treated by imposing a loose bandage.

In the second visit after the disappearance of symptoms and acute exudation conduct further medical treatment canals 5% iodine solution, 1% sodium yodinola
and instrument processing canals in full 5. Sealing canals to the apical hole sylers with prolonged antiseptic and anti-inflammatory work.treatmenth traumatic periodontitis. Acute periodontitis arising from errors and complications of treatment of pulpitis, hematoma formation when hysterectomy pulp output formalin syleriv at the top of the root, root perforation, etc., are treated primarily by physical methods: electrophoresis 1% solution of potassium iodide, 10% solution of calcium chloride rydu, UHF, laser therapy. If after 5 – 6 treatment sessions the pain does not decrease but even increases, unseal need root canal treatment of the tooth and to the method of treatment of acute infectious periodontitis. Treatment of exacerbations of chronic periodontitis includes 2 main techniques – treatment of acute periodontitis and treatment of chronic periodontitis. In the 1 st – 2 nd visiting performing stages of acute infectious periodontitis. Only after eliminating inflammation and translate it into a chronic condition treatment stages perform some form of chronic periodontitis. Treatment of chronic periodontitis – a rather difficult task. Due to the complex and highly variable anatomic and topographic structure of the teeth, presence of numerous dentinal tubules containing plasma processes, virtually impossible to completely eliminate the infected tissues. This focus contributes to the maintenance of stable and pathological changes in the periodontium. The main objectives of treatment of chronic periodontitis – the elimination of periodontal pockets of infection and the subsequent effect on the microflora of root canals and their branches, the elimination of exposure to toxins and biogenic amines – decay products of tissue proteins, the elimination or reduction of inflammation in the periodontal, provide conditions for regeneration of periodontal components; desensitization body patient.
Chronic periodontitis treated as for one, and a few visits, but regardless of the number of treatment consists of several stages. Only in case of conscientious execution of each stage can achieve success in the treatment of this complex disease teeth.
Stage 1. Dissection of the cavity and the cavity of the tooth

Fig.7 “Step-back” – Root Canal expansion technique (initial width of the canal number 10 for ISO, working length 21 mm), continued:
and – root canal treatment initial file (№ 10);
b, c, d – treatment of root canal file, one number greater than the last, until the free passage of the root canal instrument of this size (master file number 25);
Mr. with – root canal treatment file, one number higher than the initial and shorter by 1 mm, the formation of apical stops, then transfer the file to one number higher and therefore
1 mm shorter than the previous;
additional processing, expansion and shaping cone of the root canal, and – restore patency canal master file; k – final machining root canal file Hedstrema in size corresponding master file

Fig.8.

Grown-down “- technology extension root canal (working length, 21 mm) without crimping file. To perform this technique it is desirable to use flexible instruments with nickel-titanium alloy with a rounded tip.
Tool processing canal is considered complete if root canal meets the following requirements:

-Fully released from infected dentin;
-Has a conical shape all the way from the apex to the mouth;
-Sufficiently advanced;
-Has formed apical stress;
– Dry, clean, sterile.

 

 

 

 

extension:A-input file number 35 in the root canal
to the point of first resistance, b–d-root canal preparation
dril burs smaller until 16 mm possible to enter a file
Number 35, is-passing the apical part of the root canal at 19 mm;
is-preparation of the root canal drilbur, one size
lower than the previous one, ie, number thirty, the same root dissection
canal file one size smaller than the previous one, ie number 25;
of the district – root canal preparation described by a sequence
to achieve full working length of root canal

Drug treatment of root canals in the treatment of periodontitis. The main tasks of medical treatment are:

1. Influence the etiological factor – infection, toxins, chemical and toxic substances and others. Contained in the root canal and its ramifications, microtubules and periapical area.

2.Anti-inflammatory effect on periodontal tissue damaged.

3. Incentive processes periodontal tissue regeneration and damaged alveolar bone.

To solve these problems, drugs for medical treatment of root canals and afterapikal space must meet the following requirements:

1. Levy antibacterial or bactericidal effect on the bacteria – factors periodontitis.

2. Have a high capacity for diffusion of microtubules and twisted branches root canals.

3. Being chemically stable and not unaktivate in the root canal.
4. Levy-inflammatory effect, not irritate the periodontal tissue.
5. Do not have the antigen, sensybiled impact on periodontal tissue and the body in general.

