Periodontitis: etiology, pathogenesis, classification

18. Chronic apical periodontitis: etiology, pathogenesis, clinic, diagnostics, differential diagnostics. X-ray diagnostics of apical periodontitis.

PATHOGENESIS OF CHRONIC PERIODONTITIS

In a clear advantage over the body defenses weak ¬ CCW action pathogenic factor in developing chronic fibrosis periodontitis. It can occur independently vnas lidok microtrauma, chronic pulpitis or after treatment e pulpitis, but often the disease develops after treatment of other chronic forms of periodontitis.

Under the influence of periodontal tissue factor galling post ¬ converted to a child abuse grubovoloknistye connective tissue that resembles a scar. However, in the early stages of chronic periodontitis in fibrous connective tissue of the apical face islands of granulation tissue, which consists of fibroblasts, plasma cells, small foci of lymphocytic infiltration and leukocyte, resembling the remains of the inflammatory process.

Subsequently, activated tsementoblasty and osteoblasts; hipertse-mentoz, narrowing periodontalnyy space, leading to its deformation.

Chronic granulating periodontitis results from an acute inflammatory process, especially after acute purulent periodontitis may develop in patients with chronic pulpitis, especially gangrenous.

The formation of granulation tissue rich in capillaries and fibroblasts, suggests a higher level of protection possible ¬ reflect the characteristics of an organism.

Under the influence of stimuli from the root canal tooth all api ¬ radically replaced part of the periodontal granulation tissues ¬ Noah. Growing, granulation tissue resolving pryleh ¬ Lay a layer of cement on the one hand, and destroys the alveoli compact plate – on the other. Osteoblasts to penetrate kistkovomoz-term voids, rezorbuyuchy bone gully.

Granulation process may spread to soft tissue and a gingival or cutaneous fistulas.

Activating pathogenic factor causing the acute inflammatory ¬ tion process in the region of the root apex, and then the granulation tissues ¬ to undergo partial destruction. If at this stage is advantage ¬ ha body defenses, the granulation tissue restores the damaged cells. Such periodontitis is characterized in the clinic as the one that does not stand hermetyzmu or as periodontitis,

often exacerbated. This form of chronic inflammation of the periodont is very difficult to treat.

Granulomatosis Chronic periodontitis. This form of Periodontal inflammation has two ways of formation.

1. Inflammation can occur spontaneously or after acute purulent periodontitis and is accompanied by growth of granulation tissue, which takes the form of a local focus. This fire has the tendency to active growth because the outer layer of granulation replaced by fibrous connective tissue that separates it from surrounding tissue. This formation is called “granuloma”. It has a globular shape, a thick outer capsule of granulation tissue and soft inside.

2. Granuloma can develop a granulating periodontitis. In the case of a high body defenses, high resistance of periodontal tissues and slightly etiological factor (microbes and their toxins) granulating the fire may lose aggressive nature. Under such circumstances ceases infiltrative growth of granulation, on their periphery is formed by fibrous connective tissue capsule that surrounds the granulation. At the edge of the capsule is deposited a layer of bone that resembles a compact plate. Fibers woven into the periodontal capsules, granules of linking the tooth root. This is called a simple granuloma, or fibrous.

Granulation tissue within the granuloma is a self ¬ myy composition of cells, as in the granulating periodontitis. Gran ¬ Lema – a steady, stable form of chronic periodontal ¬ one that can exist for a long time – several years. If lower body defenses or under the influence of local factors nykiv may occur exacerbation of the inflammatory process. Purulent exudate breaks fibrous capsule and causes diffuse zapa ¬ tion and the surrounding periodontal tissues. After treatment, this form of periodontitis can go into fibrous.

Depending on the nature of the capsule and epithelial cells secrete more granulomas and kistohranulomy.

Epithelial granulomas – a granuloma in which the game ¬ nulyatsiyna fabric riddled with epithelial strands. In the early stages of epithelial strands are isolated, then it becomes more and more – epithelial cells almost displace pellets ¬ vation tissue that can lead to the formation of cyctlike granulomas. Cyctgranuloma – a cavity that is lined with epithelium and filled with turbid fluid. In the case of very frequent exacerbations periodontitis periodontal blood supply is disrupted, pererod ¬ zhuyutsya cells, resulting in their decay appear empty ¬ us, fluid-filled with degenerative forms of leukocytes, erythrocytes, epithelial cells and others.

