Granulating periodontitis is an inflammatory process of the connective tissue - periodontium, which is located between the cementum of the tooth root and the alveolar plate. This is the most active inflammatory form of periodontal disease. It differs from more asymptomatic and stable granulomatous and fibrous periodontitis, has a dynamic development with a short remission and serious exacerbations. The process of inflammation extends to the jaw, adjacent teeth, soft tissues of the gums and cheeks, sometimes reaching the surface of the skin of the neck or face. In the international classification of diseases of the ICD, chronic granulating periodontitis is included in class K04.5.
Views
Analyses of the clinical picture, morphological characteristics and the alleged course of chronic periodontitis made it possible to note the following varieties:
- Granulating. This form of the diseasecharacterized by the fact that under a microscope in the dental apical part of the root one can see a significant thickening. The surface of the periodontium changes, it becomes uneven. Granulation tissue grows over time, due to which the bone tissue in the area of the inflammatory focus resolves. This process is often accompanied by the appearance of purulent foci, which causes fistulas. Granulation in some cases affects soft tissues that are adjacent to the area of inflammation. Because of this, various granulomas are formed (subcutaneous, subperiosteal, submucosal), after they are opened, fistulas appear in the oral cavity and on the face, and unaesthetic scars appear at the healing site. People who have experienced granulating periodontitis experience pain during chewing of solid foods, which are aggravated by pressure, periodic exacerbations of unpleasant symptoms.
- Fibrous. It differs in the formation of a limited inflammatory focus, due to the spread of fibrous tissue. This most often occurs after the implementation of therapy for granulomatous and granulating periodontitis, but sometimes there is an independent occurrence of the fibrous form. Fibrous inflammation is often accompanied by excessive formation of cementum, sometimes sclerosis of the bone tissue adjacent to it.
- Chronic granular periodontitis. This is one of the types of the near-apex inflammation process, which is characterized by the formation of granulation tissue in the region of the root apex. The maturation of such tissue along the periphery zone causes the appearance of fibrouscapsule, which transforms into a granuloma. Depending on the specifics of the structure, cystic, epithelial and simple granulomas are distinguished. This form quite often occurs due to inflammation, which is recorded by the doctor in the medical history. Chronic granulating periodontitis can have various variants of development. Sometimes the granuloma does not increase at all or grows slowly. In this case, as a rule, it does not cause any unpleasant symptoms, and is accidentally detected during an X-ray examination.
In other patients, the granuloma may increase, which most often coincides with exacerbations of chronic periodontitis, which provoke changes in the granuloma tissue.
Reasons and principle of development
Granulating periodontitis usually develops as a result of unsuccessful treatment of caries or pulpitis, trauma or infection.
With an infectious method of development, the main role belongs to the complication of caries or pulpitis. Bacteria (staphylococci, streptococci, etc.) most often enter the periodontium from the root canal with necrotic pulp. There may also be a marginal path of the disease - the penetration of microorganisms into the periodontium through the dental ligament and the margin of the gum. Outwardly, a simple trauma to the tooth can cause significant complications.
Traumatic periodontitis
Traumatic periodontitis occurs due to physical impact on the tooth. For example, due to a blow or an incorrectly placed filling or artificial crown.
Medicationthe source of the development of the disease lies in tissue injury with endodontic instruments or the use of aggressive preparations - arsenic paste, etc.
Exacerbation of granulating periodontitis is caused by poor oral care, some pathologies (diabetes, etc.), malocclusion.
Tissue growth
The disease-causing process is expressed in the form of proliferation of granulation connective tissue (most often in the root tip), resorption of cement and dentin of the tooth, destruction of the periosteum, resorption of the alveolar plates. When the pathology spreads to the soft tissues of the jaw and gums, fistulas and abscesses are formed with the release of a serous-purulent substance from them. The development of the disease in general takes place in the following direction: the formation of connective tissue instead of destroyed tissue and bone structures; the formation of purulent cysts; expansion of the periodontal gap.
Forms of the development of the disease: the specifics of symptoms
According to pathomorphology and clinic, periodontitis can be: chronic, acute and in remission, as well as chronic in the acute stage. The clinic and symptoms depend on the form of the disease.
The main feature of the acute process is prolonged localized pain, at the beginning not too strong, then more pulsating, intense. Irradiation of pain indicates a purulent form. The duration of the acute course is from several days to two weeks.
Stages
There are conditionally two stages of the process:
- Phase one. Inflammation is characterized by aching long pains that increase if you press on the affected tooth. Increased sensitivity of the periodontium is fixed by percussion.
- Phase two. The disease passes into the exudative stage. Due to the spread of serous-purulent infiltrate, swelling of soft tissues appears, an increase and sensitivity of regional lymph nodes. Inflammation is manifested by continuous severe pain, severe soreness, if you press on the tooth. From a light touch with the tongue, severe pain appears. There is a feeling that the tooth is as if pushed out of the soft tissues. Very painful percussion, irradiation of pain is noted. General malaise is characteristic, the temperature can rise to 37-38 ° C. Blood test shows leukocytosis and elevated ESR.