Depending on the timing of action on bacteria and damaged tissue Periodontal all medications can be divided into 2 groups:

1. Preparations immediate or short-term, action. their influence begins after 5 – 10 seconds and lasts 1-3 – 5 min. This is mainly drugs acting factor which are gases and gases (chlorine, iodine, oxygen, etc.).

2. Long-acting drugs (1-3 – 5 – 7 days). These preparations or mixtures celebrating not only antiseptic or antimicrobial action, but also exert both anti-inflammatory and regenerative effect – affect inflammation in the periapical tissues.

The success of treatment depends on the correct choice of drug for pharmacological treatment canals. Since a significant role in the etiology and pathogenesis of inflammation in periodontal (acute and chronic) play as aerobes, anaerobes and yes, nesporotvorni microorganisms positive treatment effect can be obtained by using drugs that act on all types of microorganisms. For this we must know the main clinical features of a species of microorganisms.
Thus, the clinical signs of anaerobic infection is sharp putrefactive odor canal, thick yellowish gray gunk, moist gray-black gangrenous decay, absence or very low therapeutic effect of prior use of antibacterial drugs. Coccal microflora c In order to influence the anaerobic appropriate for medical treatment canal tooth used nitrofurans, 1-0,5% solution dioxidin, suspension Bactria and metronidazole, fuzidin sodium, which in this case it is better to patients under the scheme. Since patients with chronic periodontitis or acute contamination is a significant root canal pathogenic staphylococci resistant to other antiseptics, vindicated application ekterytsydu or chlorophyllipt. The choice of drugs for medical treatment canal must consider not only the length of his baktyrytsydnoyi and bacteriostatic action, solubility in water and biological fluids, but the nature and stage of periodontal tissue inflammation and the general condition of the patient.

All facilities for medical treatment of root canals and periapical tissues rather can be divided into several groups, taking into account the main mechanism of action.haracterized by a large number of sparsely purulent exudate light without noticeable odor.

1. Antiseptics, halogens and oxidizer.

A large group of antiseptic methods of treatment of root canals combines a technique based on the use of therapeutic effect gases. Applied and oxoacids chlorine compounds that can increase redox potential environment, and this appears to disinfection performance. Thus, the bactericidal effect of chlorine is related to its ability chlorination and oxidize and organic matter. Chlorine in contact with the tissues forming hydrochloric and hypochlorous acid. The latter is a labile compound because decomposed into atomic oxygen and hydrochloric acid. Oxygen produces oxidative effect of bacteria and chlorides and acid denatures proteins and destroys dead tissue, decomposing. Atomic oxygen as a powerful oxidant and reductant causes hydrolysis of proteins and also denatures them. It produces a very strong bactericidal effect. Methods of gas treatment are very diverse.

For gases using different substances. Thus, N. Prinz even in 1917 applied dyhloramin, VA Dubrovin (1927) – aqua regia and potassium salt. These methods are presently not used because these drugs irritate periapical tissues and cause irreversible processes in inflamed tissues. However, high bactericidal action chlorinated drugs can be achieved by using modern halogen compounds, of which chlorine is released, penetrating deep into microtubules and eliminates bacteria and their toxins. These drugs are 1 – 2% solution of chlorine bleach, 0.5% chlorhexidine solution. High clinical effect observed in the case of 3 – 5% solution of sodium hypochlorite, which is a very strong oxidizing agent. This drug dissolves infected Perrydentine and pulp mass of pulp tissue and simultaneously antiseptic effect on these tissues.

As oxidant also use 3% hydrogen peroxide solution. In root canal solution of hydrogen peroxide reacts with organic matter and alkali, resulting in formation of atomic oxygen bubbles that contribute to, firstly, mechanical clearing the canal, and secondly, have a weak bactericidal effect. Among the halogens for root canal treatment is widely used iodine. Atomic iodine produces a high bactericidal effect on microbial associations root canal and periapical space. To wash the root canal using 3 – 5% solution of iodine and 1% solution yodinola. Yodinola – a compound of iodine with polyvinyl alcohol, which reduces galling effect of iodine, but slows its selection of compounds and thus prolongs its action. In yodinola used yodonat – aqueous iodine complex with surfactants that produces high antibacterial and antifungal activity; joddicirinum – iodine compound with dimethyl sulfoxide and glycerol.

