Classification

• Classification scheme


  Necessary for clinicians to properly diagnose and treat patients, and for scientists to investigate etiology, pathogenesis, natural history, and treatment of diseases and conditions
• Periodontal diseases and conditions

  • Periodontal health, gingivitis, and gingival conditions
  • Periodontitis
  • Other conditions of periodontium
• Peri-implant diseases and conditions

  • Peri-implant health
  • Peri-implant mucositis
  • Peri-implantitis
  • SOFT & HARD TISSUES DEFICIENCY
• Bleeding on probing (BOP)

  • Primary parameter in gingivitis, most significant to decide its extent
  • In periodontitis, bleeding with probing is not always a sign for an ongoing attachment loss, but a sign for an existing inflammation and increased risk for future attachment loss
• Etiology of BOP


  Increase in 'red complex' bacteria (P. gingivalis, T. forsythia, T. denticola) is associated with BOP, while reduction in BOP is associated with increase in Streptococcus species
• Histopathologic features of BOP

  In early and established lesions of gingivitis, BOP occurs due to ulcerations in the sulcular epithelium associated with attempts of invasion by the pathogenic bacteria. Some bacteria (e.g. P. gingivalis) may use their virulence factors (short-chain fatty acids) for tissue invasion resulting in increased BOP.
• Conditions associated with increased BOP

  • Aggressive periodontitis
  • Necrotizing gingival diseases
  • Gingival diseases modified by systemic diseases (Blood dyscrasias such as leukemia)
  • Malnutrition (e.g. Vit. C deficiency)
  • Acute streptococcal infection
  • Chemical substance intoxication (e.g. Benzene)
• In gingivitis, BOP tend to decrease in smokers compared to non-smokers
• BOP index


  Binary index (Yes/No) that determines whether a site is bleeding on probing or not
• Clinically healthy gingiva


  Appears pink, not swollen, and firmly attached to the underlying tooth/bone with minimal BOP ( <10% of the sites may show BOP)
• Localized gingival inflammation


  Percentage of bleeding sites is 10% to 30% of the total sites
• Generalized BOP


  Bleeding sites > 30% of the total sites
• Probing depth (PD)


  Distance between the gingival margin and the bottom of the gingival sulcus or the periodontal pocket
• Gingival margin

  distance from the clinical gingival margin to any given reference such as, in most cases, the cemento-enamel junction.
• Periodontal & gingival health

  A state free from inflammatory periodontal disease that allows an individual to function normally and avoid consequences (mental or physical) due to current or past disease
• Types of gingival health on reduced periodontium

  • Non-periodontitis patient
  • Successfully treated stable periodontitis
• Dental plaque biofilm-induced gingivitis


  Gingival inflammation induced by the biofilm virulence factors and the associated host immune response, reversible following treatment
• Types of dental plaque biofilm-induced gingivitis


  • Associated with biofilm alone
  • Drug associated gingival overgrowth
  • Mediated by risk factors
• Risk factors for dental-plaque biofilm-induced gingivitis


  • Local predisposing factors: Plaque retention factors, Xerostomia
  • Systemic risk factors: Smoking, Hyperglycemia, Sex steroid hormones, Hematological disorders
• Gingival diseases: non-biofilm-induced


  • Genetic/developmental
  • Infections
  • Inflammatory/immune mediated
  • Reactive lesions/Traumatic/Neoplasms
  • Endocrine, metabolic, and nutritional
  • Pigmentation
• Periodontitis stages


  • Stage I: Mild
  • Stage II: Moderate
  • Stages III, IV: Severe
• Periodontitis grades


  • Grade A: Slow progression
  • Grade B: Moderate progression
  • Grade C: Rapid progression
• Periodontitis stage I


  Interdental CAL 1-2 mm, Radiographic bone loss in coronal third of the root (<15%), No tooth loss due to periodontitis
• Periodontitis stage II


  Interdental CAL 3-4 mm, Radiographic bone loss in coronal third of the root (15-33%), 1-4 teeth lost
• Periodontitis stage III


  Interdental CAL ≥ 5 mm, Radiographic bone loss extending to the middle or apical thirds of the root, 1-4 teeth lost
• Periodontitis stage IV


  Interdental CAL ≥ 5 mm, Radiographic bone loss extending to the middle or apical thirds of the root, 5 or more Teeth loss, Masticatory dysfunction, Severe ridge defect, Drifting, Remaining less than 10 occluding pairs
• Periodontitis grade determination methods

  • Direct measurement method (with available 5 years radiograph/CAL data)
  • Indirect evidence (% bone loss / age)
• Periodontitis grade modifiers


  • Smoking: Non-smoker, <10 Cigarettes /day, >10 Cigarettes /day
  • Diabetes: Normoglycemic, HbA1c <7%, HbA1c ≥7%
• Periodontitis as a manifestation of systemic disease

  • Papillon Lefèvre Syndrome, Chediak-Higashi syndrome, Down syndrome
• Other conditions affecting the periodontium

  • Systemic diseases affecting the periodontal supporting structures
  • Periodontal abscess - Endo-Perio lesions
  • Mucogingival deformities
  • Traumatic occlusion
  • Tooth/ prosthesis factors
• Types of periodontal abscess

  • Acute exacerbation
  • Untreated periodontitis
  • Non-responsive to treatment
  • During supportive periodontal therapy
  • After treatment
  • Post scaling
  • Post surgery
  • Post-medication
  • Systemic antibiotics
  • Drug-induced gingival overgrowth
• Types of endo-perio lesions

  • Endo-perio lesion with root damage: Root fracture or cracking, Root canal or pulp chamber perforation, External root resorption
  • Endo-perio lesion without root damage
  • Endo-perio lesion in periodontitis patient: Grade 1, Grade 2, Grade 3
  • Endo-perio lesion in non-periodontitis patient: Grade 1, Grade 2, Grade 3
• Mucogingival deformities


  • Gingival clefts/recession
  • Gingival overgrowth
  • Decreased vestibular depth
  • Aberrant frenum
  • Abnormal color
• Types of traumatic occlusion

  • Primary occlusal trauma: Healthy and abundant periodontal supporting structures exposed to greater than normal forces
  • Secondary occlusal trauma: Normal forces distributed through a deficient supporting periodontal attachment
• Onset of traumatic occlusion

  • Acute trauma
  • Chronic trauma
• Tooth/prosthesis factors affecting the periodontium

  • Prosthetic/restorative appliances with features that alter the normal anatomical and biological features of the periodontium