CLASSIFICATION OF PERIODONTAL DISEASES - 3rd year

Classification of Periodontal Diseases Hayder Alwaeli: BDS, M.Sc. & J. Board

Gingiva -Fibrous mucosa surrounding the teeth & covering the coronal of the alveolar process Consists of 3 parts 3. Free Gingiva 4. Attached Gingiva 5. Interdental Gingiva

Clinical Features of Normal (Healthy) Gingiva

New Classification System • 1999 International Workshop for the Classification of Periodontal Diseases

Classification of Periodontal Diseases

• American Academy of Periodontology (AAP) • The International Workshop 1999

 Characteristics common to all gingival diseases  Signs & symptoms are confined to gingiva  The presence of dental plaque to initiate & / or exacerbte the severity of the lesion  Clinically signs of inflammation: •

Enlarged gingival contour : edematous or fibrotic

•

Red in color &/ or bluish red

•

Bleeding upon stimulating

•

↑ gingival exudates

•

Pathological ↑ in sulcular depth

•

No radiographic evidence

4. Reversibility of the disease by removing the etiology (ies) 5. Possible role as a precursor to attachment loss around tooth

 Periodontitis -An inflammatory disease of the supporting tissue of the teeth caused by specific microorganisms or specific group, resulting in progressive destruction of periodontal ligament & alveolar bone with pocket formation, recession, or both - The primary clinical features of periodontitis a. Clinical attachment loss b. alveolar bone loss c. periodontal pocketing d. gingival inflammation( enlargement or recession ) e. increased mobility, drifting & / tooth exfoliation may occur h. progress continuously as chronic inflammation or by burst of activity -Several bacterial species associated with periodontitis . P. gingivalis

. T. denticola

. Actinobcillus actinomycetumcmitans

. E. corrodens

. P. intermedia

. E. nodatum

. C. rectus

Addition of a Section on “Gingival Diseases”

I. Gingivitis associated with dental plaque only A. Without local contributing factors B. With local contributing factors

II. Gingival diseases modified by systemic factors •

A. Endocrine system 1. Puberty-associated 2. Menstrual cycleassociated 3. Pregnancy associated a. Gingivitis b. Pyogenic granuloma 4. Diabetes mellitusassociated

•

B. Blood dyscrasias 1. Leukemia-associated gingivitis 2. Other

II. Gingival diseases modified by systemic factors •

A. Endocrine system 1. Puberty-associated 2. Menstrual cycleassociated 3. Pregnancy associated a- Gingivitis b. Pyogenic granuloma 4. Diabetes mellitusassociated

•

B. Blood dyscrasias 1. Leukemia-associated gingivitis 2. Other

II. Gingival diseases modified by systemic factors •

A. Endocrine system 1. Puberty-associated 2. Menstrual cycleassociated 3. Pregnancy associated a- Gingivitis b. Pyogenic granuloma 4. Diabetes mellitusassociated

•

B. Blood dyscrasias 1. Leukemia-associated gingivitis 2. Other

II. Gingival diseases modified by systemic factors •

A. Endocrine system 1. Puberty-associated 2. Menstrual cycleassociated 3. Pregnancy associated a- Gingivitis b. Pyogenic granuloma 4. Diabetes mellitusassociated

•

B. Blood dyscrasias 1. Leukemia-associated gingivitis 2. Other

II. Gingival diseases modified by systemic factors •

A. Endocrine system 1. Puberty-associated 2. Menstrual cycleassociated 3. Pregnancy associated a- Gingivitis b. Pyogenic granuloma 4. Diabetes mellitusassociated

•

B. Blood dyscrasias 1. Leukemia-associated gingivitis 2. Other

II. Gingival diseases modified by systemic factors •

A. Endocrine system 1. Puberty-associated 2. Menstrual cycleassociated 3. Pregnancy associated a- Gingivitis b. Pyogenic granuloma 4. Diabetes mellitusassociated

•

B. Blood dyscrasias 1. Leukemia-associated gingivitis 2. Other

II. Gingival diseases modified by systemic factors •

A. Endocrine system 1. Puberty-associated 2. Menstrual cycleassociated 3. Pregnancy associated a- Gingivitis b. Pyogenic granuloma 4. Diabetes mellitusassociated

•

B. Blood dyscrasias 1. Leukemia-associated gingivitis 2. Other

Ill. Gingival diseases modified by medications 1. Drug-influenced gingival enlargements a. Anticonvulsant “Phenytoin” b. Immunosupressent “Cyclosporin A” c. Calcium Channel Blockers “Nifedipine, Verapamil, Diltiazem, & Sodium Valporate” 2- Drug-influenced gingivitis a. Oral contraceptive-associated gingivitis b. Other