Any form of chronic periodontitis, when the body’s defenses are reduced, may worsen. Most zahos ¬ tryuyetsya chronic granulating periodontitis.

Thus, each of the three forms of chronic apical periodontitis may occur spontaneously, and can switch from one to another. This factor is very important in the treatment of periodontitis.

 

DIFFERENTIAL DIAGNOSIS

Chronic periodontitis

Chronic periodontitis – a disease that has riznoma ¬ nitnu clinical and radiological picture and the most common yet ¬ ce of individuals with periodontal pathology.

If a patient with severe periodontitis causes paiot hesitate to seek dental care and chronic periodontitis that usually does not cause much of subjective feelings. Often be found by chance on radiographs ¬ max, even when the patient does not know about the availability of this disease. Accurate diagnosis can be established only after careful clinical and radiological examination.

Chronic fibrous periodontitis (periodontitis chronica fibrosa). Symptoms. Chronic periodontitis has fibrous asymptomatic course, only sometimes patients feel little pain during chewing coarse meal. The same can you ¬ znachatysya with gangrene of the pulp if the cavity commanded ¬ nena remnants of food. Diseases found renhtenolohichno. With a history establish that the earlier (1-2 years ago) in patients ¬ th was unwarranted pain or causal treatment and conducted a tooth root.

Objectively. Detect carious or sealed de vitalizovanyy tooth. The pain from the effects of thermal stimuli and no percussion. Palpation in the area of ​​top painless. If fibrosis ¬ tion periodontitis developed after treatment of acute purulent or chronic granulating periodontitis, it may be old scar. Sometimes fibrous periodontitis may be in patients with intact teeth. In such cases, fibrotic ne ¬ riodontyt arose as a result of chronic injuries or traumatic occlusion.

Radiologically often find periodontalnoyi expansion slot in the top section in the form of genital cap.

 

Fig.3. Chronic fibrotic

periodontitis (radiograph)

 

There  for alveoly plate and cement root completely preserved (Fig. 3).

In other cases show hipertse-mentoz root of the tooth, causing thickening it in time apical – root looks like a drumstick. Hypercementozis characterizes positive immunological condition of the body and in the course of chronic-free process. At the same time can be observed ¬ dozen hiperkaltsyfikatsiyu alveolar bone that X ¬ gram has the form on the periphery of roller osteosklerotychnoho dilyan ¬ ki Periodontal fibrosis.

Chronic granulating periodontitis (periodontitis chronica granulans) is 65 -70% of all cases of chronic periodontitis.

Symptoms. Patients complain of zaterplist tooth, some pain during the meal and pressing. In the top section of the severity and the patient feels some rozpyrannya. If there is a carious defect, then fill it the remnants of food can cause heal ¬ strennya process and pain. With a history trying to find out repeated sharpening process with severe pain, swelling, formation of ab ¬ stsesiv and the emergence of fistulas with the release of manure.

Objectively. Showing gangrenous or sealed devitalizovanyy tooth with changed color. The tooth may also be externally intact or be broken crown (in the case of traumatic etiology of lesion). Vertical percussion tooth rather appreciable pain or gives light reaction. During horizontal percussion, if bone wall perforated or thinned, after the introduction of the index finger in the mouth vestibule in the area felt tapping apex, which is transmitted directly from the crown of the tooth at its root. Such transfer of percussion sound is called the phenomenon of impact and allocated most apparent in the cognate area of ​​teeth. Tooth mobility may be different depending on the degree of alveolar bone destruction. On examination, sly ¬ zovoyi shell apex is in the area of ​​congestion ¬ vatym blue tint. But congestion is not very pronounced, so its detection mouth should begin to examine prysinka. IG Lukomsky (1955) described the typical granulating periodontitis ¬ th vazoparezu symptom that occurs when pressing the swollen gums – they seem to prypuhloyu ¬ Dusko. This is due to the growth of granulation infiltration foci, which applies not only to bone but also on the soft tissue surrounding the alveoli. Once you are clear on small tool (bolt plugger or dull side of a dredge) remain hollow and poblidnennya mucosal defense ¬ lonky that is rapidly changing bright red stripe that zbe ¬ rihayetsya long, sometimes several minutes (due to paresis vessels gum). In case of frequent exacerbations in the mucosa can fault ¬ executioners permanent gingival or cutaneous fistula (fistula) which is poured out at the press of a drop of pus. Fistulnyy progress concerning bound ¬ Zuya infectious foci of the oral cavity, where it occurs fistulnym ¬ open hole, which often faces tamponuyetsya ¬ lyatsiynoyu cloth, serving with him, giving the appearance of the navel hole. Sometimes in the area of ​​fistula can see one or more scars.

