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Classification of periodontal diseases 2 /certified fixed orthodontic courses by Indian dental academy


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Classification of periodontal diseases 2 /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMYLeader in Continuing Dental
  2. 2.
  3. 3. Classification systemsIn the last 130 years, many classification system forperiodontal diseases have been used such asRamfjord and Ash 1979Page and Schroeder 1982Vogel and Cattabriga 1986Suzuki 1988.Grant, Stern, and Listgarten, 1988European workshop on Periodontology 1993World workshop in Clinical Periodontics 1989Genco 1990Ranney 1993
  4. 4. In 1989 classification system was developed that included five types of periodontitis.(i) Adult periodontitis(ii) Early onset periodontitis(iii) Periodontitis associated with systemic disease(iv) Necrotizing ulcerative periodontitis(v) Refractory periodontitis The main drawbacks of this classification were(i) Considerable overlap in disease categories(ii) Absence of a gingival disease component(iii) Inappropriate emphasis on age of onset of disease and rates of progression(iv) Inadequate or unclear classification criteria
  5. 5. The need to revise classification system for periodontaldiseases was emphasized during the 1996 World Workshop inPeriodontics. In 1997 the American academy of periodontologyresponded to this and formed a committee to plan and organize aninternational workshop to revise the classification system forperiodontal diseases. On October 30 – November 2, 1999, the InternationalWorkshop for a classification of Periodontal Diseases and conditionswas held and a new classification was agreed upon.
  6. 6. CHANGES IN THE CLASSIFICATION IN PERIODONTAL DISEASES Addition of a section on “ Gingival Diseases” Replacement of “adult periodontitis” with “chronic periodontitis” Replacement of “early onset periodontitis” with “aggressive periodontitis” Elimination of a separate disease category for “refractory periodontitis”
  7. 7.  Replacement of “necrotizing ulcerative periodontitis with “Necrotizing periodontal diseases” Addition of a category on “Periodontal abscess” Addition of a category on “Periodontic endodontic lesions” Addition of a category on “Development or acquired deformities and conditions”
  8. 8. Classification of periodontal disease and condition (1999 international workshop for a classification of periodontal disease and conditions)The new classification (1999) is as follows:1.GINGIVAL DISEASESa) Dental plaque induced gingival disease.(Can occur without attachment loss or on a periodontium with attachment loss that is not progressing)1.Gingivitis associated with dental plaque only:a) Without other local contributing factorsb) With local contributing factors (See VIII A)
  9. 9. 2.Gingival diseases modified by systemic factors a) Associated with the endocrine system 1. Puberty assoicated gingivitis 2. Menstrual cycle associated gigivitis 3. Pregnancy assoicated a) gingivitis b) pyogenic granuloma 1. Diabetes mellitus assoicated gingivitis c) assoicated with blood dyscrasias1. leukemia assoicated gingivitis2. Other3. Gingival diseases modified by medications
  10. 10. d) drug influenced gingival diseases1. drug influenced gingival enlargements2. drug influenced gingivitisa) oral contraceptive assoicated gingivitisb) other4.Gingival diseases modified by malnutritiona) ascorbic acid deficiency gingivitisb) otherB. Nonplaque induced Gingival lesions1. Gingival disease of specific bacterial origina. Nesseria gonorrhea assoicated lesionsb. Treponema pallidum associated lesionsc. Streptococcal species assoicated lesionsd. Others2. Gingival disease of viral origina) herpes virus infection3. primary herpetic gingivostomatitis4. recurrent oral herpes5. varicella zoster infections
  11. 11. b. other1. Gingival disease of fungal origina) candida species infections1. generalized gingival candidiasisb. linear gingival erythemac. histoplasmosisd. other4. Gingival lesions of genetic origina. hereditary gingival fibromatosisb. other5. Gingival manifestations of systemic conditionsa. mucocutaneous disorders1. lichen planus2. pemphigoid3. pemphigus vulgaris4. erythema multiforme5) Lupus erythematosus6) Drug-induced7) Other
  12. 12. b. Allergic reactions1) Dental restorative materials a) Mercury b) Nickel, c) Acrylic d) Other 2) Reactions attributable to a) Toothpaste’s /dentifrice’s b) Mouth rinses / mouth washes c) Chewing gum additives d) Foods and additives 3) Other
  13. 13. 6) Traumatic lesions (factitious, iatrogenic,accidental) a) Chemical injury b) Physical injury c) Thermal injury 7) Foreign body reactions 8) Not otherwise specified (NOS)
  14. 14. II. Chronic Periodontitis a) Localized b) GeneralizedIII. Aggressive Periodontitis a) Localized b) GeneralizedIV. Periodontitis as a manifestation of systemic diseases.A) Associated with hematological. disorders. 1) Acquired neutropenia 2) Leukemias 3) Other
  15. 15. B) Associated with genetic disorders1. Familial and cyclic Neutropenia2. Down syndrome3. Leukocyte adhesion deficiency syndromes4. Papillon - Lefevre syndrome5. Chediak – Higashi syndrome6. Histiocytosis syndrome7. Glycogen storage disease8. Infantile genetic agranulocytosis9. Cohen syndrome10. Ehlers – Danlos syndrome (Types IV and VIII)11. Hypophosphatasia12. Other
