Classification of Periodontal Diseases and Conditions affecting the

Classification of Periodontal Diseases and Conditions affecting the Periodontium

1. Gingival diseases 2. Periodontitis 3. Necrotizing periodontal diseases 4. Abscesses of the periodontium 5. Periodontitis associated with endodontic lesions 6. Development or acquired deformities and conditions AAP International Workshop for Classification of Periodontal diseases, 1999

Gingival diseases 1. Dental plaque-induced gingival diseases 2. Non-plaque-induced gingival lesions AAP International Workshop for Classification of Periodontal diseases, 1999

Periodontitis 1. Chronic periodontitis 2. Aggressive periodontitis 3. Periodontitis as a manifestation of systemic disesases AAP International Workshop for Classification of Periodontal diseases, 1999

Necrotizing periodontal diseases 1. Necrotizing ulcerative gingivitis 2. Necrotizing ulcerative periodontitis AAP International Workshop for Classification of Periodontal diseases, 1999

Periodontitis associated with endodontic lesions 1. Endodontic-Periodontal lesions 2. Periodontal-Endodontic lesions 3. Combined lesions AAP International Workshop for Classification of Periodontal diseases, 1999

Development or acquired deformities and conditions 1. Localized tooth-related factors that modify or predispose to plaque-induced gingival disease or periodontitis 2. Mucogingival deformities and conditions around teeth 3. Mucogingival deformities and conditions on edentulous ridges 4. Occlusal trauma AAP International Workshop for Classification of Periodontal diseases, 1999

GINGIVAL DISEASES

Gingival diseases 1. Dental plaque-induced gingival diseases 2. Non-plaque-induced gingival lesions AAP International Workshop for Classification of Periodontal diseases, 1999

Dental plaque-induced gingival disease (gingivitis) 1. Plaque-induced gingivitis may occur on a periodontium with no attachment loss. 2. Plaque-induced gingivitis may occur on a periodontium with previous attachment loss (reduced periodontal support) that is stable and not progressing. AAP International Workshop for Classification of Periodontal diseases, 1999

Dental plaque-induced gingival disease 1. Gingivitis associated with dental plaque only 2. Gingival diseases modified by systemic factors 3. Gingival diseases modified by medications 4. Gingival diseases modified by malnutrition AAP International Workshop for Classification of Periodontal diseases, 1999

Gingivitis associated with dental plaque only 1. The result of an interaction between the microorganisms found in the dental plaque biofilm and the tissues and inflammatory cells of the host. 2. The plaque-host interaction can be altered by the effects of local factors, systemic factors, or both; medications; and malnutrition that can influence the severity and duration of the response. AAP International Workshop for Classification of Periodontal diseases, 1999

Gingival diseases modified by systemic factors 1. Systemic factors contributing to gingivitis, such as the endocrine changes associated with puberty, the menstrual cycle, pregnancy, and diabetes, may be exacerbated because of alterations in the gingival inflammatory response to plaque. 2. This appears to be caused by the effects of the systemic conditions on the cellular and immunologic functions of the host. AAP International Workshop for Classification of Periodontal diseases, 1999

Gingival diseases modified by systemic factors A. Associated with the endocrine system 1. Puberty-associated gingivitis 2. Menstrual cycle-associated gingivitis 3. Pregnancy associated a. Gingivitis b. Pyogenic granuloma B. Associated with blood dyscrasias 1. Leukemia-associated gingivitis AAP International Workshop for Classification of Periodontal diseases, 1999

Gingival diseases modified by systemic factors 3. Blood dyscrasias such as leukemia may alter immune function by distributing the normal balance of immunologically competent white blood cells supplying the periodontium. 4. Gingival enlargement and bleeding are common findings and may be associated with swollen, spongy gingival tissues caused by excessive infiltration of blood cells. AAP International Workshop for Classification of Periodontal diseases, 1999

Gingival diseases modified by medications 1. Drug-influenced gingival enlargements a. Phenytoin b. Cyclosporin A c. Nifedifine, verapamil, diltiazem, sodium valproate 2. Drug-induced gingivitis a. Oral contraceptive-associated gingivitis b. Other AAP International Workshop for Classification of Periodontal diseases, 1999

Non-Plaque induced gingival lesions 1. 2. 3. 4. 5. 6. 7. Gingival diseases of specific bacterial origin Gingival diseases of viral origin Gingival diseases of fungal origin Gingival diseases of genetic origin Gingival manifestations of systemic conditions Traumatic lesions Foreign body reactions AAP International Workshop for Classification of Periodontal diseases, 1999

PERIODONTITIS

Definition of periodontitis 1. An inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms or groups of specific microorganisms. 2. Resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession, or both. AAP International Workshop for Classification of Periodontal diseases, 1999

Definition of periodontitis 3. The clinical feature that distinguishes periodontitis from gingivitis is the presence of clinically detectable attachment loss. 4. This often is accompanied by periodontal pocket formation and changes in the density and height of subjacent alveolar bone. AAP International Workshop for Classification of Periodontal diseases, 1999

Classification of periodontitis 1. Adult periodontitis 2. Early onset periodontitis (may be prepubertal, juvenile, or rapidly progressive) 3. Periodontitis associated with systemic disease 4. Necrotizing ulcerative periodontitis 5. Refractory periodontitis AAP World Workshop in Clinical Periodontics, 1989

