The periodontium is the tissue that surrounds the roots of the teeth. In fact, it is she who firmly holds all the teeth in the alveoli. Inflammation of this tissue is called periodontitis. We will find out in detail what this disease is, what types of periodontitis are isolated and how they can be treated. Let us dwell in more detail on such types as granulomatous periodontitis and granulating periodontitis.

Since the focus of inflammation can be localized in different areas, apical periodontitis and marginal periodontitis are distinguished. With an apical lesion, it is localized in that area of ​​the periodontium, which is located right near the top of the tooth root. This results in tissue infection. Its cause - the pulp was infected, and the decay process began. In this case, the products of this decay exit directly through the hole in the root apex. To clarify, apical type periodontitis is most often the result of unbaked pulpitis. Due to the lack of proper treatment, the pulp becomes inflamed and its tissues decay.

With marginal periodontitis, inflammation begins directly from the edge of the gum itself. There can be several reasons for this inflammation:

1. gum injury. This reason is the most common. Injury to the gum can be in various situations. For example, you have bitten on a hard object, chewed on nuts, tried to hold hard objects with your teeth, or received a hard blow during sports or outdoor games.
2. Allergy. Allergies rarely lead to periodontitis. But it happens that an allergic reaction to certain medications occurs, which can provoke inflammation of the gum margin.

In this case, the tissue can be destroyed and deformed to varying degrees. In the inflammatory process of periodontium, the following types are distinguished:

1. Purulent.
2. Serous.
3. Granulating.
4. Granulomatous
5. Fibrous.

We will consider in detail each type, but we will focus on granulating and granulomatous in most detail.

As the disease progresses, the bone near the top of the tooth root will eventually dissolve. At the same time, a cavity begins to form. It is filled with granulations, pus accumulates. When the suppuration process intensifies, pus either breaks out on its own (a fistula appears), or the granuloma grows, forming a cyst.

Clinical manifestations of periodontitis can be different. Depending on their intensity, stages are distinguished:

1. acute;
2. chronic.

So how can you recognize periodontitis? If you feel severe pain while biting, then most likely it is periodontitis. We emphasize that pain appears only with pressure on the tooth, and, accordingly, on its root and gum. Often the pain develops into an attack, which has a tearing character. This is a clear signal of acute periodontitis. At the beginning of the disease, pain appears only when there is a load on the teeth, for example, when chewing. Well, over time, when the disease intensifies, the pain begins to manifest itself. Seizures become longer. If we talk about sensations, then for many patients it seems that the tooth has simply increased in size. There may be other symptoms as well. The lymph nodes can swell quite strongly. If the form of the disease is more severe, then the temperature increases. If chronic periodontitis becomes aggravated, then the picture of its manifestation is identical to acute periodontitis. That is why it is important to contact a specialist as soon as possible. Only he can determine what specific form of periodontitis you are facing and how to cure it as soon as possible. To do this, an x-ray is taken, which shows the state of the tooth root.

How does chronic periodontitis proceed? In the classic chronic form, the patient does not observe any clear manifestations. This is why the chronic form is dangerous. A person does not seem to experience acute pain, but at this time the mechanism of the inflammatory process is already in full swing. The chronic form is dangerous for its complications. It can go into periostitis or osteomyelitis of the jaw. Dangerous complications such as abscess and sepsis can also occur. With chronic manifestation of periodontitis, patients almost do not feel any pain. Only during biting can there be a slight soreness or just discomfort. Therefore, it is important to carefully listen to your subjective feelings. Is there numbness in a certain area of ​​the gum or jaw? Is the mucosa slightly swollen or redder? An incomprehensible fistula has formed on the gum? Urgently seek the help of a dentist, as these symptoms can be signals of periodontitis!

So, let's sum up a little before considering in detail the symptoms of acute and chronic periodontitis. Inflammation of tissues in the slit-like space, which is limited to the roots of the teeth and the alveolus, is called periodontitis. Most often, the cause of its appearance is an infection due to the fact that the gums were injured or poisoning with medicines occurred. The most striking manifestation is characteristic of the acute form of this disease. It is especially painful when pus is actively accumulating. But in the chronic form, destruction occurs much more slowly. It is accompanied by less pronounced sensations.

Stages of periodontitis

Healthy gums hold the teeth firmly in place. Periodontitis develops in several stages.

1. There is bleeding and slight swelling of the gums. Most often, this result is caused by ordinary plaque on the teeth. If it is not removed carefully enough, it turns into tartar and accumulates in the spaces between the teeth. Plaque contains aggressive enzymes and toxins that irritate the gum tissue. Gingivitis begins to show.
2. Periodontal pockets appear. The cause of their occurrence is hardened plaque on the teeth. On the roots of the teeth, their necks begin to be exposed. They become extremely susceptible to any influence of external factors: chemical, physical, mechanical. That is why it is important to visit the dentist twice a year. If he detects a stone on his teeth and removes it in a timely manner, this will save you from many diseases.
3. If the patient has not received adequate treatment, then periodontitis progresses. Bone and connective tissue are severely destroyed. This is a direct path to tooth loss.

How does acute periodontitis manifest?

First of all, the feeling that the gums constantly ache and ache even with slight pressure on the tooth area should alert. During palpation by a dentist, such pain makes itself felt. And the patient himself encounters it in the process of eating. In this case, the place where it hurts is quite accurately determined. During the development of periodontitis, there is a feeling that the tooth is growing. By its origin, periodontitis most often has the character of carious. As the periodontium is destroyed, the pulp ceases to function. This is easy to determine by the lack of reaction at the site of the lesion to a thermal stimulus.

