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Classification of periodontal diseases 1 /certified fixed orthodontic courses by Indian dental academy


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  • 1. CLASSIFICATION OF PERIODONTAL DISEASES INDIAN DENTAL ACADEMY Leader in Continuing Dental Education www.indiandentalacademy.com
  • 4.  There has been a debate on the diagnosis and classification of periodontal diseases. Diagnosis is defined as the act of identifying a disease from its signs and symptoms. Classification is defined as the act or method of distribution into groups. www.indiandentalacadem
  • 5.  Any attempt to group the entire constellation of periodontal diseases into an early and widely accepted classification system is fraught with difficulty,and inevitably considerable controversy. Despite the dilemma,in the past hundred years,experts have periodically assembled to develop a new classification system for periodontal diseases. www.indiandentalacadem
  • 6. NEED FOR CLASSIFICATION For the purpose of diagnosis,prognosis and treatment planning. To understand the etiology,pathology of the diseases of the periodontium. For logical,systemic separation and organization of knowledge about disease. www.indiandentalacadem
  • 7.  Facts can be filed for future references. Helps to communicate among clinicians,researchers,educators,students, epidemiologists and public health workers. www.indiandentalacadem
  • 8. The development and evolution of classification systems Influenced by paradigms that reflect the understanding the nature of periodontal diseases during a given historical period. Over time,thoughts that guided the classification of periodontal diseases can be placed into three dominant paradigms. www.indiandentalacadem
  • 9.  The dominant paradigms in the historical development of classification system primarily based on I.Clinical features of the diseases (1870-1920) II.The concepts of classical pathology (1920-1970) III.The infectious etiology of the diseases (1970-present) www.indiandentalacadem
  • 10.  Classification systems in the modern era represent a blend of all three paradigms. The ideas which are believed to be clearly outmoded or incorrect have been discarded. The new paradigm rests on a foundation of the still valid components of the older or previous paradigms. www.indiandentalacadem
  • 11.  The classification systems should be viewed as dynamic works-in-progress that need to be periodically modified based on current thinking and new knowledge. www.indiandentalacadem
  • 12.  The ancient medical works refer to the various diseases of teeth & periodontium but without using any particular terminology. The first specific name for periodontal disease was introduced by Fauchard in 1723 using the term ‘SCURVY OF THE GUMS’. www.indiandentalacadem
  • 13. I.CLINICAL CHARACTERISTICSPARADIGM(1870-1920) In the late 1800&early 1900s clinicians used case descriptions and their personal interpretation of what they saw clinically as the primary basis for classifying periodontal diseases. www.indiandentalacadem
  • 14.  In 1811-1875 John M Riggs lectured on the treatment of periodontal disease.After that periodontitis was called “Rigg’s disease”. www.indiandentalacadem
  • 15.  In 1879 C.G Davis published a paper ,he believed that there were three distinct forms of destructive periodontal disease: 1.Gingival recession with minimal or no inflammation due to trauma from tooth brushing or decreased vascular action. 2.Periodontal destruction secondary to ‘lime deposits’-the gum retires slowly and the alveolar border deprived of nutrition,at the point of pressure is consentaneously absorbed. www.indiandentalacadem
  • 16.  3.Rigg’s disease : loss of alveolus without loss of gum.the perceived problem was a necrosed alveolus or death of the periodontal membrane. www.indiandentalacadem
  • 17.  In 1886 G.V.Black published on classification based on their clinical characteristics and his understanding of their cause into five groups 1.constitutional gingivitis 2.painful form of gingivitis(NUG) 3.simple gingivitis 4.the destruction of alveolar bone slowly in even or generalized pattern.(chronic periodontitis) www.indiandentalacadem
  • 18.  5.Phagedinic periodontitis:the pattern of alveolar bone destruction is irregular.it may occur rapidly or slowly. In a later publication Black replaced the term ‘phagedinic periodontitis’ with ‘chronic suppurative pericementitis’. www.indiandentalacadem
  • 19. In the later part of the 19th century periodontitis went under numerous names: Pyorrhea alveolaris Riggs disease Calcic inflammation of the periodontal membrane Phagedinic pericementitis The dominant term used for periodontal disease was pyorrhea alveolaris. www.indiandentalacadem
  • 20. II.CLASSICAL PATHOLOGY PARADIGM(1920-1970) The concept emerged from the debate on periodontal diseases by the clinical scholars in Europe and North America concluded - There were two forms of periodontal disease 1.Inflammatory (degenerative) 2.Noninflammatory(dystrophic) www.indiandentalacadem