Palpation in the area of ​​the top depending on the stage of the su ¬ provodzhuyetsya more or less severe pain. During palpation can determine bone resorption of cortical layer, regional lymph nodes are usually enlarged and painful on in ¬ tyskanni.

Chronic granulating periodontitis without aggravation is not accompanied by general symptoms.

On the radiograph apex is in the area of ​​the fire ¬ svitlennya different sizes, contours which resemble flames. Retrace gradual transition from areas of bone destruction to healthy bones as light shade. This shows the inflamed bone demineralization. In the case of a long course of the process in some areas marked resorption of cement and dentin tooth root that a composition may take the form of oblique frustum more than 1 / 3 the length of the root. You can also determine the direction fistulnoho course (Fig. 4).

Fig.4 chronic granulating periodontitis

(Radiograph)

In case of successful treatment ¬ tion periodontitis after 4 – 8 months defect begins to decrease, and on his ne ¬ ryferiyi formed new bone. ¬ ve also possible the formation of bone trabeculae local ¬, ¬ determined that a composition as defined by the charac ¬ thorns gray shadow. A year later section of enlightenment completely replaced by bone, often denser thaormal bone tissue ¬ tion.

Differential diagnosis. Chronic granulating periodontitis can easily be differentiated from fibrous periodontal iature features that are percussion and palpation, the presence of congestion and swelling of the mucous shell ¬ ki apex in the area, as well as fistula or scar at the site last ¬ noyi. Diffuse illumination of irregular shape in some dilyan ¬ kah apical part of the alveoli in the X-rays doses ¬ will clarify the diagnosis.

Chronic granulomatous periodontitis (periodontitis chronica granulomatosa) appears limited periodontal inflammation around the tooth apical aperture, usually a no-symptomatic course. Dentist discovers it as fibrous, accidentally during radiological examination. Anamnestych ¬ but you can set that at times during the catarrhal diseases or active chewing solid food patients feel heaviness on ¬ pruzhennya even pain in the tooth root apex.

Objectively. Show the modified tooth color, it can be intact or sealed. Vertical percussion often painless. However, compared with neighboring teeth causal tooth may be sensitive. Horizontal percussion in cases of considerable size granulomas defining symptom of the reflected shock. Mucosa in the area of ​​apex is not changed, only in the acute stage, it is hiperemiyovanoyu and edematous. Palpatsiyno exhibit weak pain can be defined too.

 

 

Fig.5 Chronic granulomatous periodontitis

(Radiograph)

solid performance without fluctuations of 3 – 5 mm, which is re ¬ ¬ active thickening that perios. Clarify the possible diagnosis ¬ PA only radiographically. In chronic periodontal radiography is the main study, in fact the only source that provides the lens ¬ well, information about peri-odonta. On radiograph re-enlightenment is limited in the area of ​​apex, which has oval ¬ well or round shape with a diameter of 5 mm. Paths granulomas clearly restrict her from healthy bone and resemble compact plas ¬ particles alveoli. Along with the granulomas are often osteosklero-Atlantic rollers.

The differential diagnosis is carried out on the basis of clinical symptoms (appearance of the tooth and surrounding sly ¬ zovoyi shell data percussion, etc.), research elektrozbudly ¬ Vost, radiography. Granulomatous periodontitis vidriznyayet ¬ Xia from fibrous weaker pain during palpation, and sometimes percussion. From granulating periodontitis differs absence ¬ nistyu gum swelling and fistula, which periodically opens in the top section. The main differential diagnosis in a thou ¬ pova X-ray picture with well-constrained periapikal his enlightenment, confirming the diagnosis of chronic periodontitis matoznoho granules, and avoids the ne-granulating riodontyt (Fig. 5).