There is also non-carious periodontitis. In this case, the crown of the tooth is not damaged. In this case, the symptoms will be as follows: at the site of the lesion, the filling of blood vessels increases. This manifests itself in the form of swelling and redness. For this type of periodontitis, this symptomatology is not considered specific. But it is these symptoms that help determine the place of development of the disease.

The gums can also swell with carious periodontitis. This happens at the moment when the serous exudate turns into purulent. Due to the fact that the disease develops, the cheek and lip begin to swell on the side where periodontitis develops. The patient is worried about tearing severe pain, which appears already without any external influence. It becomes almost permanent. There is swelling and soreness of the lymph nodes under the lower jaw. The temperature rises (up to 37.5). There is some movement of the tooth. During a clinical examination, the dentist will find purulent discharge.

With percussion (tapping of the tooth), the patient also feels severe pain. If periodontitis is located near the top of the tooth, then the reaction will follow a vertical percussion. But cervical periodontitis is more responsive to lateral percussion.

How does chronic periodontitis manifest?

Chronic periodontitis makes itself felt with much weaker signs. Very often it can be detected only by taking an x-ray. In this case, the periodontium can be affected in varying degrees and forms. Based on such differences, the following types of chronic periodontitis are distinguished:

1. fibrous;
2. granulating;
3. granulomatous.

With fibrous periodontitis, the course is almost asymptomatic. The main thing that should alert is the fact that the tooth has changed in color. But only an X-ray taken will give complete confidence. On the radiograph, it will be noticeable that the periodontal fissure has become deformed, the root apex has become thicker, the bone tissue has partially sclerosed in the wall of the alveolus, which directly surrounds the area where the inflammation began.

Chronic granulating periodontitis has such symptoms. During pressure on the tooth, pain periodically appears. Also, the tooth can react painfully to hypothermia, the gums turn red and swell. Often you can see the appeared fistula. On an x-ray, the doctor will detect a sufficiently strong destruction of bone tissue, this defect will not have a clear border.

Chronic granulomatous periodontitis makes itself felt with a feeling of some bursting in the jaw area. This is due to the fact that a granuloma is formed. Then it can develop into a cyst. Very often, this type of periodontitis occurs due to the fact that the filling of the tooth was performed poorly. On x-ray, the doctor will find that the bone tissue is damaged. But at the same time, the boundaries of the damage will already be clearly visible. They will take on a spherical shape.

Forms of periodontitis

Let us now dwell in more detail on the forms of periodontitis. In dentistry, the following forms are now distinguished:

1. Exudation and intoxication as a result of acute periodontitis.
2. Complex form and simple in the development of chronic periodontitis.

The form of intoxication is manifested by a feeling of discomfort. It appears only in the place where the diseased tooth is located. Small discharges are observed. They can be bloody and (or) serous. The gum tissue does not change in color or volume. This is a very short period, which takes place in two days. In the second period, pus appears. Due to the fact that it accumulates, there is severe pain. The periodontal fibers are separated. There is a violation in the distribution of the load on the tooth. Visually, you can observe signs that the gum has become inflamed. At the same time, a lot of pus accumulates, which wants to come out. Pus can exit through the root canal. If he did not find it, then the pus goes into the bone tissue, the periosteum, or into the soft tissue.

With chronic periodontitis, a simple form will manifest itself in different ways. It depends on the nature of the damage that the periodontium received (granuloma, fibrosis). With a simple form, aching pain may disturb. She makes herself felt both during meals and after it. A rather acute painful reaction is manifested to percussion. Gingivitis may appear or just the gums may turn red, swell. There are also forms that occur with little or no pain. In places, even sensitivity to various stimuli disappears.

With a complex form, the same symptoms are observed as described above, but the periodontal gap is expanded. Because of this, the tooth becomes mobile. Vertical resorption of the bone is also observed, pockets are formed inside it.

Periodontitis granulomatous

Our body fights infection in all sorts of ways. In the event that periodontal infection occurs, the body tries to protect itself from the infection and encloses it in a special capsule. This protective capsule is called a granuloma. It appears so that the infection and toxins do not spread further. This type of inflammation is called granulomatous periodontitis. It appears on those teeth in which the root system is fully formed.

What is this granuloma. It consists of fairly young connective tissue fibers. They have blood vessels. A granuloma is capable of pushing the body to fight infection by its appearance. When the immune system detects its presence, it turns on its protective functions. Over time, strands appear on the epithelium of the granuloma. But the granuloma carries a danger. It can turn into a cyst, and it can push back bone tissue and provoke its decay. Because of this, there is a real threat that the tooth will fall out. Even a fracture in the area of ​​\u200b\u200bthe bone can occur. If for some reason a granuloma opens, suppuration begins, fever, headache appear. Pain intensifies at the inflamed area. This is a very serious process that can be followed by an abscess, and even infective endocarditis.

Flow features

Granuloma arises and develops rather slowly, because granulomatous periodontitis practically does not make itself felt with any symptoms. When the capsule grows to a large enough size, the person feels like a tooth is swelling inside his gum. At this time, pain appears with each biting. Infrequently, the enamel may also darken and a fistula may appear. When the load increases, the tooth becomes more sensitive.

At this stage, the radiograph will clearly reveal the defect in the periodontal area. The focus of inflammation itself will have a round or oval shape. Its diameter can be up to half a centimeter. The boundaries will be clear. Destruction in the bone tissue near the granuloma is most often not observed. Sometimes a layer near the granuloma can become sclerosed. It isolates healthy bone tissue from the granuloma. This is clear evidence that inflammation has been developing for quite some time. Resorption of the root apex near the granuloma is practically not observed.

