4. Although not all patients with gingivitis develop periodontitis, it is known that all
patients with periodontitis experienced prior gingivitis.
5. • Chronic periodontitis is the most prevalent form of periodontitis, and
it generally demonstrates the characteristics of a slowly progressing
• Systemic and environmental factors (diabetes mellitus, smoking) may
modify the host’s immune response to the dental biofilm so that
periodontal destruction becomes more progressive.
• Although chronic periodontitis is most frequently observed in adults,
it can occur in children and adolescents in response to chronic plaque
and calculus accumulation.
6. Major clinical and etiologic characteristics of the disease:
(1) microbial biofilm formation (dental plaque);
(2) periodontal inflammation (gingival swelling, bleeding on probing)
(3) attachment as well as alveolar bone loss.
7. Clinical Features
Characteristic clinical findings in patients with untreated chronic periodontitis:
• 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 (angular or horizontally)
• Bone loss
• Root furcation involvement
• Increased tooth mobility
• Change in tooth position
• Tooth loss
8. • 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
1) The rate of disease progression over time,
2) The familial nature of aggressive disease,
3) The disease’s resistance to periodontal anti-infective therapy,
4) The presence of local factors.
9. Disease Distribution
The number of teeth with clinical attachment loss classifies chronic
periodontitis into the following types:
Localized chronic periodontitis: less than 30% of the sites show
attachment and bone loss
Generalized chronic periodontitis: 30% or more of the sites show
attachment and bone loss
10. Disease Severity
Mild chronic periodontitis: when no more than 1 mm to 2 mm of clinical
attachment loss has occurred
Moderate chronic periodontitis: when 3 mm to 4 mm of clinical attachment
loss has occurred
Severe periodontitis: when 5 mm or more of clinical attachment loss has
With increasing age, attachment loss and bone loss become more prevalent
and more severe as a result of an accumulation of destruction.
• Chronic periodontitis is commonly a slowly progressive disease that
does not cause the affected individual to feel pain. Therefore, most
patients are unaware that they have developed a chronic disease.
• For the majority of the patients, gingival bleeding during oral hygiene
procedures or eating may be the first self-reported sign of disease
• As a result of gingival recession, patients may notice black triangles
between the teeth or tooth sensibility in response to temperature
18. • In those individuals with advanced disease progression, areas of
localized dull pain or pain sensations that radiate to other areas of the
mouth or head may occur.
• The presence of areas of food impaction may add to the patient’s
• Gingival tenderness or “itchiness” may also be found.
19. Disease Progression
• Patients appear to have the same susceptibility to plaque-induced
chronic periodontitis throughout their lives.
• The rate of disease progression is usually slow, but it may be modified
by systemic, environmental, and behavioral factors.
• The onset of chronic periodontitis can occur at any time, and the first
signs may be detected during adolescence in the presence of chronic
plaque and calculus accumulation.
• Because of its slow rate of progression, however, chronic periodontitis
usually becomes clinically significant when a patient reaches his or
her mid-30s or later.
20. • Chronic periodontitis does not progress at an equal rate in all affected
sites throughout the mouth.
• More rapidly progressive lesions occur most frequently in
interproximal areas, and they may also be associated with areas of
greater plaque accumulation and inaccessibility to plaque control
• Patients with poorly adjusted diabetes mellitus show a significantly
higher risk of developing a severe progression of chronic periodontitis
• Chronic periodontitis increases in prevalence and severity with age,
and it generally affects both genders equally.
21. • Models that have been proposed to describe the rate of disease
• The continuous model
• The random or episodic-burst model
• The asynchronous, multiple-burst model
22. Risk Factors for Disease
• Microbiological Aspects
• Local Factors
• Systemic Factors
• Immunologic Factors
• Genetic Factors (50%)
• Environmental and Behavioral Factors
23. Microbiological Aspects
• Attachment and bone loss are associated with an increase in the
proportion of gram-negative organisms in the subgingival biofilm, with
specific increases in organisms that are known to be exceptionally
pathogenic and virulent.
• Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola
• chronic periodontitis is the result of a multispecies infection with a number
of different bacteria that influence the pro-inflammatory immune response
of the host.
24. Local Factors
• Plaque accumulation and biofilm development are the primary causes
of periodontal inflammation and destruction.
• factors that facilitate plaque accumulation or that prevent plaque
removal by oral hygiene procedures can be detrimental to the
• Plaque-retentive factors are important for the development and
progression of chronic periodontitis, because they retain
microorganisms in proximity to the periodontal tissues, thereby
providing an ecologic niche for biofilm maturation.
25. • Calculus is considered the most important plaque-retentive factor as a
result of its ability to retain and harbor plaque bacteria on its rough
• As a consequence, calculus removal is essential for the maintenance of a
• Tooth morphology
• Subgingival and overhanging margins of restoration
• Carious lesions extend subgingivally,
• furcations exposed by loss of bone
26. Systemic Factors
• Systemic disorders: Papillon–Lefèvre syndrome, Ehlers–Danlos
syndrome, Kindlers syndrome
• Impaired host immune response: human immunodeficiency virus,
acquired immunodeficiency syndrome
• osteoporosis, a severely unbalanced diet, and stress as well as
dermatologic, hematologic, and neoplastic factors
• diabetes mellitus, cardiovascular disorders, stroke, and lung disorders
27. • For diabetes mellitus and periodontitis, it is known that there is an
interaction during which both diseases mutually correlate with each
• Patients with poor glycemic control (a glycated hemoglobin level of
>9%) tend to experience a more severe progression of periodontitis
as compared with patients with good glycemic control.
• No difference was found between patients with good glycemic control
and non-diabetic patients.
• Periodontal therapy may contribute to the glycemic control of the
diabetic patient. It has been shown that systematic periodontal
therapy leads a 0.4% reduction of glycated hemoglobin.
28. Immunologic Factors
• Chronic periodontitis is a disease that is induced by bacteria
organized in the dental biofilm. However, the onset, progression, and
severity of the disease depend on the individual host’s immune
• Patients may show alterations in their peripherial monocytes, which
are related to the reduced reactivity of lymphocytes or an enhanced
• Reduced neutrophil counts influence the degree of periodontal
29. Environmental and Behavioral Factors
• Smoking is a major risk factor for the development and progression of
generalized chronic periodontitis.
• The intake of more than 10 cigarettes per day increases the risk of
disease progression as compared with non-smokers and former
30. • As compared with non-smokers, the following features are found in
• Increased periodontal pocket depth of more than 3 mm
• Increased attachment loss
• More recessions
• Increased loss of alveolar bone
• Increased tooth loss
• Fewer signs of gingivitis (less bleeding with probing)
• Greater incidence of furcation involvement
31. • Psychological factors (stress, depression) also negatively influence the
progression of chronic periodontitis.
• In addition, stress as an etiologic factor was even more strongly
associated with periodontitis when patients were smokers as
compared with non-smokers.