Ill. Gingival diseases modified by medications 1. Drug-influenced gingival enlargements a. Anticonvulsant “Phenytoin” b. Immunosupressent “Cyclosporin A” c. Calcium Channel Blockers “Nifedipine, Verapamil, Diltiazem, & Sodium Valporate” 2- Drug-influenced gingivitis a. Oral contraceptive-associated gingivitis b. Other

IV. Gingival diseases modified by malnutrition A. Ascorbic acid deficiency gingivitis B. Other

Non-Plaque-Induced Gingival Lesions I- Gingival diseases of specific bacterial origin A. Neisseria gonorrhea B. Treponema pallidum C. Streptococcal species D. Other II. Gingival diseases of viral origin A. Herpesvirus infections 1. Primary herpetic gingivostomatitis 2. Recurrent oral herpes 3. Varicella zoster B. Other

III. Gingival diseases of fungal origin A. Candida-species infections: Generalized gingival candidosis B. Linear gingival erythema C. Histoplasmosis D. Other

B. Allergic reactions IV- Gingival lesions of genetic origin 1. Dental restorative materials (mercury, acrylic, nickel) A. Hereditary gingival fibromatosis 2. Reactions attributable to B. Other

V. Gingival manifestations of systemic conditions A. Mucocutaneous lesions 1. Lichen planus 2. Pemphigoid 3. Pemphigus vulgaris 4. Erythema multiforme 5. Lupus erythematosus 6- Drug induced 7. Other

a- tooth pastes b- mouth washes c- chewing gum d- foods and additives

VI: traumatic lesions: “Factitious, Iatrogenic, & Accidental” A- chemical injury B- physical injury C- thermal injury VII: Foreign body reactions VIII: not otherwise specified

Hereditary Gingival Fibromatosis Clinical Features: • no sex predilection • apparent when the teeth are erupting, usually enlargement begins in puberty • gingival overgrowth, gingiva may cover the teeth possibly completely • more common in posterior mandibular areas • pink, firm, smooth and uniform • asymptomatic, nonhemorrhagic, nonexudative • possible apparent delay in dental eruption • malpositioning of teeth, retention of deciduous teeth, esthetic and functional problems

Classification of Periodontal Diseases

• American Academy of Periodontology (AAP) • The International Workshop 1999

Periodontitis The Old Classifications

World Workshop in Clinical Periodontics (1989) Form of Priodontitis Adult Periodontitis

Early onset Periodontitis - Prepubertal - Juvenile - Rapidly progressive Periodontitis associated with systemic diseases Necrotizing Ulcerative Periodontitis

Basic Characteristics  >35 years  Slow rate of progression  No defects in host defenses  < 35 years  Rapid rate of progression  Defects in host defenses Associated with specific microflora Systemic diseases that predispose to rapid rates of destruction (e.g. Diabetes) Similar to NUG but with clinical attachment loss

European Classification (1993) Form of Priodontitis Adult Periodontitis

Early onset Periodontitis - Prepubertal - Juvenile - Rapidly progressive Periodontitis associated with systemic diseases Necrotizing Ulcerative Periodontitis

Basic Characteristics  4th decade  Slow rate of progression  No defects in host defenses  Prior to 4th decade  Rapid rate of progression  Defects in host defenses Systemic diseases that predispose to rapid rates of destruction (e.g. Diabetes) Tissue necrosis with clinical attachment loss & bone loss

Drawbacks of the old classifications Form of Priodontitis Adult Periodontitis

Basic Characteristics  4th decade  Slow rate of progression  No defects in host defenses  Prior to 4th decade  Rapid rate of progression  Defects in host defenses

Early onset Periodontitis - Prepubertal - Juvenile - Rapidly progressive Periodontitis associated with Systemic diseases that predispose to systemic diseases rapid of destruction (e.g. Considerable overlap inrates disease categories Diabetes) Necrotizing Ulcerative Tissue necrosis with attachment Periodontitis clinical attachment & bone loss

Drawbacks of the old classifications Form of Priodontitis Adult Periodontitis

Basic Characteristics  4th decade  Slow rate of progression  No defects in host defenses  Prior to 4th decade  Rapid rate of progression  Defects in host defenses

Early onset Periodontitis - Prepubertal - Juvenile - Rapidly progressive Periodontitis associated with Systemic diseases that predispose to systemic diseases of a gingival rapiddisease rates of destruction (e.g. Absence component Diabetes) Necrotizing Ulcerative Tissue necrosis with attachment Periodontitis clinical attachment & bone loss

Drawbacks of the old classifications Form of Priodontitis Adult Periodontitis

Basic Characteristics  4th decade  Slow rate of progression  No defects in host defenses  Prior to 4th decade  Rapid rate of progression  Defects in host defenses

Early onset Periodontitis - Prepubertal - Juvenile - Rapidly progressive PeriodontitisInappropriate associated with emphasis Systemic diseases that predispose to on age of systemic diseases rapid rates of destruction (e.g. onset of disease and rates of progression Diabetes) Necrotizing Ulcerative Tissue necrosis with attachment Periodontitis clinical attachment & bone loss