Quaternary ammonium compounds. To this group belong antiseptics 0.5 – 1% solutions etoni, 1% solution of benzalkonium chloride 0.15% solution decametoxine. These drugs exert bactericidal and bacteriostatic effect on microbial associations and yeast fungi, almost irritating periodontal tissue.

 Compounds of phenol. Preparations based on phenol cause denaturation of proteins deep cytoplasm of microorganisms, providing high undifferentiated bactericidal action. Use 3 – 5% solution of carbolic acid (phenol) or a compound of camphor, 5% solution of phenol not only affects all kinds of bacteria, but also coagulates the cells of granulation tissue in the compound phenol camphor last mitigates this effect due to the gradual release phenol. Applied as 1% solution kamforoparamonohlor–phenol.

Krezofen (cresophene) – polyvalent germicide from chlorophenols, thymol and dexamethasone, it is also used for antiseptic processing canals.
Similar properties have some complex preparations: krezodent (crezodent), mepatsyl (mepacil solution), endotyn (endotine), which are based on camphor, phenol, metakryzolu, they are also used for antiseptic processing canals for 2 – 5 days.
If you use only antiseptic methods processing canals to reach their sterility is very difficult, in addition, it is supported by a very limited time. Antiseptics coagulate proteins, and this, in turn, prevents the penetration deep into preparations for the removal of microflora in dentinal tubules.

Impregnation methods. To address the shortcomings of some antiseptic drugs for treatment of root canals using special medications able to penetrate to different depths in the dentinal tubules, condense the remains of necrotic tissue – impregnated them and prevent reinfection canal. As a result of these drugs stop the collapse of tissue irritation periapical tissues and the conditions for regeneration. Such properties impregnation substances make these methods very valuable.

On these principles are based method silvering root canal, first proposed by J. Howe in 1916, he is the introduction to the tooth cavity concentrated silver nitrate, which recovers 10% solution of formaldehyde. Because chemical reduction reaction of silver in necrotic pulp and dentinal tubules precipitated in metallic silver. Given that silver and formaldehyde have high diffuse properties dentinal tubules and thin branching root canals fulfilled silver throughout, and coagulant protein silver covers them like a seal.

In practical medical work used modification of this method for prevention of periodontal irritation. Yes, Goldschmidt (1935) proposed the use of 2.5% alcoholic solution of silver nitrate, and to restore it – 4% ​​solution pirohalovoyi acid. JS Pekker (1950) proposed to apply ZO% aqueous solution of silver nitrate and a reducing agent –
4% solution of hydroquinone.

Methods silver: peeled root canal moistened with alcohol or isotonic sodium chloride solution and contribute to tooth cavity with tweezers or pipette 2 – 3 drops of silver nitrate, pushing his root canal with a needle, the procedure is repeated to fill the canal, and then brought into the cavity of the tooth (or at the mouth of the canal) 3 – 4 drops of silver reductant (4% solution of hydroquinone or pirohalov acid). After 3 -4 min ball of wool remnants suck and depending on the form of periodontitis or sealed canal, or close tightly, leaving over orifice ball with resume silver in 2 – 3 days. The disadvantage of this method is the color of the tooth in the dark, which greatly limits its use, especially in front teeth. This disadvantage can be reduced if before plating grease wall cavity and in cavity tooth glycerine or petroleum jelly to prevent diffusion of silver. The method is very common in pediatric dentistry and in the treatment of periodontitis in elderly patients with sclerotic changed and distorted canals.

For impregnation infectious and toxic substances used as resorcinol–formalin liquid prepared ex tempore. Impregnation technique: a glass plate consistently mix 2 parts of 40% formaldehyde solution (formalin), 2 parts of saturated solution of resorcinol and 1 part 10% solution of sodium hydroxide.

Prepare a mixture of pink and red make very carefully at the mouth of the prepared root canal in small portions and gradually pushed along the canal. Above left canal ball of cotton wool soaked in resorcin–formalin liquid, then dry ball and tooth close tight bandage over 2 -3 days. To prevent tooth coloring in pink, the liquid must not fall into the wall cavity or need time to wash it.

To enhance the diffusion of fluid microcanals SY Weiss (1965) proposed the first to enter the canal resorcinol–formalin mixture, and then the catalyst (sodium hydroxide or antyformin).