Granulomatous periodontitis can occur both on carious teeth and already sealed ones. If there is a carious cavity, it often does not communicate with the cavity of the tooth. When tapping, the doctor will find a weak degree of sensitivity. And with temperature irritants, it will be absent. There will also be no reaction to probing. There may be slight redness at the site of inflammation, but more often it occurs in the later stages. Also, the doctor will establish increased electrical excitability. This is a characteristic feature of any type of periodontitis. The lymphatic system will not react with this form.

How to treat

Granulomatous periodontitis is treated for three visits to the dentist. For the first time, the doctor will clean the prepared tooth with tools and take antimicrobial measures. At the end, a paste for a temporary filling or a disinfectant turunda is injected into the root of the tooth. In the second session, you will need to open a hole at the top of the root in order to exude. In this case, antibiotics, antiseptics and enzymes are used. It is important that the doctor does not use too strong medicines. They slow down the periodontal recovery process.

In the treatment of such periodontitis, hyposensitizing drugs are also used. This is due to the fact that due to the granuloma, allergic sensitivity is growing. In addition, other medications are also prescribed. The doctor must use drugs in the treatment that inhibit the growth of granulomas and have a regenerative effect.

At the third session, if the exudation is completed, the doctor will obturate the root and place a filling. If a cyst has been found, it must be therapeutically or surgically removed. It all depends on its size. If it is small, removal can be done non-surgically.

Periodontitis granulating

Its essence lies in the fact that due to the growth of granulation tissue, the periodontium is deformed. In this way, the body tries to fight the source of infection. This is the result of healing. The most common cause of its occurrence is infection with bacteria. Through the hole in the apex of the root, they penetrate into the periodontium, affecting it. This is the result of severe caries damage, in which the infection penetrates the pulp. Granulations are formed and begin to actively grow. At the same time, they destroy the alveolar process, breaking through. This opens a channel through which pus comes out. There may be several such fistulas. Microbes can easily pass through them. So the disease becomes chronic. If the fistula closes, granulating periodontitis worsens, severe pain appears, soft tissues swell at the site of inflammation.

Flow features

Dull periodic pains appear in the gum area. They appear randomly. This is a clear symptom of granulating periodontitis. During chewing, biting, contact with cold, tapping on the tooth and a cold, pain is most often manifested. The tooth becomes slightly mobile. Obvious symptoms of granulating periodontitis:

1. Bad smell;
2. Purulent discharge;
3. fistulas;
4. Redness of the mucosa.

At the site of the fistula, the mucous membrane becomes thinner. If the channel is closed to allow outflow, a scar appears. When an infection enters the adipose tissue, an infiltrate is formed.

When examined by a dentist, it is found that there is no reaction of the carious cavity to the probe, as well as the mouths at the roots. With vertical percussion, a slight soreness is observed. The threshold of the electrical excitability index will be high (100 μA or more). If the doctor presses the probe on the gum area, he will find that the mucosa is first pale, and then it turns red for a while. This reaction is called vasoparesis syndrome. On the radiograph, it will be found that the upper zone of periodontitis and the bone tissue that is adjacent to it are damaged. The defect will have fuzzy boundaries. The patient will complain of headaches, poor appetite, lethargy and irritability. These are all clear symptoms of intoxication. Lymph nodes are often enlarged.

When probing, the doctor can find the internal strand. This is the result of the formation of a fistula, around which the connective tissue is significantly compacted. This strand is called a "migratory granuloma", since the purulent openings periodically close and appear in new places. Fistulas can appear even on the face, at the bottom of the neck. Outwardly, it will resemble subcutaneous actinomycosis.

How to treat

Granulating periodontitis is well treated. There is every chance to make the process reversible. But it is important to consult a doctor in time, who will eliminate the source of infection that has appeared. During treatment, the following activities are performed:

1. the tooth is being prepared for the disinfection process;
2. roots are cleaned of bacteria;
3. special medicines are administered to restore the bone;
4. root canals are cleaned;
5. an insulating medical pad is applied;
6. a filling is placed.

So, we have tried to provide the most complete information about the two types of periodontal disease - granulating and granulating. Take care of the health of your teeth, gums, and be healthy!

Yet

Periodontitis is an infectious disease characterized by the accumulation of purulent masses in the apex of the tooth root.

Usually this disease is the result of poorly cured pulpitis or caries. One of them is granulomatous periodontitis. What is this disease, how is it recognized and can it be cured?

Forms of the disease

The body does its best to resist the spread of infection throughout the body. Moreover, the disease in question is one of those in the fight against which immunity is practically powerless.

Periodontal itself prevents the spread of infection. It creates a kind of bag in which all the pus accumulates. For a while, this becomes a reliable barrier to the spread of pathogenic microorganisms.

Depending on the size of this purulent sac, there are three forms of granulomatous periodontitis:

• granuloma (the size of the formation does not exceed 0.5 cm);
• cystogranuloma (pouch from 0.5 to 1 cm);
• cyst (more than 1 cm).

The cyst can grow up to 4-5 cm. This is due to an increase in the amount of pus in the sac due to the constant activity of bacteria. If the neoplasm is located on the lower jaw, then over time, the bones may be displaced, and sometimes it comes to their fracture. When the sac is located on the upper jaw, the consequences can also be very deplorable - pus risks getting into the maxillary sinus, which often leads to the death of the patient.

One of the main dangers is the possibility of rupture of the bag with pus. After that, the infection enters the bloodstream, quickly spreads throughout the body and causes a general infection. The worst of the consequences of such a development of events is death.

Read about why the tooth reacts to cold in this.

Causes

This disease comes from pulpitis or caries. If you do not get rid of these pathologies within a short time, then the amount of pus in the apex of the tooth root becomes large, periodontitis is formed. There are several permanent foci of inflammation that "poison" the body. Over time, dense borders appear at these foci, the so-called sac is formed. But this is not the only cause of granulomatous periodontitis.