 

ACUTE CHRONIC PERIODONTITIS

Exacerbation of inflammation may occur regardless of periodontitis, but often exacerbated granulating periodically ¬ dontyt, at least – fibrous. Pointed periodontitis ¬ observes an observed more often from acute. His clinical picture similar to symptoms of acute periodontitis. Clinical heightened chronic periodontitis caused by the presence of GOST ¬ ruktsiyi in periodontal and alveolar bone. Therefore, charac ¬ thorns in history not only repeated exacerbation of pain, swelling, general malaise, but also very fast development of inflammation with the formation of fistulae. All the symptoms – pain, swelling Federal ¬ circles, the reaction of lymph nodes and other – q. ¬ yutsya in the same sequence as in the case of severe periodontitis. His sharpness and severity, however, significantly reduced due to fistulnoho go. Pain when you touch and receive ¬ mannya eating less intense than in patients with acute purulent periodontitis.

Objectively. Detect carious or sealed de vitalizovanyy tooth, horizontal and vertical especially Perks ¬ siya is painful. Depending on the phase and stage of disease manifestation ¬ tooth mobility lyayut I-II degree. Mucosa in the area of ​​apex hiperemiyovana, edematous. Transitional fold smoothed and painful during palpation. There may be an abscess in a particular phase of development and collateral soft tissue swelling. Lymph ¬ tical units are also inflamed. Possible degradation by ¬ eral condition.

Radiological picture of the picture corresponds to previous chronic periodontitis. Additional changes in it depend on the severity and duration of the inflammatory process. So, if exacerbate ¬ tion fibrous periodontal periodontalnyy space more deformed – a clear expansion periodontalnoyi cracks in the apex region, a focus of softening bones.

In case of exacerbation of granulomatous periodontitis disappear precise contours of condensed bone around the granulomas, and bone and brain spaces on its periphery enlightened.

Radiological picture of granulating periodontitis generally stushovana, but more pronounced contours of enlightenment. In the case of periodontitis should be sharpened differential diagnosis ¬ nostyku with acute purulent periodontitis (see Table. 19). These anamnestic data as Repeated acute symptoms and speed the development of inflammation ¬ cue up to the formation of fistula in the short term (within hours), indicate exacerbation of chronic periodontitis. The diagnosis is confirmed radiographically ¬ you are periapical changes.

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. 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.

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.

In small amounts in the walls of blood vessels is Periodontal elastic fibers. Between the walls of blood vessels and the main fibers in an oblique direction are periosteum–new fibers, which are also immature collagen fibers.They provide attachment of blood vessels and deformation during operationpe riodontium.
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 aLveoly. The most common cells it contains fibroblasts, which devel ¬ disposed along the main direction of bundles of fibers as involved in their formation. These cells produce elastin, glycoproteins, glycosaminoglycans. In addition, there periodontal epithelial cells, which are the remnants of the epithelial root sheath Hertviha. They form bands, stripes, follicles that In addition, there periodontal epithelial cells, which are the remnants of the epithelial root sheath Hertviha. They form bands, stripes, follicles that placed are closer to the cement,  and are called islands Malyasse. Sometimes epithelial strands anastomosing together, permeating the entire periodontium. These epithelial cells in the case of specific pathological conditions may participate in the formation of granulomas, cystogranulomas and aroundroot cysts.

An important component of cellular Periodontal are poorly differentiated mesenchymal cells. They are located around blood vessels and, if necessary, differentiate into fibroblasts, osteoblasts and cementoblasts.

Throughout Periodontal especially in periapical part located reticuloendothelial cells and blood sells who migrated from the vessels: erythrocytes, leukocytes, lymphocytes, monocytes, at least – macrophages and plasmocytes.

Periodontal Blood supply is making by dental branches  departing from the main arteries – aa. dentalis, interradicularis, interdentalis. They branch out and closely anastomosing, forming dense vascular network periodontium. Venous vessels are parallel to the artery. They have a larger diameter than the artery and receive blood from the capital-In the main, collagen, fibers in periodontium is a small amount of randomly oriented thin, unripe collagen fibers – reticular.

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.

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 chronic periodontitis

In a clear advantage over defenses weak action of pathogenic factors develop chronic fibrotic periodontitis. It can occur as a result of microtrauma independent form, chronic pulpitis pulpitis or after treatment, but often the disease develops after treatment of other chronic periodontitis. Under the action of irritating factor periodontal tissue gradually become thickfiber connective tissue that resembles a scar. However, in the early stages of chronic periodontitis in fibrous connective tissue apical part are islands of granulation tissue composed of fibroblasts, plasma cells, small foci of lymphocytic and leukocyte infiltration, resembling the remains of the inflammatory process. Subsequently, activated cementoblasts and osteoblasts; hipertse–cementoz, narrowing the periodontal space, leads to its deformation.