Resorcinol–formalin fluid (liquid Albrecht) diffusing in the dentinal tubules and branching root canals, imprehnat necrotic masses available for instrumental treatment, produces a bactericidal effect on the microflora.
Antiseptics vegetable. For the treatment of root canals are used as finished dosage forms of herbal remedies and tinctures, decoctions and extracts of plants that have the antiseptic action. Different types of plants operate on different types of root canal microflora. Thus, drugs with celandine (Cheldonium majus) have a fungicide action, walnuts (yuhlon) – acting on coca and simpler Kalanchoe juice produces anti-inflammatory effects through its impact on mixed microflora and others. Therefore, for washing root canal used a mixture of various herbs or combination of drugs. Here are the most common and effective herbal antiseptic.

Novoimanin – a drug made ​​from Hypericum perforatum, is available in a 1% alcoholic solution, effect on anaerobic and aerobic strepto–and staphylococci.
Khlorophilipt – preparation of a mixture of chlorophylls eucalyptus leaves, comes in the form of 1% alcohol and 2% oil solutions, has high antistaphylococcal activity.
Salvini – preparation of Salvia leaves, comes in a 1% alcoholic solution, produces high antiseptic, antifungal and disinfecting action. For cleaning root canals prepared solution was diluted isotonic sodium chloride solution 1:10.

Antibacterials. Preparations nitrofuran.

             These agents have a wide antibacterial spectrum of both Gram-positive and Gram-negative on mikroorha ¬ nisms in addition, they have a high agaised exudative effect, which is very important for the treatment of acute and chronic heightened ¬ tion of periodontitis.
             For cleaning root canals using 0.5 – 1% solutions furatsillina, 0.1 – 0.2% Furamagum solutions, emulsions furazolidone, furadonina.
Metronidazole and drugs based on it (metrahil, trihopol et al.) Is used for treatment of root canals in the treatment of periodontitis, caused by anaerobic infections and microbial associations, which are simpler (Trichomonas).

Given the diversity of microorganisms contained in root canals for their processing used broad-spectrum antibiotics – penicillin, streptomycin, tetracycline and others. However, their activity in infected root canal and periapical presence of fire was not high enough. Special conditions requiring pathological focus not only on the impact of micro-organisms, but also to other stimuli: necrotic tissue, exudate, detritus, contributing to the development and reproduction of microbes and maintain inflammation in the periodontium. Because antimicrobials are useful in conjunction with other drugs that increase the effect and complex influence on all aspects of the pathogenesis of periodontal inflammation. The most common and effective is the composition of antibacterial drugs with proteolytic enzymes.

Proteolytic enzymes. According to its biological properties of proteolytic enzymes facilitate the dissolution of necrotic tissue, releasing thick, viscous fluid root canal and periapical hole. Thin fluid is easily removed from the root canal, which positively affects the inflammatory process. In addition, proteolytic enzymes – trypsin, chymotrypsin, and especially terylityn lysozyme – stimulate phagocytosis, exert anti-inflammatory, bacteriological action, inhibit the growth of Gram-positive microorganisms. All this creates conditions for stimulating regeneration processes.
Proteolytic enzymes reduce antibiotic resistance microflora root canal, so they should be used together with antibiotics, sulfanilamidnymi, nitrofuran drugs.
Indications for the use of enzymes is sharp and pointy chronic periodontitis, the course is accompanied by the formation of large necrotic mass in the canals, especially in the case of dental treatment that caot withstand tightness.

For decades, members of our department for treatment of acute exacerbations of chronic periodontitis and especially inflammation in the teeth that do not maintain integrity, apply proteolytic enzymes (trypsin, chymotrypsin and terylityn) in combination with antibiotics (streptomycin, monomycin) Microcide, novoimanin in an aqueous or oily solution, depending on the phase of the inflammatory process and the required time of enzyme action. Oil antibiotic solution and enzyme activity can keep it for a long time – up to thirty days. Enzymes and antibiotics administered through the root canal into the periapical tissue. This is especially necessary for teeth that do not maintain tightness. In the canal leave turundy with a solution of enzyme and antibiotic and hermetically closed tooth. To improve the permeability of the enzymes developed techniques of administration by direct electric current

Corticosteroid drugs. Treatment of periodontitis by corticosteroid preparations based on high anti-inflammatory, antiallergic and analgesic their actions. In addition, a very important property of these drugs is inhibition of exudation phase of the inflammatory process. Given the low antibacterial effect of corticosteroid drugs, their effect reinforce the use of antibiotics or antiseptics, enzymes and antifungal drugs.
To enter the root canal with chronic periodontitis advisable to use 2.5% hydrocortisone suspension and teramicin, mix threeoximethylene and diiodthymol.