Chronic stage and remission period
Chronic granular periodontitis is characterized by a dynamic course, with short remissions and frequent exacerbations.
The disease is manifested by periodic, not too pronounced discomfort or minor sensations of pain - awkwardness, heaviness, bursting. Vasoparesis and hyperemia are noted. Percussion and palpation are uncomfortable. From time to time, in chronic periodontitis, pus is formed, fistula passages appear in soft tissues, carious cavities, and mouth. This is more often asymptomatic, but only when the pus has the ability to freely exit, which is reflected in the medical history.
Whenchronic granulating periodontitis, if the channels are blocked, for example, by the remains of food or the closure of the fistula, pus accumulates, causing increased pain and tissue swelling. Infection with a deterioration in immunity can spread more strongly, causing an escalation of the disease.
Worse
Exacerbations occur when the abscess capsule ruptures, immunity deteriorates and pus is prevented from leaving the inflamed area. Granulating granulomatous periodontitis at the acute stage often accompanies a fistula. A fistula can form in the mouth, on the face (corners of the eyes, cheeks, chin). Exudate comes out of the mouth of the fistula. It is subsequently tightened by a scar.
Manifestations
For exacerbation of granulating periodontitis with a fistula, paroxysmal pain is characteristic, which increases with physical and thermal effects on the tooth. Swelling, pastosity and hyperemia of the gums are visually noticeable. On palpation of the lymph nodes of the lower jaw from the side of the inflamed teeth, there is a slight soreness and an increase. The affected tooth is slightly mobile. During exacerbation, areas of inflammation are formed, from which pathogenic bacteria and their metabolic products enter the bloodstream, causing sensitization of the body. Intoxication decreases with the removal of pus, and the disease passes into an asymptomatic stage. Blockage of the fistula again causes exacerbation, intoxication intensifies.
Diagnosis
With granular periodontitis, differential diagnosis consists in the exclusion of fibrous andgranulomatous forms of the disease, osteomyelitis of the jaw, pulpitis, actinomycosis of the face and cysts near the root. The following diagnostic tests are used:
- Clinical. Inspection, as a rule, diagnoses the destroyed affected tooth of a changed color. The cavity of caries most often communicates with the dental canal. Probing does not cause significant pain, there may be a little painful percussion. When the probe is pressed on the gum, it turns pale, a deepening occurs, which persists for some period after pressure, that is, vasoparesis. This is also supported by a case history of granulating periodontitis.
- X-ray examination. Radiography is indispensable in the differential diagnosis. It fixes a darkened flame-like rarefaction area in the root apex. The blackout has fuzzy contours. An increase in the periodontal gap is noted, destruction of cement and dentin is noticeable.
- Electroodontometry. The method is based on the pain and tactile reaction of pulp receptors to an electric current that is passed through it. The excitability of the inflamed pulp in the granulating form of periodontitis reaches 100 μA or more.
Treatment methods
Granulating periodontitis is treated surgically (surgical) or therapeutically (endodontic) way:
- Chronic stage. Therapeutic measures consist of the following actions: removal of exudate from the inflamed focus; elimination of the infected inflamed part -the canal is cleared of infected dentin and decayed pulp; destruction of anti-inflammatory and antimicrobial pastes that are placed in the tooth root, antiseptics of pathogenic flora, if necessary, use broad-spectrum antibiotics, sulfonamides, ultrasound (physiotherapy); carry out activities that ensure the restoration of periapical tissues and bone structures; canal filling. If necessary, surgical intervention is performed.
- Remission. Anti-inflammatory local agents of complex action and physiotherapy are used. Vitamins are prescribed (mainly groups B and C), as well as biogenic stimulants.
- Exacerbation of chronic granulating periodontitis. Pain is administered and treated as in a chronic illness.
- Surgical treatment. The teeth are removed with a strong destruction of part of the crown; with high mobility (3-4th stage); if the channel cannot be opened due to curvature, obstruction of the lumen or narrowing. Preference is given to operations that save the patient's tooth. These include: amputation - the affected root is removed before moving into the crown; cystotomy - the cyst is partially removed; hemisection - the root of a multi-rooted tooth is cut along with the crown; cystectomy - removal of the cyst completely; resection of the root tip - removal of the area of inflammation and infection.
Prognosis of pathology
Proper treatment of granulating periodontitis in most cases allows you to completely restore tissue, savetooth as a functional unit. If there is no therapy, the disease is characterized by constant exacerbations, and the tooth has to be removed completely.
Prevention
Prevention is understood as: elimination of risk factors such as lack of proper oral care; inattention to pulpitis and caries; smoking; deposits of tartar. A diet with a high content of hard plant foods is recommended, which ensures the equal participation of all teeth in the chewing process. You should also visit your dentist regularly.
