Granulating periodontitis is an inflammatory process of connective tissue - periodontal, which is located between the cement of the root of the tooth 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 tissue 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.
Kinds
Analysis of the clinical picture, morphological characteristics and the alleged course of chronic periodontitis allowed the following varieties to be noted:
- Granulating. This form of the disease is characterized by the fact that under a microscope in the dental apical part of the root, a significant thickening can be seen. 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. Such a process is often accompanied by the appearance of purulent foci, which causes the appearance of fistulas. Granulation in some cases affects soft tissues that are adjacent to the area of inflammation. Because of this, various granulomas (subcutaneous, subperiosteal, submucosal) are formed, after opening them in the oral cavity and on the face, fistulas appear, and unaesthetic scars appear on the healing site. People who have encountered granulating periodontitis experience pain during chewing of solid foods, which intensify with 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 therapy of granulomatous and granulating periodontitis, but sometimes an independent occurrence of the fibrous form occurs. Fibrous inflammation is often accompanied by excessive formation of cement, sometimes sclerosis of the bone tissue adjacent to it.
- Chronic granular periodontitis. This is one of the types of periapical inflammation, which is characterized by the formation of granulation tissue in the apex of the root. The maturation of such tissue in the peripheral zone causes the appearance of a fibrous capsule, which is transformed into granuloma. Cystic, epithelial and simple granulomas are distinguished depending on the specific structure. This form often occurs due to inflammation, which is recorded by the doctor in the medical history. Chronic granulating periodontitis can have various developmental options. Sometimes 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, granuloma may increase, which most often coincides with exacerbations of periodontitis of a chronic nature, which provoke changes in granuloma tissue.
Reasons and principle of development
Granulating periodontitis usually develops due to 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. A marginal pathway of the disease may also be present - penetration of microorganisms into the periodontium through the dental ligament and the margin of the gum. Externally, simple tooth trauma can cause significant complications.
Traumatic periodontitis
Traumatic periodontitis occurs due to physical effects on the tooth. For example, due to a blow or if the seal or artificial crown is incorrectly placed.
A drug source of the development of the disease is tissue injury with endodontic instruments or the use of aggressive drugs - arsenic paste, etc.
Exacerbation of granulating periodontitis causes poor oral care, some pathologies (diabetes, etc.), malocclusion.
Tissue proliferation
The pathogenic process is expressed in the form of proliferation of granulation connective tissue (most often in the root apex), resorption of cement and dentin of the tooth, destruction of the periosteum, resorption of alveolar plates. With the spread of pathology to the soft tissues of the jaw and gums, fistulas and abscesses are formed with the release of 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: specifics of symptoms
According to pathomorphology and clinic, periodontitis can be: chronic, acute and in remission, as well as a chronic form 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 two conventional stages of the process:
- Phase One Inflammation is characterized by aching long pains that increase if you click on the affected tooth. An increased sensitivity of periodontal is fixed by percussion.
- Phase two. The disease passes into the exudative stage. Due to the spread of serous-purulent infiltrate, there is swelling of the soft tissues, an increase and sensitivity of regional lymph nodes. Inflammation is manifested by continuous severe pain, severe pain, if you click on the tooth. From a light touch of the tongue, severe pain appears. There is a feeling that the tooth seems to be pulled out of the soft tissues. Very painful percussion, pain radiating. General malaise is characteristic, the temperature can rise to 37-38 ° C. A blood test shows leukocytosis and an increase in 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 slight sensations of pain - awkwardness, heaviness, bursting. Vasoparesis and hyperemia are noted. Percussion and palpation are uncomfortable. From time to time with chronic periodontitis, pus forms, fistular passages appear in the soft tissues, carious cavities, and mouth. This often occurs asymptomatically, but only when the pus has the possibility of an unhindered exit, which is reflected in the medical history.
In chronic granulating periodontitis, if the channels are blocked, for example by food debris or by closing the fistula, pus accumulates, causing increased pain and tissue bursting. Infection with a worsening of immunity can spread more, causing an escalation of the disease.
Aggravation
Exacerbations occur when the capsule of the abscess ruptures, immunity worsens, and pus exits from the inflamed area. Granulating granulomatous periodontitis at the acute stage often accompanies fistula. Fistula can form in the oral cavity, on the face (corners of the eyes, cheeks, chin). Exudate exits from the mouth of the fistula. It is subsequently tightened by a scar.
Manifestations
An exacerbation of granulating periodontitis with fistula is characterized by paroxysmal pain, which is aggravated by physical and thermal effects on the tooth. Swelling, pastiness and gingival hyperemia are visually noticeable. On palpation of the lymph nodes of the lower jaw from the part of the inflamed teeth, a slight pain and an increase are noted. The affected tooth is slightly mobile. With 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 discharge of pus, and the disease goes into an asymptomatic stage. Blockage of the fistula again causes exacerbation, intoxication intensifies.
Establishing diagnosis
With granular periodontitis, the differential diagnosis is the exclusion of fibrous and granulomatous forms of the disease, jaw osteomyelitis, pulpitis, actinomycosis of the face and cysts near the root. The following diagnostic tests are used:
- Clinical. Inspection, as a rule, diagnoses a damaged 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 presses on the gum, it turns pale, a depression appears, which persists for some period after pressure, that is, vasoparesis. This is also confirmed by the history of the disease of granulating periodontitis.
- X-ray examination. Radiography is indispensable in the differential diagnosis. It fixes in the root apex the darkened region of rarefaction of a flame-shaped form. Dimming outlines are fuzzy. An increase in the gap of the periodontium is noted, the destruction of cement and dentin is noticeable.
- Electrodontometry. The method is based on the painful and tactile reaction of pulp receptors to an electric current that passes through it. The excitability of inflamed pulp with a granulating form of periodontitis reaches 100 μA or more.
Treatment methods
Granulating periodontitis is treated with a surgical (surgical) or therapeutic (endodontic) method:
- Chronic stage. Therapeutic measures consist of the following: removal of exudate from the inflamed area; elimination of the infected inflamed part - the canal is cleaned of infected dentin and decayed pulp; destruction with anti-inflammatory and antimicrobial pastes, which are laid in the tooth root, with antiseptics of the pathogenic flora, if necessary, use broad-spectrum antibiotics, sulfonamides, ultrasound (physiotherapy); carry out activities that ensure the restoration of periapical tissues and bone structures; filling channels. If necessary, perform surgical intervention.
- Remission. Local anti-inflammatory drugs 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. Anesthetize and carry out treatment as in a chronic disease.
- Surgery. The teeth are removed with a strong destruction of part of the crown; with great 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 allow the patient to retain a tooth. They include: amputation - the affected root is removed before the transition to the crown; cystotomy - a cyst is partially removed; hemisection - the root of a multi-root tooth is trimmed with the crown; cystectomy - removal of the cyst completely; resection of the root apex - removal of the area of inflammation and infection.
Pathology prognosis
The correct treatment of granulating periodontitis in most cases allows you to completely restore the tissue, save the tooth as a functional unit. If there is no therapy, the disease is characterized by constant exacerbations, and the tooth has to be completely removed.
Prevention
Prevention refers to: the exclusion of risk factors, such as the lack of proper oral care; inattention to pulpitis and caries; smoking; tartar deposits. A diet with a high content of hard plant foods is recommended, ensuring the equal participation of all teeth in the process of chewing. You should also visit your dentist regularly.