For the treatment of periapical inflammation in root canal impose comprehensive hormones consisting of corticosteroids, antibiotics and enzymes such as krezofen, mycologist, septomiksyn et al. However, the use of corticosteroids may cause a number of complications, especially in patients with rheumatic diseases, with cardiovascular disease, oncological disease. Because corticosteroids for the treatment of periodontitis should be administered with caution, given the general state of the patient.
         Immobilized drugs and sorbents. The above methods and treatments often do not provide the desired action and the complete elimination of the pathological focus, because antimicrobials have a short-term effect. This may result where the emergence of resistant and multiresistant forms of microorganisms, dysbiosis, prolonging treatment, the appearance of foci of chronic sepsis.

Important role in the pathogenesis of periodontitis with microorganisms play a variety of toxic substances that accumulate in the damaged tissues – mediators of inflammation, tissue proteolytic enzymes, acidic toxic metabolites and others. To remove these products of tissue metabolism to create a depot drugs in pathological focus. This problem can be solved by using sorbents. Sorbents, on the one hand, provide removal of periodontal tissues toxic products that are formed due to pathological processes, and on the other – they can be used as a matrix for the immobilization of drugs, rolling their action.

For endocanal therapy is widely used siliceous sorbent medicine – polymethilsiloxan (PMS), which is non-toxic, has properties of an allergen, indifferent to the surrounding tissues and body fluids. Therapeutic efficacy of ICP due to its universal physico-chemical and biological properties: the drug clears fire from toxic substances by absorption of fluid and adsorption of toxins, activating tissue regeneration and produces bacteriostatic effect on pathogens.
Given that the periodontitis in root canal teeth contain a fair amount of pathogenic organisms in the form of associations that lead toxicity, irritation, complicating the disease used in dental practice along with furazolidone, metronidazole drugs and silver.

After the instrumental and antiseptic treatment of root canal preparations exert anti-inflammatory and regenerative action transchanelling deduce from apical hole by squeezing the canal is well moistened turundas or by root needle entering of the previous medication in the tooth cavity at brushes tweezers or rotary paste filler.
Finish the treatment of chronic periodontitis quality sealing canal.

Canal filling

Root canals in patients with periodontitis is an important step in endodontic therapy. In case the quality of its execution are resolved two major tasks. First of all, filling the canal aims to create a barrier between the external and internal environment. Morphology tooth cavity can not completely remove organic matter that decayed and reach a state of sterility canal. So tight obturation canal is the only means of blockade and disposal of toxic degradation products and microorganisms in the canal, apical delta and dentinal tubules.

Secondly, it means that the canal fills, inevitably in contact with periodontal, so it must be biologically neutral substance, did not produce irritating effect on tissue. Drier seal must protect Periodontal from external stimuli. Furthermore, as in the periapical tissues is an inflammatory process seal should play the role of a kind of medical dressings, which produces drug effect on inflammation and thus stimulates regeneration processes. This role canal fillings can be realized, especially if its introduction into the root canal and dense filling it to the periodontium. Only in this case, the conditions for biological effects on pathological lesion in periapical tissues.

At the end of the XIX century. to canal seals were following requirements:
1. The seal should not disintegrate.
2. Must have antiseptic properties.
3. They should not produce irritating effect on periodontal and periapical tissue.
4. They should not have porosity and absorb the secrets that stand out from the periapical area and disintegrate.
5. Material of seal should easily administered in root chanel.
6. Material of seal should not change the color of the tooth.
7. Material of seal should be easily removed from the canal. Later YM Hofunh (1943) added the following requirements for the seal:
8. The seal should reach the apex, densely filling the canal and dentinal tubules.
9. Being opaque.
10. Decontaminating the contents of the root canal, forming with it a chemical compound.
11. Not washed tissue fluid that comes from the periapical area.
12. Must fill not only the main canal, but lateral root canals.

