Periodontal Disease - Diagnosis - Established Lesion

Established Lesion

The hallmark of the established lesion if the overwhelming presence of plasma cells in relation to the prior stages of inflammation. Beginning two to three weeks after first plaque formation, the established lesion is widespread in both human and animals populations and can be seen commonly associated with the placement of orthodontic bands on molars.

Similar to the initial and early lesions, the established lesion features an inflammatory reaction confined to the area near the base of the gingival sulcus, but unlike prior stages, displays plasma cells clustered around blood vessels and between collagen fibers outside the immediate area of the reaction site. While most of the plasma cells produce IgG, a significant number do produce IgA (and rarely, some produce IgM). The presence of complement and antigen-antibody complexes is evident throughout the connective and epithelial tissue.

It is in the established lesion that epithelial proliferation and apical migration begin. In health, the junctional epithelium creates the most coronal attachment of the gum tissue to the tooth at or near the cementoenamel junction. In the established lesion of periodontal disease, the connective tissue lying subjacent to the junctional epithelium is nearly destroyed, failing to properly support the epithelium and buttress it against the tooth surface. In response to this, the junctional epithelium proliferates and grows into the vacant underlying spaces, effectively causing the level of its attachment to migrate towards apically, revealing more tooth structure than is normally evident supragingivally (above the level of the gumline) in health.

While many established lesions continue to the advanced lesion (below), most either remain as established lesions for decades or indefinitely; the mechanisms behind this phenomenon are not well understood.

Features of the Established Lesion:

• Predominance of plasma cells without bone loss
• Presence of extravascular immunoglobulins in the connective tissue and junctional epithelium
• Continuing loss of collagen
• Proliferation, apical migration and lateral extension of the junctional epithelium, with or without pocket formation