It may occur due to:

• an allergic reaction to any medication;
• trauma;
• improperly selected orthodontic structures, such as braces.

Provoking factors that increase the risk of developing the disease include a lack of vitamins, problems with the endocrine system and immunity, as well as malocclusion.

Smoking, oddly enough, is a provoking factor in granulomatous periodontitis. It weakens the body as a whole, making it vulnerable to the pathogenic effects of microorganisms.

Symptoms

The difficulty lies in the fact that there are no clear signs of this disease, most often it is asymptomatic. This circumstance makes diagnosis and treatment somewhat difficult.

However, the disease can be recognized by some signs:

• The affected tooth changes color. It becomes yellowish.
• In a tooth that is susceptible to infection, fillings fall out. This is due to the growth of the cyst and tissue deformation.
• While chewing food in the area of ​​​​the diseased tooth, discomfort occurs. It can be expressed as pain, and a pressing sensation.

By the way, the feeling of squeezing is one of the additional symptoms of the disease.

However, with an exacerbation of the disease, the symptoms become bright. It practically coincides with the signs of acute periodontitis: severe pain localized at the lesion. In this case, the pain subsides somewhat if you press on the aching tooth. There is no swelling, but the tooth may lose stability, which distinguishes this form of the disease from the acute one.

On palpation, a cyst can be detected only if it is displaced. If the dislocation of the neoplasm is under the roots of the tooth, then it will not be possible to feel it tactilely.

Diagnostics

The basis for the detection of granulomatous periodontitis is the collection of anamnesis. The doctor should know that there used to be severe pain, the gums were swollen, and at the same time there was discomfort when cold or hot was applied to a specific place.

Now this is gone, the pain is gone, there is a feeling of squeezing. If the doctor sees a tooth with a changed color that has lost stability, then the diagnosis is practically established.

But doctors never start treatment without clarifying their assumptions. To confirm such a diagnosis, an x-ray of the affected tooth should be taken. The image will clearly show a spherical formation in the form of a shadow. It can either be in contact with the root of the tooth, or look like a “cap”. At the same time, at advanced stages, an x-ray will show changes in bone structures. This indicates the onset of complications and high risks of cyst rupture. Treatment must begin immediately!

The difficulty lies in the fact that the patient rarely experiences discomfort, the disease proceeds secretly. As a result, people seek help late, which leads to serious damage to the jaw bones and general blood poisoning.

Exacerbation of granulomatous periodontitis

The disease is also dangerous because it often worsens. And it happens abruptly and unexpectedly. A person begins to feel severe pain in the area of ​​the affected tooth. The reaction to pressure is different: pain can both subside and increase many times over. An inflammatory process may occur, for example, general weakness, fever, headache and nausea with vomiting.

Aggravating factors include:

• additional infection;
• hypothermia;
• impact or compression in the area of ​​​​the diseased tooth;
• strong emotional shock.

Treatment of exacerbation is achieved by removing the tooth, but this can be avoided. To save the organ, the accumulated pus should be removed, further therapy follows the classical scheme.

One of the signs of an exacerbation of the disease is an increase in the lymph nodes closest to the affected area. And often they start to get sick. Sometimes this is the only symptom of an exacerbation. In this case, the diagnosis is carried out using x-rays.

Treatment and prevention

There are two main treatment regimens for granulomatous periodontitis.

The choice rests entirely with the doctor. It depends on the individual characteristics of the patient:

• age;
• general health;
• tolerance to certain medications;
• root canal patency.

If the pus sac is small and there is little or no bone damage, then surgery may be avoided.

conservative method

The method consists in antiseptic treatment of root canals and removal of pus from them. First, the doctor expands these channels and injects a drug into them that destroys harmful microorganisms. Also, this medication destroys the granuloma shell, accelerating the regeneration of damaged bone. Such therapy is possible only in the initial form of the disease.

The main drug used is Metapeks.

Surgical method

If the neoplasm is too large or has already managed to turn into a cyst, then surgical intervention cannot be avoided. Such treatment of granulomatous periodontitis consists in resection of the apex of the tooth root. Moreover, if more than a third of the organ is subject to the procedure, then it would be more rational to completely remove the affected tooth, followed by cleaning the hole.

The steps of the operation are as follows:

• the doctor gives anesthesia (local);
• an incision is made directly on the root, after which a flap of gum tissue is folded back;
• a “window” is cut into the bone with a special file, through which the protruding parts of the root are removed;
• the bone cavity is scraped, after which it is filled with special materials;
• sutures are placed on the mucous membranes.

After the operation, severe pain may occur, but they are easily stopped by classical anesthetics, and they disappear quite quickly.

Prevention

The main way to prevent the development of granulomatous periodontitis is the timely treatment of other dental diseases. In this case, there will be no initial ailment, from which the disease in question grows.

Also follows:

• follow the rules of oral hygiene;
• take care of maintaining immunity;
• Get regular check-ups with your dentist, even if you don't have any problems with your teeth.

At the same time, one should go to the doctor at the first signs of the disease, for example, if pressure and the feeling of a “grown tooth” are clearly felt.

Granulomatous periodontitis is an infectious disease of the oral cavity, leading to damage to the jaw bones and general blood poisoning.

The reason for the development of the disease is untimely or poor-quality treatment of pulpitis or caries. The disease can develop asymptomatically, making it difficult to diagnose.

The basis for the detection of pathology is the collection of anamnesis and x-rays. Treatment can consist both in cleansing the root canals from pus, and in the complete removal of part of the root system or the entire tooth. To prevent the disease, it is enough to treat other dental ailments in a timely manner and visit the dentist regularly for examination.

Related video

This is one of its main differences from, in which the destruction zone is not clearly encapsulated and can quickly increase.