I.             Biological properties of
1. Endocanal seal must not damage the periapical tissue.
2. Must make a long antibacterial activity.
3. Should stimulate reparative processes in the periodontium.
4. Not to sensitize the body and have antigenic qualities.
II. Physicochemical
2. 1. Endocanal seal must have high adhesiveness to ensure its adhesion to the walls of the canal even in wet, tightly closed apical hole and dentinal tubules. They should not change physically, that have no porosity and shrinkage.
3. They should not change chemically, ie not dissolve in tissue fluid.
4. Being opaque.
5. Do not paint the tooth.

II.          Technology (practical)
1. Endocanal seal should be easily prepared and subjected to treatment.
2. Be flexible and easy to fill the canal.
3. Undergo removal of canal as needed. there variety of grouping rotary paste fillers funds.
In their aggregate state in which they are used and administered in feed, they are divided into 3 groups.
I. Soft paste (not harden).
II. Plastic material that gradually hardens in the canal in different duration time and to varying degrees (sylery).
III. Solid materials that do not change the canal tracker (metal, plastic and gutta-percha pins).
Basic endocanal filling materials used for the treatment of chronic periodontitis are shown in Table. 21.
Choice of filling material for endocanal seals depends on clinical and radiographic features of some form of chronic periodontitis, the general condition of the patient.

Method of sealing the canal depends on the properties of the selected sylera or detectives and presented in the previous section. No matter which filling material selected for obturation of root canal sealing properly executed will be considered only under tight obturation canal throughout, especially in the apical part. The optimal level is the level of the apical sealing the hole. Reach sealing canal exactly at the apical hole hard enough. Slight withdrawal of filling material on the top is not very serious complication, but we caot allow special output for top filling material or fill it fire collar bone destruction. Especially careful to work with materials that are high. galling properties and non-absorbable with periapical area.
Thus, the procedure for the treatment of periodontitis, regardless of clinical features, consists of the following successive stages:

Table 21 Materials for root canals (sylery)

1. Dissection of the cavity and the cavity of the tooth.
2. Antiseptic treatment and removal pulp masses of tooth cavity and canals.
3. Determining the length of the root canal.

4. Tool processing canal.

5. Drug treatment canal.

6. Zaapikalna therapy.

7. Sealing canal.

8. Filling or restoration of coronal tooth.

From the time that is required to perform all of these steps depends on the number of visits the patient. Treatment of some forms of periodontitis possible in one session, if other forms need 2 – 3 – 5 visits. Everything depends on the success of each stage and the dynamics of the clinical condition. one visit treatment of chronic periodontitis. Indications for one visit method of treatment of periodontitis:

1.           Chronic periodontitis fibrotic one root or permanent teeth with dobreprohidnymy canals in the absence of putrefactive odor in the canal.

            2. Chronic granulating periodontitis one root or permanent teeth with crowded canals in the presence of fistula on the gums.

           3. Exacerbations of chronic periodontitis in the teeth of crowded canals, which requires underperiosteum autopsy abscess.

For proper implementation of all phases of treatment in one visit should be able to make 3 radiographs: before treatment, after treatment and instrumental forming apical margin, and after canal filling.

Features of treatment of chronic periodontitis teeth with root canal impassable. Particular difficulties in the selection and implementation of treatment arise in the case of chronic periodontitis in multi teeth with partially or completely impassable root canal. The appearance of these canals caused anatomical features of the root (significant distortion), physiological (narrowing of the canal in elderly and senile age sediments petrificates the root pulp) and biological (use of resorcinol–formalin mixture of pulp mummification in amputation method of treatment of pulpitis) reasons.

In case of unsuccessful attempts instrumental expansion of these canals using a chemical method based on the use complexones – neutral nontoxic chemical means they are actively responding to different ions, including calcium ions, forming complexes of calcium by displacing it with oxyapatite dentin. The most effective 20% solution of tri-and chotyryzamischenoyi sodium etylendi–amine tetra acetic acid (EDTA, EDTA-C, Verifix, Antacim et al.; Table. 22). Solution is introduced into the passage of the canal every 3 seconds for 2 – 5 minutes, pre-heating of it to body temperature. Then use the files and remove Riemer decalcined dentin, thus expanding the lumen of the canal.

If any of the following ways to expand the canal is not possible, and in the case of breakage of the tool was used impregnation resorcinol–formalin mixture or prescribed physical treatment (electrophoresis, ultra-phonophoresis, Depotphorese copper hydroxide, calcium, etc.).