1. Chronic Periodontitis
Dr. Mahmoud Mudalal
B.Sc. Dental surgery
M.Sc. Periodontology
Ph.D. Periodontology and Implantology
Asst. Professor at Arab American university
Member of ADEE.
Research fellow at Jilin Provincial Experimental School.
Google scholar. Mahmoud MUDALAL 64 citations.
Research Gate Ref #: 11.9.

2. • Chronic periodontitis is the most prevalent form of periodontitis, and it
generally shows the characteristics of a slowly progressing inflammatory
disease. Periodontitis belongs to the group of complex inflammatory
diseases in humans.
• In this context, the word complex not only describes the fact that there
are multiple clinical symptoms that account for the disease, but also
explain the multiple factors that lead to and influence periodontal
inflammation.
• Chronic periodontitis occurs most frequently in adults.
• Nonetheless, it may also be diagnosed in children and adolescents when
associated with chronic plaque and calculus accumulation.
• Therefore chronic periodontitis should be understood as age-associated,
but not age-dependent, complex chronic inflammation of the periodontal
tissues.

3. • Chronic periodontitis represents major clinical and etiologic
characteristics such as
(1) Microbial biofilm formation (dental plaque).
(2) Periodontal inflammation (gingival swelling, bleeding on probing).
(3) Attachment as well as alveolar bone loss.

4. Clinical Features
Characteristic clinical findings in patients with untreated chronic periodontitis
include the following symptom
• Supragingival and subgingival plaque (and calculus)
• Gingival swelling, redness, and loss of gingival stippling
• Altered gingival margins (rolled, flattened, cratered papillae, recessions)
• Pocket formation
• Bleeding on probing
• Attachment loss
• Bone loss (angular/vertical or horizontal)
• Root furcation involvement
• Increased tooth mobility
• Change in tooth position
• Tooth loss

5. • Clinical features of generalized chronic periodontitis in a 49-
year-old, medically healthy male patient who presented to the
clinic for the first time.
• The patient reported smoking 15 cigarettes per day.
• Note the abundant dental plaque and calculus deposits,
gingival redness and swelling, and alteration of the gingival
texture (loss of gingival stippling).
• The patient noticed multiple recessions.
• In this case, recessions were the result from loss of clinical
attachment and alveolar bone.

7. • Collage of the radiographic periodontal status (a total of 11 x-rays) at the
time of diagnosis.
• Generalized horizontal and localized angular, vertical bone loss on the
mesial and distal sites of molars was noted.
• Radiographs present deep subgingival restorations (teeth #2 and #19),
overhanging margins of restorations (teeth #14 and #15), carious lesion
(tooth #14), and insufficient root canal treatment(tooth #18).

9. • Documentation of the same
patient at the time of the first
visit.
• The red line displays the gingival
margin reflecting recessions.
• CAL is illustrated by the filled
(blue) The deepest periodontal
pocket was 9 mm.
• Class I and class II furcation
involvement.
• Bleeding upon periodontal
probing(gingival inflammation)
is reflected by orange dots.
Tooth mobility is indicated by
the green line (tooth #19).

10. • Subsequent to the anti-infective therapy and periodontal
reevaluation, resective periodontal surgery was performed in
the patient introduced.
• Surgical method: apically repositioned flap.
• (A)Intrasulcular incision at buccal sites; notice class I furcation
involvement on tooth #19 and horizontal bone loss in teeth
#18 to #20.
• (B) Sutured using 5-0 Prolene, buccal view.

12. The distinction between aggressive and chronic
periodontitis is sometimes difficult, because the clinical
features may be similar at the time of the first
examination.
At later time points during treatment, aggressive and
chronic periodontitis may be differentiated by the rate of
disease progression over time, familial nature of
aggressive disease, and presence of local as well as
systemic factors.

13. Disease Distribution
• Due to the site-specific nature and based on the number of
teeth with clinical attachment loss, chronic periodontitis can
be classified into the following categories:
• Localized chronic periodontitis, meaning that less than 30% of
the teeth show attachment and bone loss
• Generalized chronic periodontitis, meaning that 30% or more
of the teeth show attachment and bone loss

14. Disease Severity
• With chronic periodontitis, severity and extent of periodontal destruction
will occur over time in combination with systemic disorders impairing or
enhancing host immune responses.
• Patients with chronic periodontitis experience a progression in
attachment and bone loss as they become older.
These degrees are defined as follows:
• Mild chronic periodontitis: clinical attachment loss of 1 to 2 mm.
• Moderate chronic periodontitis: clinical attachment loss of 3 to 4 mm.
• Severe chronic periodontitis: clinical attachment loss of 5 mm or more.

15. Symptoms
• Chronic periodontitis is commonly a slowly progressing complex disease
without a pain experience.
• Therefore most patients are unaware that they have developed a chronic
disease.
• For the majority of patients, gingival bleeding during oral hygiene procedures
or eating may be the first sign of disease occurrence.
• Areas with advanced periodontal inflammation may present with purulence
emanating from the periodontal pocket.
• As a result of gingival recession, patients may notice black triangles between
teeth or tooth sensitivity in response to temperature changes (cold and heat).

16. • In addition, food impaction may occur in the space of
interdental triangles, leading to increased discomfort and bad
breath.
• In cases with advanced attachment and bone loss, tooth
mobility, tooth movement, fanned out or elongated front teeth,
and, in rare occasions, tooth loss maybe reported.
• In cases with advanced disease progression, areas of localized
dull pain or pain sensations radiating to other areas of the
mouth or head may occur.

17. Disease Progression
• Chronic periodontitis may develop at any time in life.
• First clinical signs of inflammation may occur even during
adolescence when the oral hygiene is neglected and dental
plaque and calculus were allowed to accumulate.
• In general, the progression rate of chronic periodontitis is slow,
so that symptoms of the disease appear around the age of 40 or
later in life.
• Onset and the rate of disease progression, however, may be
influenced by a number of modifiable (e.g., smoking, diet)and
nonmodifiable (e.g., genetic disorders and risk issues) factors.

19. Three different models have been proposed to describe the rate of disease progression
and determine the degree of attachment loss over time.
The continuous model:
• Describes slow and continuous disease progression.
• Suggests that sites exhibit a constant progression rate of attachment loss throughout the duration of the disease.
The random or episodic-burst model:
• Describes the episodic occurrence of short progressive bursts of periodontal destruction followed by periods of
stagnation.
• Sites, teeth, and the chronology of bursts and stagnation are subject to random effects.
The asynchronous, multiple-burst model:
• Describes the occurrence of periodontal destruction (bursts) during defined periods, which are asynchronously.
interrupted by periods of stagnation or remission for individual sites and teeth.

21. Treatment of Chronic Periodontitis
Chronic periodontitis can be treated effectively by a systematic
periodontal therapy that includes optimal long-term plaque control,
debridement of soft and hard deposits, or surgical pocket reduction.
Depending on the individual periodontal risk, each patient should be
remotivated, reinstructed, and retreated(if necessary) during a systematic
supportive periodontal therapy regimen.

22. Stress and Periodontal Disease: Potential
Mechanisms
1. Immunosuppression via cortisol secretion.
2. Poor oral hygiene compliance in patients with chronic stress.
3. Patients with stress are less likely to seek professional care.
4. Patients with stress may smoke more frequently.