Chronic granulating periodontitis occurs as a consequence of acute inflammation, especially after acute suppurative periodontitis may develop in patients with chronic pulpitis, especially gangrenous.
The formation of granulation tissue rich in capillaries and fibroblasts, indicating a higher level of protection of the organism. Under the influence of stimuli from the entire root canal tooth apical part Periodontal replaced by granulation tissue. Growing, resolving granulation tissue adjacent layer of cement on the one hand, and destroys the alveoli compact plate – on the other. Osteoblasts penetrate to the bone marrow cavities, resorbable bone gully. Granulation process may spread to soft tissue and create gingival or skin fistula.

Activation pathogenic factor causing acute inflammation in the area of ​​the root apex, and then granulation tissue undergoes partial destruction. If at this stage the advantage defenses, the granulation tissue restores damaged cells. Such periodontitis is characterized in the clinic as the one that does not stand hermetically or as periodontitis, often escalates. This form of chronic inflammation of the periodontium is very difficult to treat. granulomatous

Chronic periodontitis. This form of periodontal inflammation has 2 ways of education.
1. The inflammatory process may occur spontaneously or after acute suppurative periodontitis and is accompanied by the growth of granulation tissue, which takes the form of a local focus. This fireplace has no tendency to active growth because the outer layer of granulation replaced by fibrous connective tissue that separates it from surrounding tissue. This formation is called “granuloma”. It has a spherical shape, dense outer capsule and soft granulation tissue inside.

3.           Granuloma can develop a granulating periodontitis. In the case of very high defenses, Resistive periodontal tissues and slightly etiological agent (bacteria and their toxins) granulating fireplace can lose aggressive nature. Under these conditions cease infiltrating growth of granulation, on their periphery formed fibrous connective tissue capsule surrounding the granulation. At the edge of the capsule deposited layer of bone that resembles a compact plate. Fiber capsules woven into periodontal linking granuloma with the root of the tooth. This is called a simple granuloma, or fibrous.

Granulation tissue inside granulomas has the same composition of cells, as in granulating periodontitis. Granuloma – a fairly steady, stable form of chronic periodontitis, which may be a long time – several years. If you decrease the body’s defenses or under the influence of local factors may occur acute inflammation. Purulent exudate breaks fibrous capsule and causes diffuse inflammation of periodontal and surrounding tissues. After treatment of this form of periodontitis can go in fibrous.

Depending on the nature of the capsule and the cells emit more epithelial granulomas and cystogranolomas.

Epithelial granuloma is a granuloma in which granulation tissue riddled with epithelial strands. In the early stages of epithelial strands are isolated, then they become more – epithelial cells almost replacing granulation tissue, which can lead to the formation of granulomas like cysts. cystogranuloma – a cavity that is lined with epithelium and filled with turbid fluid. In the case of very frequent exacerbations periodontal blood supply is disrupted periodontal degenerate cells, resulting in their decay appear cavity filled with fluid with degenerative forms of leukocytes, erythrocytes, epithelial cells and others.

CLASSIFICATION OF PERIODONTISIS

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.

3. Chronic granulating 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

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
            Acute apical periodontitis
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
chronic periodontitis

Chronic periodontitis is a disease that has a variety of clinical and radiological picture and the most common among people with periodontal pathology.
If a patient with acute periodontitis causes pain without hesitation to seek dental care, then chronic periodontitis usually does not cause subjective sensations. Often he found by chance on radiographs when the patient is not even aware that he has the disease. Accurate diagnosis can be established only after a thorough clinical and radiological examination.

Chronic fibrotic periodontitis (periodontitis chronica fibrosa). Symptoms. Chronic fibrotic periodontitis is asymptomatic, only occasionally patients experience minor pain during chewing coarse meal. The same may be determined by gangrene of the pulp if cavities filled remnants of food. Diseases found ba x-ray. From history establish that before (1-2 years ago), the patient was unwarranted causal or pain and were treated tooth root.

OBJECTIVE. They exhibit a carious tooth or sealed devitalization. The pain from the effects of thermal stimuli and percussion available. Palpation in the area of ​​apex painless. If fibrotic periodontitis developed after treatment of acute suppurative or chronic granulating periodontitis, it may be outdated scar. Sometimes fibrotic periodontitis may be a patient with intact teeth. In such cases, fibrotic periodontitis arose as a result of chronic injury or traumatic occlusion.