Classification of periodontitis 1. Adult periodontitis 2. Early onset periodontitis 3. Necrotizing periodontitis European Workshop on Periodontology, 1993

Classification of periodontitis 1. Chronic periodontitis 2. Aggressive periodontitis 3. Periodontitis as a manifestation of systemic disesases AAP International Workshop for Classification of Periodontal diseases, 1999

Characteristics of chronic periodontitis 1. Prevalent in adults but can occur in children 2. Amount of destruction consistent with local factors 3. Associated with a variable microbial pattern 4. Subgingival calculus frequently found 5. Slow to moderate of progression with possible periods of rapid progression AAP International Workshop for Classification of Periodontal diseases, 1999

Characteristics of chronic periodontitis 6. Possibly modified by or associated with the following : systemic diseases such as diabetes mellitus and HIV infection, local factors predisposing to periodontitis, environmental factors such as cigarette smoking and emotional stress. AAP International Workshop for Classification of Periodontal diseases, 1999

Sub-classification of chronic periodontitis 1. Localized form : < 30% of sites involved 2. Generalized form : > 30% of sites involved 3. Slight : 1 to 2 mm of clinical attachment loss 4. Moderate : 3 to 4 mm of clinical attachment loss 5. Severe : 5 mm of clinical attachment loss AAP International Workshop for Classification of Periodontal diseases, 1999

Common characteristics of aggressive periodontitis 1. Otherwise clinically healthy patient 2. Rapid attachment loss and bone destruction 3. Amount of microbial deposits inconsistent with disease severity 4. Familial aggregation of diseased individuals AAP International Workshop for Classification of Periodontal diseases, 1999

Common but not universal characteristics of aggressive periodontitis 1. Diseased sites infected with Actinobacillus actinomycetemcomitans 2. Abnormalities in phagocyte function 3. Hyperresponsive macrophages, producing increased PGE 2 and IL-1 4. In some cases, self-arresting disease progression AAP International Workshop for Classification of Periodontal diseases, 1999

Localized form of aggressive periodontitis 1. Circumpubertal onset of disease 2. Localized first molar or incisor disease with proximal attachment loss on at least two permanent teeth, one of which is a first molar. 3. Robust serum antibody response to infecting agents AAP International Workshop for Classification of Periodontal diseases, 1999

Generalized form of aggressive periodontitis 1. Usually affecting persons under 30 years of age (however, may be older) 2. Generalized proximal attachment loss affecting at least three teeth other than first molars and incisors 3. Pronounced episodic nature of periodontal destruction 4. Poor serum antibody response to infecting agents. AAP International Workshop for Classification of Periodontal diseases, 1999

Periodontitis as a manifestation of systemic diseases 1. Hematologic disorders a. Acquired neutropenia b. Leukemias c. Other 2. Genetic disorders a. b. c. d. Familial and cyclic neutropenia Down syndrome Leukocyte adhesion deficiency syndromes Papillon-Lefévre syndrome

Periodontitis as a manifestation of systemic diseases 2. Genetic disorders e. f. g. h. i. j. k. l. Chediak-Higashi syndrome Histiocytosis syndromes Glycogen storage disease Infantile genetic agranulocytosis Cohen syndrome Ehlers-Danlos syndrome (Type IV and VIII AD) Hypophosphatasia Other 3. Not otherwise specified

NECROTIZING PERIODONTAL DISEASES

Clinical characteristics 1. May include but are not limited to ulcerated and necrotic papillary and marginal gingiva covered by a yellowish-white or grayish slough or pseudomembrane, blunting and cratering of papillae, bleeding on provocation or spontaneous bleeding, pain, and fetid breath. 2. These diseases may be accompanied by fever, malaise, and lymphadenopathy, although these characteristics are not consistent.

Clinical characteristics 3. Recent reviews of the etiologic and clinical characteristics of NUG and NUP have suggested that the two diseases represent clinical manifestations of the same disease, except that distinct features of NUP are clinical attachment and bone loss. 4. As a result, both NUG and NUP have been determined as a separate group of diseases that has tissue necrosis as a primary clinical feature.

PERIODNOTITIS ASSOCIATED WITH ENDODONTIC LESIONS

Endodontic-Periodontal Lesions 1. Pulpal necrosis precedes periodontal changes. 2. A periapical lesion originating in pulpal infection and necrosis may drain to the oral cavity through the periodontal ligament, resulting in destruction of the periodontal ligament and adjacent alveolar bone.

Endodontic-Periodontal Lesions 3. This may present clinically as a localized, deep, periodontal pocket extending to the apex of the tooth. 4. Pulpal infection also may drain through accessory canals, especially in the area of the furcation, and may lead to furcal involvement through loss of clinical attachment and alveolar bone.

Periodontal-Endodontic Lesions 1. Bacterial infection from a periodontal pocket associated with loss of attachment and root exposure may spread through accesory canals to the pulp, resulting in pulpal necrosis. 2. Scaling and root planing removes cementum and underlying dentin and may lead to chronic pulpitis through bacterial penetration of dentinal tubules

Periodontal-Endodontic Lesions 3. However, many periodontitis-affected teeth that have been scaled and root planed show no evidence of pulpal involvement.