  • 21.  Gottileb is generally considered to be the first author who clearly distinguished various forms of periodontal disease. In 1920s he classified periodontal disease into four groups. 1.Schmutz pyorrhea: due to accumulation of deposits on the teeth and was characterised by inflammation,shallow pockets, and resorption of alveolar crest. www.indiandentalacadem
  • 22.  2.Alveolar atrophy or diffuse atrophy: Non inflammatory disease exhibiting loosening of teeth,elongation of and wandering of teeth in individuals who were free of caries & dental deposits,pockets are formed in later stages www.indiandentalacadem
  • 23.  3.Paradental-pyorrhoe: Irregularly distributed pockets varying from shallow to extremely deep.this may be started as Schmutz-pyorrhoe or diffuse atrophy. 4.Occlusal trauma: A form of physical overload was believed to result in resorption of the alveolar bone and loosening of teeth. www.indiandentalacadem
  • 24.  Mc Call & Box in 1925 introduced a term ‘periodontitis’ to denote those inflammatory diseases in which the gingiva,bone & periodontal ligament are involved. Periodontitis was sub classified on the basis of presumed etiologic factors into 1.simplex periodontitis:due to local bacterial factors 2.complex periodontitis:due to systemic etiologic factors. www.indiandentalacadem
  • 25.  Becks (1931) made a distinction between PARADENTITIS,a disease ‘which originates from the gum tissue in the form of gingivitis’ and GENUINE PARADENTOSIS ‘which originates in the bony alveolus,perhaps in the form of an osteopathy’. www.indiandentalacadem
  • 26.  Orban & Weinmann (1942) used the term periodontosis to designate this ‘non inflammatory disease’. Periodontosis was considered a separate disease entity,distinctly different from periodontitis,which was considered as the sequel of gingivitis of deeper periodontal structures and therefore of a inflammatory origin. It is not mentioned specifically that it was a disease entity particular to young patients. www.indiandentalacadem
  • 27.  Orban classified periodontal diseases according to the “pathologic” categories of Inflammation Degeneration Atrophy Hypertrophy Traumatism. www.indiandentalacadem
  • 28. *InflammationI.gingivitis(little or no pocket formation) A.local- calculus,foodimpaction,irritating restorations,drug action etc. B.systemic- pregnancy,diabetes,tuberculosis,syphilis,nutritional disorders,drug action,allergy,hereditary,idiopathic etc.II.periodontitis A.simplex(secondary to gingivitis)-bone loss,pockets,abscess can form:cases have calculus. B.complex(secondary to periodontosis)-etiologic factors similar to periodontitis:cases have little,if any calculus. www.indiandentalacadem
  • 29. *DegenerationI.Periodontosis)A.Systemic disturbances 1.Diabetes 2.Endocrine dysfunctions 3.Bood dyscrasias 4.Nutritional disturbances 5.Nervous disorders 6.Infectious diseases(acute &chronic)B.HereditaryC.Idiopathic www.indiandentalacadem
  • 30. *Atrophy I.Peridontal atrophy(recession,no inflammation,no pockets) A.Local trauma(eg;from tooth brush) B.Presenile C.Senile D.Disuse E.Following inflammation F.Idiopathic www.indiandentalacadem
  • 31. *Hypertrophy I.gingival hypertrophy A.Chronic irritation B.Drug action C.Idiopathic*Traumatism I.Periodontal traumatism A.Occlusal trauma www.indiandentalacadem
  • 32.  During 1950 & 1960s the importance of dental plaque as the major etiologic factor for periodontal diseases became more and more evident. The ultimate proof of association between plaque and gingival inflammation was shown by Loe and coworkers in their experimental gingivitis studies(1965,1966). www.indiandentalacadem
  • 33. In 1966 the workshop in periodontics concluded the report: ‘Evidence to support the conventional concept of periodontosis is unsubstantiated.It was the consensus of the section that the term periodontosis is ambiguous and it should be eliminated from nomenclature.Nevertheless,the committee is aware that some evidence exists to indicate that a clinical entity different from adult periodontitis may occur in adolescents and young adults’. www.indiandentalacadem
  • 34.  Soon after the workshop a study was published by Butler(1969) introducing the JUVENILE PERIODONTITIS instead of periodontosis. www.indiandentalacadem
  • 35. III.Infection/Host response Paradigm(1970-present) In1876 Robert Koch published the experimental proof of the germ theory of disease and established the koch’s postulates. Miller (1890) was an early advocate of this paradigm that would come to dominate the field nearly a hundred years later. www.indiandentalacadem
  • 36.  Harald & loe in 1965-1968 studied on experimental gingivitis and concluded there is a significant relationship between plaque flora and development of gingivitis. The next major discovery in periodontal microbiology was the preliminary demonstration in 1976-1977 of microbial specificity at sites with periodontosis. www.indiandentalacadem
  • 37.  This finding is coupled with demonstration in 1977-1979 that neutrophils from patients with juvenile periodontitis had defective chemotactic and phagocytic activities,marked the beginning of the dominance of infection/host response paradigm. www.indiandentalacadem