Drawbacks of the old classifications Form of Priodontitis Adult Periodontitis

Basic Characteristics  4th decade  Slow rate of progression  No defects in host defenses  Prior to 4th decade  Rapid rate of progression  Defects in host defenses

Early onset Periodontitis - Prepubertal - Juvenile - Rapidly progressive Periodontitis associated with Systemic diseases that predispose to systemic diseases or inappropriate rapid rates of destruction (e.g. Inadequate classification criteria Diabetes) Necrotizing Ulcerative Tissue necrosis with attachment Periodontitis clinical attachment & bone loss

Periodontitis • Chronic • Aggressive • Periodontitis as a manifestations of systemic diseases

Chronic periodontitis • • • • • •

The most prevalent form in adults Amount of destruction consistent with local factors Associated with a variable microbial pattern Subgingival calculus frequently found Slow to moderate rate of progression Possibly modified by or associated with the

following:

Systemic diseases Local factors predisposing factors Environmental factors

Chronic periodontitis Localized form: 30% of sites involved Slight: 1-2 mm of clinical attachment loss Moderate: 3-4 mm of clinical attachment loss Severe: ≥5 mm of clinical attachment loss

Generalized Severe Chronic Periodontitis

Generalized Severe Chronic Periodontitis

Generalized Severe Chronic Periodontitis

Generalized Severe Chronic Periodontitis

Aggressive Periodontitis Primary Features • Except for the presence of periodontitis, patients are otherwise clinically healthy • Rapid attachment loss and bone destruction • Familial aggregation

Aggressive Periodontitis Secondary Features • Amounts of microbial deposits are inconsistent with the severity of periodontal tissue destruction • Elevated proportions of Aa and, in some populations, P. gingivalis may be elevated • Phagocyte abnormalities • Hyper-responsive macrophage phenotype, including elevated levels of PGE2 and IL-1β • Progression of attachment loss and bone loss may be self-arresting

Localized Aggressive Periodontitis • Circumpubertal onset of disease • Localized presentation with

interproximal attachment loss on at least two permanent teeth, one of which is a first molar, and involving no more than two teeth other than first molars and incisors

• Robust serum antibody response to infecting agents

Localized Aggressive Periodontitis

Generalized Aggressive Periodontitis • Usually affects persons under 30 years of age • Generalized proximal attachment loss affecting at least three teeth other than first molars and incisors • Pronounced episodic nature of periodontal destruction • Poor serum antibody response to infecting agents

Generalized Aggressive Periodontitis

Periodontitis as a Manifestation of Systemic Diseases 1.

Hematologic disorders

2. Genetic disorders

a. Acquired neutropenia b. Leukemias c. Other

a. Familial and cyclic neutropenia b. Down syndrome c. Leukocyte adhesion deficiency syndromes d. Papillon-Lefevre syndrome e. Chediak-Higashi syndrome f. Histiocytosis syndromes g- Glycogen storage disease h. Infantile genetic agranulocytosis i. Cohen syndrome j. Ehlers-Danlos syndrome k. Hypophosphatasia l. Other 3. Not otherwise specified

Hematologic disorders • Agranulocytosis • Neutropenia

Genetic disorders

Necrotizing Periodontal Diseases • Necrotizing ulcerative gingivitis • Necrotizing ulcerative periodontitis

Abscesses of the periodontium • Gingival • Periodontal • Pericoronal

Periodontitis associated with endodontic lesions

• Combined perio-endo lesions

Developmental or acquired deformities and conditions A. Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis 1. Tooth anatomic factors a. Enamel Pearls; Associated with attachment loss specially in furcation areas b. Cervical Enamel Projections; found 15 % to 24 % of mandibular molars found 9 % to 25 % of maxillary molars 2. Dental restorations/appliances 3. Root fractures 4. Cervical root resorption and cemental tears

Developmental or acquired deformities and conditions B. Mucogingival deformities and conditions around teeth 1. Gingival/soft tissue recession A. facial or lingual surfaces B. interproximal (papillary) 2. Lack of keratinized gingiva 3. Decreased vestibular depth 4. Aberrant frenum/muscle position 5. Gingival excess A. pseudopocket B. inconsistent gingival margin C. excessive gingival display D. gingival enlargement E. Abnormal color

Developmental or acquired deformities and conditions C. Mucogingival deformities and conditions on edentulous ridges 1. Vertical and/or horizontal ridge deficiency 2. Lack of gingiva/keratinized tissue 3. Gingival/soft tissue enlargement 4. Aberrant frenum/muscle position 5. Decreased vestibular depth 6. Abnormal color D. Occlusal trauma 1. Primary occlusal trauma 2. Secondary occlusal trauma

FINALLY ,, Please read; • Chapter 4 pages; 64 – 72 Classification of Diseases and Condition Affecting the Periodontium