Classification of Periodontal Diseases Hayder Alwaeli: BDS, M.Sc. & J. Board
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
1. Free Gingiva
2. Attached Gingiva
3. Interdental Gingiva
Clinical Features of Normal (Healthy) Gingiva
New Classification System
• 1999 International Workshop for the Classification of Periodontal Diseases
Classification of Classification of Periodontal DiseasesPeriodontal Diseases
• American Academy of Periodontology (AAP)
• The International Workshop 1999
Characteristics common to all gingival diseases
1. Signs & symptoms are confined to gingiva
2. The presence of dental plaque to initiate & / or exacerbte the severity of the lesion
3. 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
. B. forsythus
Addition of a Section on “GingivalDiseases”
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 cycle-
associated 3. Pregnancy associated a. Gingivitis b. Pyogenic
granuloma 4. Diabetes mellitus-
associated
• B. Blood dyscrasias 1. Leukemia-associated
gingivitis 2. Other
II. Gingival diseases modified by systemic factors
• A. Endocrine system 1. Puberty-associated 2. Menstrual cycle-
associated 3. Pregnancy associated a- Gingivitis b. Pyogenic
granuloma 4. Diabetes mellitus-
associated
• B. Blood dyscrasias 1. Leukemia-associated
gingivitis 2. Other
II. Gingival diseases modified by systemic factors
• A. Endocrine system 1. Puberty-associated 2. Menstrual cycle-
associated 3. Pregnancy associated a- Gingivitis b. Pyogenic
granuloma 4. Diabetes mellitus-
associated
• B. Blood dyscrasias 1. Leukemia-associated
gingivitis 2. Other
II. Gingival diseases modified by systemic factors
• A. Endocrine system 1. Puberty-associated 2. Menstrual cycle-
associated 3. Pregnancy associated a- Gingivitis b. Pyogenic
granuloma 4. Diabetes mellitus-
associated
• B. Blood dyscrasias 1. Leukemia-associated
gingivitis 2. Other
II. Gingival diseases modified by systemic factors
• A. Endocrine system 1. Puberty-associated 2. Menstrual cycle-
associated 3. Pregnancy associated a- Gingivitis b. Pyogenic
granuloma 4. Diabetes mellitus-
associated
• B. Blood dyscrasias 1. Leukemia-associated
gingivitis 2. Other
II. Gingival diseases modified by systemic factors
• A. Endocrine system 1. Puberty-associated 2. Menstrual cycle-
associated 3. Pregnancy associated a- Gingivitis b. Pyogenic
granuloma 4. Diabetes mellitus-
associated
• B. Blood dyscrasias 1. Leukemia-associated
gingivitis 2. Other
II. Gingival diseases modified by systemic factors
• A. Endocrine system 1. Puberty-associated 2. Menstrual cycle-
associated 3. Pregnancy associated a- Gingivitis b. Pyogenic
granuloma 4. Diabetes mellitus-
associated
• 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
IV- Gingival lesions of genetic origin
A. Hereditary gingival fibromatosis 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
B. Allergic reactions1. Dental restorative materials
(mercury, acrylic, nickel)2. Reactions attributable to
a- tooth pastes b- mouth washes c- chewing gum d- foods and additives
VI: traumatic lesions:“Factitious, Iatrogenic, & Accidental”A- chemical injuryB- physical injuryC- 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 Classification of Periodontal DiseasesPeriodontal Diseases
• American Academy of Periodontology (AAP)
• The International Workshop 1999
PeriodontitisThe Old Classifications
World Workshop in Clinical Periodontics (1989)
Form of Priodontitis Basic Characteristics
Adult Periodontitis >35 years Slow rate of progression No defects in host defenses
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
< 35 years Rapid rate of progression Defects in host defensesAssociated with specific microflora
Periodontitis associated with systemic diseases
Systemic diseases that predispose to rapid rates of destruction (e.g. Diabetes)
Necrotizing Ulcerative Periodontitis
Similar to NUG but with clinical attachment loss
European Classification (1993)
Form of Priodontitis Basic Characteristics
Adult Periodontitis 4th decade Slow rate of progression No defects in host defenses
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
Prior to 4th decade Rapid rate of progression Defects in host defenses
Periodontitis associated with systemic diseases
Systemic diseases that predispose to rapid rates of destruction (e.g. Diabetes)
Necrotizing Ulcerative Periodontitis
Tissue necrosis with clinical attachment loss & bone loss
Drawbacks of the old classifications
Form of Priodontitis Basic Characteristics
Adult Periodontitis 4th decade Slow rate of progression No defects in host defenses
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
Prior to 4th decade Rapid rate of progression Defects in host defenses
Periodontitis associated with systemic diseases
Systemic diseases that predispose to rapid rates of destruction (e.g. Diabetes)
Necrotizing Ulcerative Periodontitis
Tissue necrosis with attachment clinical attachment & bone loss
Considerable overlap in disease categories
Drawbacks of the old classifications
Form of Priodontitis Basic Characteristics
Adult Periodontitis 4th decade Slow rate of progression No defects in host defenses
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
Prior to 4th decade Rapid rate of progression Defects in host defenses
Periodontitis associated with systemic diseases
Systemic diseases that predispose to rapid rates of destruction (e.g. Diabetes)
Necrotizing Ulcerative Periodontitis
Tissue necrosis with attachment clinical attachment & bone loss
Absence of a gingival disease component
Drawbacks of the old classifications
Form of Priodontitis Basic Characteristics
Adult Periodontitis 4th decade Slow rate of progression No defects in host defenses
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
Prior to 4th decade Rapid rate of progression Defects in host defenses
Periodontitis associated with systemic diseases
Systemic diseases that predispose to rapid rates of destruction (e.g. Diabetes)
Necrotizing Ulcerative Periodontitis
Tissue necrosis with attachment clinical attachment & bone loss
Inappropriate emphasis on age of onset of disease and rates of progression
Drawbacks of the old classifications
Form of Priodontitis Basic Characteristics
Adult Periodontitis 4th decade Slow rate of progression No defects in host defenses
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
Prior to 4th decade Rapid rate of progression Defects in host defenses
Periodontitis associated with systemic diseases
Systemic diseases that predispose to rapid rates of destruction (e.g. Diabetes)
Necrotizing Ulcerative Periodontitis
Tissue necrosis with attachment clinical attachment & bone loss
Inadequate or inappropriate classification criteria
Periodontitis
• Chronic
• Aggressive
• Periodontitis as a manifestations of systemic diseases
• 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
Chronic periodontitis
Localized form: <30% of sites involved Generalized 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 PeriodontitisSecondary 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
a. Acquired neutropenia b. Leukemias c. Other
2. Genetic disorders
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. pseudopocketB. inconsistent gingival marginC. excessive gingival displayD. gingival enlargementE. 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
Please read;
• Chapter 4pages; 64 – 72
Classification of Diseases and Condition Affecting the Periodontium
FINALLY ,,