Inflammatory periodontal disease

1. Inflammatory periodontal disease 가천의대 길병원 치과센터 보철과 나기원

2. Inflammatory periodontal disease • 세계 인구의 10-20%가 경험 • 그 중 40% plaque-induced periodontal disease • Gingivitis –아동, 청소년기 Advanced periodontitis – 30, 40대 • 대부분이 치아와 인접 조직의 microbial plaque에 의해 시작

3. Gingivitis • 치은의 표층 염증 • Redness, swelling, loss of stippling • 골소실, 동요도 X • Gingival swelling에 의한 pseudo-pocket

4. Types of Gingivitis • Acute traumatic gingivitis • Acute non-specific gingivitis • Acute hypersensitivity reations • Acute necrotising ulcerative gingivitis • HIV-associated gingivitis • Acute herpetic gingivostomatitis • Chronic marginal gingivitis • Chronic desquamative gingivitis

5. Acute traumatic gingivitis • Physical cause • Tooth brush trauma • Damage from sharp item • Hard food • Iatrogenic damage by bur and brush • Gingivitis artefacta :환자의 고의로 인해 발생한 손상 • Gingivitis artefacta major – psychiatric disorder • Gingivitis artefacta minor – innocent habit

6. Acute traumatic gingivitis • Thermal causes • Hot food • Dental cautery or overheated ultrasonic scaler • Chemical causes • Burns caused by the application of aspirin

7. Acute non-specific gingivitis • 기존에 존재하던 chronic gingivitis의 급성 악화로 인해 흔히 발생 • 전신 질환이 있을 때 숙주 저항성 감소와 관련 • 입술 피개 결여에 따른 상악 전치부의 노출 • 구호흡

8. Acute hypersensitivity reactions • 치약 성분(cinnamonaldehyde)에 대한 과민 반응 Allergic gingivitis • Common features • 부착 치은 전반에 걸친 광범위한 diffuse granular gingivitis • Oral ulcerations • glossitis and cheilitis • 조직학적으로 plasma cell infiltration

9. Acute necrotizing ulcerative gingivitis • necrotizing interdental ulcer • 인접 치은 조직으로 빠르게 확산 • Fusiforms, spirochetes 등으로 구성된 yellowish pseudomembrane 으로 덮여있음 • Painful, very sore to touch, halitosis • 전신적 발열, 피로를 동반한 림프절 부종 및 T/d • 급성으로 시작하나 adult-type periodontitis와 유사한 만성 상태로 쉽게 변한다

10. Acute necrotizing ulcerative gingivitis • Common predisposing condition • 18-20세 • 염증성 치주 질환 • Smoker • 조직 저항성을 낮추는 전신 질환, stress • HIV-infection • Microbiology • Fusospirochaetal complex of Bacillus fusiformis & Borrelia vincentii (Vincent 1898) • Vibrios, Bacteroides and Selenomonas species

11. HIV-associated gingivitis • HIV 감염 환자에서 보이는 acute form • 면역 결핍 때문에 dental plaque에 unusual or exaggerated response • Commonest symptom • HIV 감염 환자의 intense marginal gingivitis • ANUG와 유사한 ulceration

12. Acute herpetic gingivostomatitis • HSV infection • Type I : 청소년기, 성인에 흔함 • Type II : 성인에서 흔함(sexually transmitted) • Oral sign • Soreness of oral mucosa • Small vesicle ulcer surrounded by red halo • Marginal herpetic gingivitis • Systemic symptom • Malaise, fever and lymphadenitis • Dehydration

13. Chronic marginal gingivitis • Dental plaque • Initiate and maintaine gingivitis • Gram-negative anaerobic flora irritant metabolites destructive enzyme and antigen breakdown of gingival tissue • 대부분 symptomless, but… • 치은 출혈, 특히 양치 후 • 색 변화, 질감 변화(점몰 소실) • 형태, 경도 변화

14. Chronic desquamaitive gingivitis • 40-50대 여성에서 호발 • thin, poorly keratinized, red, sore gingiva • 가벼운 자극에 쉽게 벗겨진다 • 뜨겁고 자극적 음식에 쓰리다 • 대부분 dermatological problem • lichen planus or lichenoid reaction • BMMP 조직 저항성 약화 치은 성질 변화

15. Periodontitis • loss of attachment with bone loss by apical migration of junctional epithelium • Pocketing and/or recession • Mobility and drifting of affected teeth • Bleeing on deep probing • Pus formation lateral periodontal abscess • halitosis