Radiologically often exhibit periodontitis expansion slot in the top section in the form of genital cap.

Fig.3. Chronic fibroticperiodontitis (X-ray)

Compact disc alveoli and cement root completely preserved (Fig. 3).
In other cases show hipertsementoz tooth root that causes thickening of the apical part of it – the root looks like drum sticks. Hinertsementoz characterizes positive immunological condition of the body and slow the progress of chronic process. Simultaneously you can observe hypercalcification alveolar bone that radiograph looks osteosclerotic roller on the periphery of the area Periodontal fibrosis.
Chronic granulating periodontitis (periodontitis chronica granulans) is 65 70% of all cases of chronic periodontitis.

Symptoms. Patients complain numb tooth, some pain while eating and pressing. In the top section of patient feels heaviness and slight fullness. If there is a carious defect, then filling it with food remnants can cause deterioration process and pain. From history clarifies the process repeated exacerbation of severe pain, swelling, formation of abscesses and fistulas appearance and oozing pus.

OBJECTIVE. They exhibit a gangrenous or sealed devitalization tooth with changed color. The tooth may also be externally intact or have broken the crown (in the case of traumatic etiology lesions). Vertical percussion tooth quite palpable or gives light pain reaction. During horizontal percussion if bone perforated wall or thinned after the introduction of the index finger in the mouth vestibule area Apex felt tapping, which is transmitted directly from the crown of the tooth to its root. Such a percussion entitled phenomenon allotted effort and most apparent in the area of ​​one root of the teeth. Tooth mobility may vary depending on the degree of destruction of the alveolar bone. During the inspection of the mucous membrane in the region of the apex is congestion with a bluish tinge.

But congestion is not too severe, so its detection mouth should begin to examine with porch. IG Lukomski (1955) described the typical granulating periodontitis vazopareus symptom that occurs when pressing the swollen gums – they seem swollen pillow. This is due to the growth of granulation infiltration foci, which applies not only to the bone, but also the soft tissue surrounding the alveoli. When you click on such a clear fine instrument (head plugger or blunt side of the excavator) remain hollow and grinding mucosa, which is rapidly changing bright red stripe, stored long time, sometimes a few minutes (due to paresis vessels ash).

In case of frequent exacerbations in the mucosa may occur permanent gingival or cutaneous fistula (fistula), which while pressing pours a drop of pus. Fistula course connects the source of infection of the mouth, where it opens fistula hole, which is often plugging granulation tissue that acts with him, giving the hole look navel. Occasionally plot fistula may see one or more scars.

Palpation in the area depending on the top step of the process is accompanied by more or less severe pain. During palpation can be defined cortical layer of bone resorption, regional lymph nodes are usually enlarged and painful when pressed.

Chronic granulating periodontitis without exacerbation is not accompanied by general symptoms.

On radiographs in the area of ​​apex turns focus enlightenment different sizes, shapes which resemble flames. There has gradual transition from areas of bone destruction to healthy bones in a light shade. This shows the inflamed bone demineralization. In the case of a long course of the process in some areas there is resorption of cement and dentin of the tooth root that a picture can be obliquely truncated cone shape more than 1/3 the length of the root. You can also determine the direction fistulnoho speed (Fig. 4).

Fig.4 chronic granulating periodontitis

In case of successful treatment of periodontitis in 4 – 8 months defect begins to decrease, and on its peripherals, a new bone. It is also possible the formation of bone trabeculae, which is defined in the picture as a characteristic gray shadow. A year later section enlightenment completely replaced by bone, sometimes more dense thaormal bone.

Differential diagnosis. Chronic granulating periodontitis can be easily differentiated from fibrous periodontitis in character traits that are percussion and palpation, the presence of hyperemia and edema of the mucous membrane in the region of the apex, and fistulas or scar in place of the latter. Diffuse illumination irregular in some areas of the alveoli in the apical radiographs helps to clarify the diagnosis.

Chronic granulomatous periodontitis (periodontitis chronica granulomatosa) appears limited periodontal inflammation around the apical hole tooth usually has no symptom–course. Dentist finds it as fibrous accidentally during radiological examination. Medical history can establish that sometimes during colds or active chewing solid foods patients feel heaviness, tension, even pain in the root apex of the tooth.