By danger, granulomatous periodontitis is located between fibrous and granulating. The first is the most stable and safe, the second is the most dynamic and destructive.

Causes and features of development

Granulomatous periodontitis is the result of a granular process or develops independently. As already noted, the main feature of the granulomatous process is that the area of ​​inflammation is enclosed in a fibrous capsule with a dense wall. This prevents the spread of infection from the diseased tooth to other organs and tissues. There is a kind of balance between the pathogenic microflora, concentrated in, and immunity.

At the location of the granuloma, the bone tissue of the tooth or alveoli is usually destroyed to some extent. It looks good on . The focus of destruction has a clearly defined oval or round shape. A compacted rim is formed around it - the result of osteosclerosis.

Chronic granulomatous periodontitis sooner or later leads to the destruction of the cementum of the root and dental crown, and their gradual replacement by deposition in the form of a club crowning the top of the tooth. In appearance, the granuloma looks like an oval or round sac with a dense smooth shell, which is firmly attached to the roots.

Variety of forms

Forms of periodontal inflammation differ in the phase in which they are (remission or exacerbation), as well as the shape and size of the lesion (, cystogranuloma or). The difference is as follows:

1. Granuloma appears at the beginning of the inflammatory process, and is a small (up to 0.5 mm) capsule-shaped focus of infection, isolated from the surrounding tissues by a dense membrane.
2. Cystogranuloma- This is a formation 5-10 mm in size. Its important feature is the presence of epithelial cells lining the inner surface of the granuloma. Increased acidity is created inside it, destroying existing bone tissue and preventing the regeneration of a new one.
3. Cyst- This is a fully formed, fluid-filled cavity formation larger than 1 cm with a mucous membrane. Inside it there are cholesterol crystals. Their detection in the exudate (when a cyst ruptures or exits through a fistula) during differential diagnosis speaks in favor of a granulomatous process.

Features of the clinical picture

In remission, granulomatous inflammation proceeds in a latent form and does not bother the patient, who sees no reason to consult a doctor. In the absence of complications, which are relatively rare, granulomatous periodontitis is often

The photo shows that on x-ray the granuloma looks like a ball

discovered by chance with another disease. Fistulas, as a rule, are not formed.

With exacerbations, granulomatous periodontitis resembles or exacerbated granulating. Severe pain appears, swelling of adjacent tissues occurs, it is noted that intoxication of the body increases.

When pressing on a diseased tooth, increased pressure is created in the cyst, which can lead to a violation of the integrity of the capsule, the release of pus into the underlying tissues and the spread of infection.

Symptoms of the chronic and acute stages of the process

In the chronic course of the disease in remission, there is a relative balance between the body's defenses and infection localized in the cyst, which is disturbed during exacerbation.

The latter can occur when the destructive process is activated due to a decrease in immunity. In this case, it is possible to melt the bone structures under the action of the contents of the cyst, the capsule may rupture and infection of neighboring tissues with pus may occur.

With complications, the size of the basal cyst and the zone of destruction can be so significant that there is a danger of a jaw fracture even with a minor injury.

Diagnosis and differentiation from similar processes

Diagnosis occurs on the basis of the clinic and hardware diagnostic data.

When questioning the patient and the initial examination, the presence of pain, its nature and time of occurrence are established. A symptom that speaks in favor of granulomatous periodontitis is an increase in pain when biting. Examination of a diseased tooth allows you to establish a change in its color, the presence, hyperemia.

If there is a cyst on the surface of the jaw, a slight bulge may be palpated. Probing with granulomatous periodontitis is painless, the reaction to heat and cold can be both positive and negative. Questioning the patient about the time of occurrence of discomfort or pain allows you to establish an acute or chronic nature has a destructive process.

The main hardware method for diagnosing periodontitis is. She is able to answer almost all questions. In the granulomatous form of the disease, the radiograph shows a shading zone with a rounded configuration with clear outlines in the apex zone.

Radiography is the most informative method in differential diagnosis. The focus of destruction in granular periodontitis does not have a clearly defined contour, and in fibrous, only the expansion of periodontium is recorded.

It is characterized by large zones of destruction, which are located outside the apex zone. and the X-ray does not show any changes in the periodontium at all.
Diagnosis is indeed a very important stage of the whole complex of treatment:

dental care

Treatment of granulomatous periodontitis depends on the type and size of the granuloma, the condition of the dental canals (passable or not), as well as the state of the patient's immunity. If the destruction of bone structures is not critical, and the body resists inflammation well, conservative treatment is carried out.

• destroyed tooth structures are removed - necrotic pulp, infected dentin from the walls of the canal;
• pathogenic flora is destroyed with the help of antiseptic preparations introduced into the canal;
• the regeneration of damaged bone structures is activated by the introduction of appropriate drugs into the tooth;

An effective drug with a bactericidal and regenerating effect is having a pH of 12.5. During the day, it destroys 90% of pathogenic microflora and stimulates the formation of osteoblasts, from which osteocytes (normal bone tissue) are subsequently formed.

Actions in case of exacerbation

The first action in an exacerbation is to block the pain. Then the exudate is removed from the cyst or granuloma and prescribed. Further therapy is determined by the form of granulation formation - granuloma, cystogranuloma or cyst.

Surgical treatment

If conservative therapy is not possible, surgical treatment is performed, which consists in partial or complete removal of the tooth. Usually performed as a tooth-saving operation. Access to it is made from the side of the gum (a window is cut in the alveolar plate). The affected root tip is cut off, the resulting space is filled with a material that regenerates bone tissue.

If the size of the granuloma is such that more than 1/3 of the root is required to be removed, resection is abandoned and the tooth is removed completely.