  • 38.  In 1982 Page & Schroder defined periodontitis as an inflammatory disease of the periodontium characterised by the presence of periodontal pockets and active bone resorption with acute inflammation. They suggested four different forms of periodontitis. 1.prepubertal periodontitis 2.juvenile periodontitis 3.rapidly progressive periodontitis 4.adult periodontitis 5.ANUG/P www.indiandentalacadem
  • 39.  In 1986 the AAP adopted the following classificationI.Juvenile periodontitis A.prepubertal periodontitis B.localized juvenile periodontitis C.generalized juvenile periodontitisII.Adult periodontitisIII.NUG/P Necrotizing ulcerative gingivo periodontitis.IV.Refractory periodontitis www.indiandentalacadem
  • 40.  In 1988 Jhonson et al presented a more extensive classification to detect the groups and individuals at high risk for periodontal disease.I.Childhood periodontitisII.Juvenile periodontitis -localized,generalizedIII.Post juvenile periodontitisIV.Adult onset periodontitis -slowly progressive -rapidly progressiveV.periodontitis associated with systemic diseases(diabetes,scurvy,immunodeficiencies, immunosupressive states,blood dyscrasias) www.indiandentalacadem
  • 41. VI.Traumatic periodontitis eg:gingival recession and loss of attachment as a result of abrasion during oral hygiene practice(tooth brushing,woodsticks,charcoal,brick dust)VII.Iatrogenic periodontitis due to inappropriate restorations or inappropriate instrumentation of the gingival crevice. www.indiandentalacadem
  • 42.  The next major landmark in classification emerged from the 1989 World Work Shop in clinical periodontics follows as:I. Adult periodontitisII.Early onset periodontitis A.Prepubertal periodontitis -localized,generalized B. Juvenile periodontitis -localized,generalized C. Rapidly progressive periodontitis www.indiandentalacadem
  • 43. III. Periodontitis associated with systemic diseasesIV.Necrotizing ulcerative PeriodontitisV.Refractory Periodontitis www.indiandentalacadem
  • 44.  The short comings of 1989 classification:1.considerable overlap in clinical characteristics of the different disease categories2.Absence of gingival diseases3.Inappropriate emphasis on age of onset of disease and rates of progression4.Inadequate or unclear classification criteria5.Rapidly progressive & prepubertal perodontitis and refractory periodontitis were heterogenous category6.The periodontitis categories had non validated age dependent criteria www.indiandentalacadem
  • 45.  In 1993 Ranney et al recommended the elimination of refractory periodontitis and periodontitis associated with systemic diseases.he suggested to consider these in specific context rather than treating them as a unique category. Ranney proposed four major categories I. Adult periodontitis II. Early onset periodontitis III. Necrotizing ulcerative Periodontitis IV.periodontal abcess www.indiandentalacadem
  • 46.  In 1993 first European Work Shop on periodontology given a statement on the basis of the reports produced by papapanou. ‘There is a insufficient knowledge to separate truly different diseases (disease heterogenicity)from differences in the presentation/severity of the same disease(phenotypic variation). www.indiandentalacadem
  • 47.  1993 classification I.Adult periodontitis II.Early onset periodontitis III.Necrotizing periodontitis www.indiandentalacadem
  • 48.  The need for a revised classification system for periodontal diseases was emphasized during the 1996 World Work Shop in periodontics. www.indiandentalacadem
  • 49.  On October 30 – November 2nd 1999, the International Work Shop for a classification of periodontal diseases and conditions was held and a new classification was agreed upon. www.indiandentalacadem
  • 50. Classification of periodontal diseases &conditions www.indiandentalacadem
  • 51. Gingival diseaseswww.indiandentalacadem
  • 52. www.indiandentalacadem
  • 53. www.indiandentalacadem
  • 54. www.indiandentalacadem
  • 55. www.indiandentalacadem
  • 56. www.indiandentalacadem
  • 57. Conclusion The classified system proposed by ‘1999 international work shop for a classification of periodontal diseases and conditions’ has corrected some of the problems associated with the previous system that had been in use since 1989. Nevertheless the new system is far from perfect and will need to be modified once there are sufficient new data to justify revisions. www.indiandentalacadem
  • 58.  Since it is probable that essentially all dentists & periodontists in the world are convinced that most periodontal diseases are infections,it is unlikely that the Infection/Host response paradigm will be replaced in the near future. www.indiandentalacadem
  • 59. References1.Clinical periodontology-Carranza 9th edition.2.Critical issues in periodontal diagnosis- Periodontology 2000;vol 39:2005.3.Controversies in periodontology- Periodontology 2000;vol30:2002.4.Classification & Epidemiology of periodontal diseases-Periodontology 2000;vol2:1993.5.Annals of periodontology 1999. www.indiandentalacadem
  • 60. Thank youwww.indiandentalacadem