               OBJECTIVE. Identify tooth color changed, it may be intact or sealed. Vertical percussion often painless. However, compared to neighboring teeth causal tooth may be sensitive. Horizontal percussion in cases of considerable size granulomas determine symptom of the reflected shock. Mucosa in the area of ​​Apex is not changed, only in the acute stage it is hyperemic and edematous. Palpatsiyno exhibit moderate pain can be defined as

Fig.5 Chronic granulomatous periodontitis
(X-ra solid performance without the fluctuations of 3 – 5 mm, which is reactive thickening periosteum. Refine diagnosis is only possible radiographically. Chronic periodontitis is a major X-ray study, in fact the only source that provides objective information on periodontal status. On radiographs is limited enlightenment in the area of ​​Apex, which has an oval or round shape with a diameter of 5 mm. Contours granulomas clearly restrict her from healthy bone and compact plate resembling alveoli. Along with granuloma is often osteoplastic roller.y)

The differential diagnosis is carried out on the basis of clinical symptoms (appearance of the tooth and surrounding mucosa, data percussion, etc.), research electro excitability, radiography. Granulomatous periodontitis differs from fibrous weaker pain during palpation, and sometimes percussion. From granulating periodontitis is non-gum swelling and fistula, periodically opening in the top section. The main differential diagnosis is with a typical X-ray picture of periapical clearly limited enlightenment, confirming the diagnosis of chronic periodontitis matos granulation and eliminates granulating periodontitis (Fig. 5).

 

 

 

Radiography is an important part of dental diagnostic x-ray and high-quality made​​, if possible, a way Langtubus, is highly informative.

Diagnostic X-ray. Incomplete filling of the canal mandibular molar.
  Diagnostic data is limited to one shot as three-dimensional object depicted in a two-dimensional plane. Therefore recommended that images in different projections. There ortoradial, Mesa, eccentric or eccentric distal-rays.

Radiograph provides information about:
• Dimensions of cavities and fillings,
• volume of the pulp cavity,
• the rate of formation secondary and third dentine
• apical localization of the hole,
• presence of root resorption
• availability of re apical damage
• The state of periodontal
• perforation,
• broken teeth.

For the diagnosis of pulp and apical periodontium radiological examination is conducted by: to determine the working length during root canal treatment,
suspected Via falsa, after treatment and root canal filling.
By studying the X-rays should take into account the level of personnel skills and technique of X-ray studies. Interpretation of the image depends on for its two different persons, and holding her by one person at different times. As an alternative to traditional X-rays recently widely used radiovisiograph. One of the major benefits of method – reducing patient exposure by 80%.

 

Exacerbations of chronic periodontitis

             Exacerbation of inflammation can occur regardless of the form of periodontitis, but often escalates granulating periodontitis, at least – fibrous. Sharpened periodontitis occurs far more often than acute. Its clinical picture resembles acute symptoms of periodontitis. Clinical exacerbations of chronic periodontitis caused by the presence of destruction in periodontal and alveolar bone. So typical history is not only repeated exacerbation of pain, swelling, general malaise, but also very fast development of inflammation with formation of fistulas. All symptoms – pain, swelling of the collateral, the reaction of the lymph nodes and other – are in the same sequence as in the case of acute periodontitis. Its sharpness and severity, however, significantly reduced due to the presence fistul way Pain during pressing and eating less intense than in patients with acute suppurative periodontitis.

                   OBJECTIVE. Identify or sealed devitalized carious tooth, horizontal and vertical percussion which is particularly painful. Depending on the phase and stage of the disease exhibit mobility tooth I-II degree. Mucosa in the area of ​​apex hyperemic, edematous. Transitional fold smoothed and painful at palpation. There may be an abscess in a particular phase of development and collateral soft tissue swelling. Lymph nodes are also swollen. Possible deterioration.
X-ray picture corresponds to the picture of the previous chronic periodontitis. Additional changes in it depending on the severity and duration of the inflammatory process. Thus, in the case of heightened fibrous periodontitis periodontal space more deformed – a clear expansion of periodontal gap in the area of ​​Apex, is focus of softening bones.

                In case of acute granulomatous periodontitis disappear sharp contours compacted bone around the granulomas and bone and brain spaces on the periphery enlightened.
When pointed periodontitis should be carried out differential diagnosis of acute suppurative periodontitis (see Table. 19). Such medical history as recurrence of acute symptoms and rapid development of inflammation until the fistula formation in a short time (a few hours), indicate exacerbation of chronic periodontitis. The diagnosis is confirmed radiographically detected periapical changes.

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.

Crown-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