Consequences and preventive measures

The consequences of granulomatous periodontitis primarily depend on the timeliness of contacting a doctor and the correctness of treatment.

With proper conservative treatment of the disease in the stage of granuloma or cystogranuloma, inflammation passes into a fibrous form and ceases to disturb the patient. The tooth is preserved as a functional unit.

If the visit to the doctor was delayed, and the granuloma developed into a cyst, the tooth must be removed. In the worst case, the cyst spreads to the roots of adjacent teeth, which, depending on the degree of damage, will require appropriate treatment.

The best prevention is to visit the dentist every six months. It is recommended to do this even if the teeth do not bother. The dentist will detect the disease at the earliest stages, if necessary, send for x-rays.

Measures to prevent the development of periodontitis include:

• correct and daily;
• timely treatment and;
• fight with;
• to give up smoking;
• keeping a healthy diet.

With regard to the latter, the best food for maintaining healthy teeth are hard vegetables and fruits, which provide a significant and uniform load on the dental apparatus.

Granulomatous periodontitis is a disease that affects the membrane of the tooth root and is characterized by the appearance of granulomas. The resulting capsule serves as a barrier between healthy tissue and inflammation. The problem is that the disease is characterized by a sluggish course, and external signs appear only during exacerbation. Consider what methods are used to treat the disease and what ways you can prevent its development.

Causes and symptoms of granulomatous periodontitis

Granulomas that form in tissues due to inflammation change over time. There are three forms of formations containing pus:

• granuloma with a sac 0.5 cm in diameter;
• cystogranuloma - 0.5–1 cm;
• cyst - from 1 to 4-5 cm.

The disease most often develops against the background of caries or pulpitis, but it can also occur for other reasons:

The development of chronic periodontitis is almost asymptomatic. Only the acute stage of the disease, which occurs under the influence of various factors, causes concern, but it does not manifest itself in every patient. Most people learn about the disease at the next examination at the dentist. An acute inflammatory process is characterized by signs:

• feeling of fullness and swelling of tissues;
• mild pain in the jaw;
• enlargement of the adjacent lymph node;
• pain in the gums when chewing;
• discoloration of tooth enamel to yellow;
• filling loss due to tissue deformation and cyst growth;
• bad breath.

In the chronic stage, only a short-term increase in the sensitivity of the diseased tooth is possible, which soon disappears. On palpation, a small seal is felt in the jaw or on the gum.

The disease is dangerous because often there is an exacerbation that occurs unexpectedly. A person feels severe pain, which, when pressed, can subside or intensify.

The tooth may begin to wobble, but there will be no swelling - this is the main difference between the acute stage and the acute inflammatory process.

The provoking factors are:

• decreased immunity;
• hypothermia;
• emotional shock;
• a blow to the area of ​​\u200b\u200bthe diseased tooth;
• additional infection.

Methods for diagnosing the disease

Diagnosis of chronic periodontitis in the early stages of development can be difficult due to the lack of symptoms. A dentist can suspect a disease only if there are complaints from the patient and externally visible changes - a large carious cavity and a yellowish tooth. If a cyst is present, a small ball may be felt.

The main way to diagnose granulomatous periodontitis is radiography, in which changes become clearly visible in the picture:

• the center of destruction has the shape of a circle;
• darkening in the region of the root, which indicates bone destruction;
• the cyst provokes the divergence of the teeth.

Features of the treatment of granulomatous periodontitis

Treatment of granulomatous periodontal inflammation is prescribed based on the size of the formation, the state of the patient's immunity and the canals of the tooth. With a small capsule size and good patency of the dental canals, conservative therapy is used. It includes several stages:

• Manual processing of canals and disinfection using an antiseptic.
• Filling the channel with a special substance with lime and iodoform. For treatment, Metapeks is often used, which helps to destroy pathogenic microorganisms and restore the activity of cells that are responsible for bone regeneration.
• At the last stage, the dentist fills the canals of the tooth. Then the doctor prescribes antibacterial drugs for home treatment.

To prevent complications of periodontitis, antibiotics Amoxin, Augmentin or Flemoxin are prescribed. If the funds are ineffective, the specialist prescribes Sumamed or Hemomycin.

With granulomatous periodontitis with a large neoplasm (more than 1 cm) or in the presence of a purulent cyst, surgical treatment is performed. If the tooth can be saved, the doctor opens the cystic bladder and removes the purulent exudate. An operation to resect the root apex can also be performed:
(we recommend reading: resection of the apex of the tooth root: what is it and how is it performed?)

• anesthesia is applied;
• a gum incision is made and a part of the bone is sawn out to gain access to the neoplasm;
• part of the root is removed;
• the bone cavity is filled with osteoplastic material to stimulate bone growth.

This type of intervention in the presence of granulomatous formation has good efficiency, however, it is resorted to in exceptional cases, since severe tissue injury occurs during the operation. For patients with weakened immune systems, as well as diseases of the heart and nervous system, it is safer to completely remove the tooth. Indications for extraction also include:

• severe destruction of the unit crown;
• tooth mobility of 3–5 degrees;
• pathological changes in education.

Complications and prevention

Chronic granulomatous periodontitis is a dangerous disease, since the granuloma can develop into a cyst, which over time pushes back the bone tissue and provokes tooth loss. If left untreated, other consequences are possible:

To prevent the development of periodontitis, it is necessary:

• take proper care of the oral cavity;
• stop smoking;
• carry out professional cleaning to remove tartar;
• adhere to a healthy diet and eat solid vegetables and fruits, allowing you to evenly distribute the load on the teeth;
• timely treat diseases of the oral cavity;
• avoid damage to soft tissues;
• visit the dentist twice a year, which will allow early detection of the disease.