16. Adult periodontitis • Commest type of periodontitis • Plque-induced damage • Break down slowly – probing depth 증가 느림 • Large amount of reparative fibrosis in the inflamed gingiva

17. Adult periodontitis • Clinical features • Loss of attachment – pocketing and/or recession • Bone resorption • Tooth mobility • Drifting • Suppuration from the active sites

18. Aggressive forms of periodontal disease • Prepubertal periodontitis • Juvenile periodontitis • Rapidly progressive periodontitis • Refractory periodontitis • Acute necrotising ulcerative periodontitis • HIV-associated periodontitis occur in younger age progress at a more rapid rate ∴ aggressiveor progressive disease

19. Prepubertal periodontitis • 사춘기 전 아동시기, 영구치 맹출 시기에 호발 • acute gingival inflammation • Gingival recession • Rapid destruction of alveolar bone • granulation or proliferation from active site epulide (gingival swelling) • Little known about microbiology

20. Prepubertal periodontitis • associated with systemic disease • Papillon-Lefevre syndrome • Insulin-dependent diabetes • Primary or acquired immunodeficiency • Leukemia • Hypophosphatasia • Histiocytosis X • Neutropenia • Chediak-Higashi syndrome • Agranulosytosis

21. Juvenile periodontitis • 청소년기 영구치 주위에 발생 • 11-13세, 여성 호발 • 제 1 대구치, 전치 • gingival inflammation : low breakdown : excessive • 가족력 및 유전적 경향 有 • Fuctional defect of neutrophil or monocyte • A.actinomycetemcomitans Capnocytophaga phagocytic function 억제 Toxin

22. Rapidly progressive periodontitis • Severe, generalized, rapidly advancing lesion • 25-35세 호발 • Porphyromonas gingivalis A. actinomycetemcomitans • Active phase • Acute inflamed • Proliferate granulomatous gingival epulides • Fuctional defects of neutrophil or monocyte • Systemic disorder Papillon-Lefevre syndrome Down’s syndrome Chediak-Higashi syndrome Insulin-dependent diabetes

23. Refractory periodontitis • Continued signs of inflammation, pus formation or pocket deepening depite active tx. • Common reason • Inadequate oral hygiene • Persistence of root surface deposits • Root surface defects • Inadequate host reponse • Unidentified systemic factor • Periodontic-endodontic lesions

24. Refractory periodontitis • Inadequate oral hygiene • Supragingival plaque에 한정 • Marginal gingiva에 염증이 없도록 관리 • Root surface deposit • due to difficulties with access, visibility or root contour • Root surface defects • Groove, flute, gingival pit enamel projection

25. Refractory periodontitis • Inadequate host response • Defects of PMNL of monocyte • Difficult to detect • Impossible to treat reduce the level of plaque • Unidentified systemic factor • Multiple active site, tissue highly inflamed plaque levels low hematological screening • periodontic-endodontic lesions • Perisistent periradicular infection Endodontic tx. + Periodontal tx.

26. Acute necrotizing ulcerative periodontitis • ANUG의 손상이 더 깊은 치주 조직으로 파급 • HIV infection으로 인해 host resistance가 감소시 발생

27. HIV-associated periodontitis • Manifestation • Inflammatory periodontal disease • HIV-associated gingivitis • ANUG, ANUP • Acute necrotizing stomatitis • Gingival ulceration associated with • herpes simplex, herpes zoster, human cytomegalovirus • Non-Hodgkin’s lymphoma • Kaposi’s sarcoma • neutropenia

28. HIV-associated periodontitis • intense marginal gingiva necrotic overlying soft tissue marginal bone exposure • deep pocketing • associated candidal infection

29. Acute periodontal abscess • not a type of periodontitis but a particular feature or symptom • Periradicular abscess와 감별하는 것이 중요 • history • clinical examination • vitality test • appropriate radiograph

30. Acute periodontal abscess • Main cause • Pocket에 인접한 connective tissue로 organism entry • SRP시 plaque, calculus 등이 pocket에 영향 • Impaction of foreign body • Blockage of a pocket with obstruction of drainage • Reduction of host resistance

31. Acute periodontal abscess • T/d to biting or percussion • Throbbing pain – relieved by pressure • Fluctuant swelling • Lymphadenitis, 체온 상승 • 보통 acute하나, 일단 drainage되면 abscess는 chronic해지고 증상도 감소