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Periodontium- part of the periodontal tissue complex, represented by highly differentiated connective tissue, which is located in a closed space between the compact alveolar plate and the cementum of the tooth root. Periodontitis is an inflammatory disease of the periodontium.

Classification

Periodontitis is classified by origin:

• infectious;
• traumatic;
• medical.

By clinical course:

• spicy;
• chronic.

Acute periodontitis occurs in two phases:

• intoxication;
• pronounced exudation.

Chronic periodontitis according to the nature and degree of damage to the periapical tissues is divided into:

• chronic fibrous;
• chronic granulating;
• chronic granulomatous;
• chronic in the acute stage.

Etiology

The main reason for the development of periodontitis is infection, when microorganisms, their toxins, biogenic amines coming from the inflamed and necrotic pulp, spread into the periodontium. The cause may also be a tooth injury resulting from a bruise, dislocation, fracture (with untimely treatment).

Periodontal damage is possible during treatment (excessive removal of filling material beyond the top of the tooth root, trauma with the instrument when expanding the root canal, chemical irritation - arsenic preparations, phosphoric acid, etc.).

Pathogenesis

Biologically active components and chemicals cause a sharp increase in vascular permeability, swelling and infiltration increase. Microcirculation is disturbed, thrombosis, hyperfibrinolysis and secondary hypoxia are observed, which leads to depolymerization of the main periodontal substance. Hypoxia increases, trophism is disturbed, all five signs of inflammation appear. The fabric becomes permeable due to the formation of voids in the base substance, i.e. its main function is not fulfilled - protective.

Clinical signs and symptoms

Acute periodontitis

Phase of intoxication: complaints of constant localized pain of varying intensity, aggravated by biting, are characteristic. Percussion of the causative tooth is slightly painful. Exudation phase: characterized by complaints of continuous pain, a feeling of a "grown" tooth, pain when biting and touching the tooth. Percussion is painful in all directions, the tooth is mobile. The cavity of the tooth is opened or not opened, but when it is opened, necrotic decay of the pulp is observed, the mucous membrane of the gums is hyperemic, edematous, palpation is painful. The serous phase of acute periodontitis can turn into a purulent one.

Chronic fibrous periodontitis

Usually no complaints. Objectively, there is a change in the color of the tooth; the dental pulp is necrotic, EDI is 100 or more μA.

Chronic granulating periodontitis

It is characterized by an asymptomatic course, but with a careful history taking, it turns out that the tooth was previously sick. In the cavity of the tooth and root canals, the decay of the pulp is determined. A putrid odor is characteristic, sometimes there is pain in the area of ​​the apex of the root canals and bleeding, which is explained by the growth of granulation tissue through the resorbed apical foramen. A fistulous tract may be observed on the gum, EDI exceeds 100 μA.

Chronic granulomatous periodontitis

It is characterized by an asymptomatic course. Often there is a deep carious cavity, filled with necrotic dentin, with the decay of the pulp - a putrid odor, EOD - more than 100 μA. Regional lymph nodes are enlarged, their palpation is painful.

Exacerbation of chronic periodontitis

Characterized by localized continuous aching pain when touching and biting on the causative tooth. Possible pathological tooth mobility II-III degree; the mucous membrane of the gums around the causative tooth is edematous, hyperemic. A fistulous tract with purulent discharge may be detected. Untimely treatment of the patient or delayed treatment contribute to the growth of the inflammatory process, the development of periostitis, phlegmon and osteomyelitis. The diagnosis is made on the basis of anamnesis, complaints of the patient, examination (presence of a destroyed tooth, fistula), X-ray data and EDI.

Differential Diagnosis

Acute forms of periodontitis differentiate:

• with exacerbation of chronic periodontitis;
• acute apical periodontitis in the phase of intoxication - with acute apical periodontitis in the phase of exudation;
• with acute diffuse pulpitis;
• with exacerbation of chronic gangrenous pulpitis;
• with acute odontogenic osteomyelitis;
• with festering periradicular cyst of the jaw;
• with periostitis;
• with a local form of periodontitis in the stage of abscess formation.

Chronic forms of periodontitis differentiate:

• between themselves;
• with medium caries;
• with chronic gangrenous pulpitis;
• with acute apical periodontitis in the phase of stopping the process.

Chronic periodontitis in the acute stage is differentiated:

• with acute apical periodontitis in the exudation phase;
• with a local form of periodontitis in the stage of abscess formation;
• with trigeminal neuralgia.

Treatment of periodontitis is aimed at eliminating the infectious focus, preventing sensitization of the body, the development of inflammatory processes in the maxillofacial region and infectious and allergic diseases of internal organs and systems.

The main objectives of the treatment of periodontitis:

• influence the microflora of root macro- and microchannels;
• eliminate the influence of biogenic amines, stop the inflammatory process in the periodontium;
• promote the regeneration of all periodontal structures;
• to stop the access of infection from the root canal to the periodontium.

For this you need:

• phased, under the cover of antiseptics, evacuation of putrefactive masses from the root canals;
• removal of necrotic tissues and predentin;
• expansion of the apical opening of the root canals and giving them a conical shape;
• filling of root canals.

The question of saving a temporary tooth and choosing a rational method of treatment should be decided individually, taking into account the age of the child, the state of the crown of the tooth, the root, the nature and spread of the inflammatory process, the involvement of the rudiment of the permanent tooth in the inflammatory process, as well as the state of health of the child. Application anesthesia is performed by the doctor before the injection. Conduction and infiltration anesthesia are performed by a doctor before manipulations.

For application anesthesia apply:
Benzocaine/glycerin topically 5/20 g before injection or
Lidocaine 2.5-5% ointment or 10% aerosol, topically before injection or
Tetracaine, 2-3% solution, topically before injection.

Instead of glycerin in a benzocaine solution, olive or peach oil can be used. For conduction and infiltration anesthesia, 4% articaine solution, 1-2% lidocaine solution, 2-3% mepivacaine solution and 2% procaine solution are used.

For pain and fever, non-narcotic analgesics and NSAIDs are used, which have analgesic, antipyretic and anti-inflammatory effects:
Ketorolac 10 mg orally 1-2 r / day, for pain or
Metamizole sodium/paracetamol/phenobarbital/caffeine/codeine PO 300mg/300mg/10mg/50mg/8mg, for pain or Metamizole sodium/pitofenone/fenpiverinium bromide PO 500mg/5mg/100mcg qid, for pain or
Metamizole sodium/triacetonamine-4-toluenesulfonate PO 500 mg/20 mg, for pain or
Paracetamol inside 0.2-0.5 g (adults); 0.1-0.15 g (children 2-5 years old); 0.15-0.25 g (children 6-12 years old) 2-3 r / day, with pain.

With a pronounced pain syndrome and a violation of the psycho-emotional sphere, tranquilizers are prescribed (after consulting a psychoneurologist):
Oral diazepam 5–15 mg 1–2 r/day, 4 weeks or
Medazepam inside 10 mg 2-3 r / day, 4 weeks.

For disinfection of root canals, antiseptic drugs are used:
Hydrogen peroxide, 1-3% solution, topically, 1-2 times or
Iodine / potassium iodide, solution, topically, 1-2 times or
Potassium permanganate, 0.02% solution, topically, 1-2 times or
Miramistin, 0.01% solution, topically, 1-2 times or
Chloramine B, 0.25% solution, topically, 1-2 times or
Chlorhexidine, 0.06% solution, topically, 1-2 times or
Ethanol, 70% solution, topically, 1-2 times.

In order to accelerate the cleansing of the purulent cavity, proteolytic enzymes are used:
Trypsin 5 mg (in isotonic solution of sodium chloride) topically, 1-2 times or
Chymotrypsin 5 mg (in isotonic solution of sodium chloride) topically, 1-2 times.

For the rehabilitation of the oral cavity, the destruction of the microflora of the root canals, antibacterial drugs are prescribed:Amoxicillin orally 20 mg/kg in 2-3 divided doses (children under 2 years of age); 125 mg 3 r / day (children 2-5 years old); 250 mg 3 r / day (children 5-10 years old); 500-1000 mg 3 r / day (children over 10 years old and adults), 5 days or
Amoxicillin/clavulanate orally at the start of a meal 20 mg/kg in 3 divided doses (children under 12 years of age); 375-625 mg 3 r / day (children over 12 years old and adults), 5 days or
Ampicillin orally 250 mg 4 r / day, 5-7 days or
Co-trimoxazole inside after meals 160 mg / 800 mg 2 r / day (adults); 20 mg / 100 mg 2 r / day (children), 14 days or
Lincomycin orally 250 mg 3-4 r / day, 5-7 days or
Roxithromycin inside 150 mg 2 r / day (adults); 2.5-4 mg / kg 2 r / day (children), 5-7 days.

In order to desensitize the body and reduce capillary permeability, antihistamine drugs are prescribed:
Clemastine inside 0.001 g (adults); 0.0005 g (children 6-12 years old) 1-2 r / day, 7-10 days or
Loratadine inside 0.01 g (adults); 0.005 g (children) 1 r / day, 7-10 days or
Mebhydrolin inside 0.05-0.2 g (adults); 0.02-0.05 g (children) 1-2 r / day, 7-10 days or
Hifenadine inside after meals 0.025-0.05 g 3-4 r / day (adults); 0.005 g 2-3 r / day (children under 3 years old); 0.01 g 2 r / day (children 3-7 years old); 0.01 g or 0.015 g 2-3 r / day (children 7-12 years old); 0.025 g 2-3 r / day (for children over 12 years old), 7-10 days or
Chloropyramine inside 0.025 g (adults); 8.33 mg (children under 7 years old); 12.5 mg (children 7-14 years old) 2-3 r / day, 7-10 days or
Cetirizine inside 0.01 g (adults and children over 6 years old); 0.005 g (children under 6 years old) 1 r / day, 7-10 days.

Evaluation of the effectiveness of treatment

Treatment is considered effective in the case of complete root canal filling with removal of a biologically active paste based on calcium hydroxide beyond the apical foramen. This gives grounds to count on favorable long-term results - the gradual elimination of the focus of rarefaction (tissue resorption). The results of treatment should be monitored according to x-ray data no earlier than 6-9 months, because. bone regeneration is slow.

Mistakes and unreasonable appointments

• Insufficient history taking.
• Incorrect assessment of the prevalence of the inflammatory process.
• Underestimation of pain syndrome.
• Misdiagnosis.
• Perforation of the bottom of the cavity of the tooth or the wall of the root canal.
• Incomplete or excessive opening of the tooth cavity.
• Broken instrument in the root canal.
• Incomplete filling of root canals.
• Excessive removal of the filling material beyond the apical opening and its penetration into the paranasal sinuses of the upper jaw or the mandibular canal.
• Irrational choice of antiseptic.
• The use of potent preparations for the treatment of root canals with a wide apical opening.

Forecast

With successful treatment of periodontitis, the prognosis is favorable: the tooth freely participates in chewing food, the patient does not experience pain, the radiograph shows that the root canal is completely sealed, there are no complaints, and the width of the periodontal gap is normalized. In the absence of positive dynamics, it is necessary to remove the periapical focus by removing the tooth, resection of the apex of the tooth root, etc. Persistence of a periapical chronic inflammatory focus can provoke the development and maintenance of a chronic septic condition and its associated complications.

G.M. Barer, E.V. Zoryan