  16. 16. V. Necrotising Periodontal Diseasesa) Necrotising ulcerative gingivitisb) Necrotising ulcerative periodontitisVI. Abscesses of the periodontiuma) Gingival abscessb) Periodontal abscessc) Periocoronal abscessVII Periodontitis assoicated with endodontic lesionsA. Combined periodontal endodontic lesionsVIII. Developmental or Acquired Deformities and conditionsA. Localized tooth related factors that modify or predispose to plaqueinduced gingival disease / periodontitis1. Tooth anatomic factors2. Dental restorations / appliances3. Root fractures4. Cervical root resorption and cemental tears
  17. 17. B. Mucogingival deformities and conditions around teeth1. gingival / soft tissue recession a. facial or lingual surfaces b. interproximal (papillary)2. lack of keratinized gingiva3. decreased vestibular depth4. aberrant frenum / muscle position5. gingival excess a. pseudopocket b. inconsistent gingival margin c. excessive gingival display d. gingival enlargement (see section I, parts A3 and B4)1abnormal color
  18. 18. C. Mucogingival deformities and conditions on edentulousridges1. vertictal and / or horizontal ridge deficiency2. lack of gingiva / keratinized tissue3. gingiva / soft tissue enlargement4. aberrant frenum / muscle position5. decreased vestibular depth6. abnormal colorD. Occlusal trauma1. Primary occlusal trauma2. Secondary occlusal trauma
  19. 19. 1. GINGIVAL DISEASESDental plaque induced gingival diseases• Gingivitis that is associated with dental plaque formation is the most common form of the gingival disease.• It has been proved that plaque induced gingivitis may occurs on a periodontium with no attachment loss or on a periodontium with previous attachment loss that is stable and not progressing.
  20. 20. Gingivitis associated with dental plaque only• Plaque induced gingival disease is the result of an interaction between the microorganism found in the dental plaque biofilm and the tissues and inflammatory cell of host.• 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.
  21. 21. Gingival Diseases Modified by Systemic Factors• Systemic factors contributing to gingivitis, such as the endocrine changes associated with puberty, menstrual cycle, pregnancy and diabetes may be exacerbated because of the alterations in the gingival inflammatory response to plaque.• This is caused by the effects of the systemic conditions on the cellular and immunological functions of the host.• These changes are most apparent during pregnancy, when the prevalence and severity of gingival inflammation may increase even in the presence of low levels of plaque.
  22. 22. • Blood dyscrasias such as leukemia may alter immune function by disturbing the normal balance of immunologically competent white cells supplying periodontium.• Gingival enlargement and bleeding are common findings and may be associated with, swollen, spongy gingival tissues caused by excessive infiltration of blood cells.
  23. 23. Gingival Diseases Modified by medications:• Gingival diseases modified by medications are increasingly prevalent because of the increased use of anticonvulsant drugs, known to induce gingival enlargement.• Such as phenotoin, immunosuppressive drugs such as cyclosporine A, and calcium channel blockers such as nifedipine, verapamil, diltiazem and sodium valproate.
  24. 24. • The development and severity of gingival enlargement in response to medications is patient- specific and may be influenced by uncontrolled plaque accumulations.• The increased use of oral contraceptives by pre- menoposal woman has been associated with a higher incidence of gingival inflammation and development of gingival enlargement.
  25. 25. Gingival disease modified by Malnutrition• Gingival disease modified by malnutrition may have clinical descriptions of bright red, swollen and bleeding gingiva associated with severe ascorbic acid deficiency or scurvy.• Nutritional deficiencies are known to affect immune function a may have an impact on the hosts ability to protect itself against some of the detrimental effects of celluar products such as oxygen radicals.
  26. 26. Non – Plaque Incduced Gingival LesionsGingival Disease of Specific Bacterial Origin• These disease are increasing in prevalance especially as a result of sexually transmitted disease such as gonorrhea and to a lesser degree syphillis.• Oral lesions may be secondary to systemic infections or may occur through direct infection.• Streptococcal gingivitis or gingivo stomatitis is a rare condition that may present as an acute condition with fever, malaise and pain associated with acutely inflammed diffuse red, and swollen gingiva with increased bleeding and occasional gingival abscess formation.• The gingival infections usually are preceded by tonsillitis and have been associated with group A β hemolytic steptococcal infections.
  27. 27. Gingival disease of Viral Origin• It may be caused by a variety of deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) viruses, the most common being the herpes viruses.• Lesions are frequently related to reactivation of latent viruses especially as a result of reduced immune function.
  28. 28. Gingival Disease of Fungal Origin• It occurs most frequently on individuals who are immunocompromised or in whom the normal oral flora has been disturbed by long term use of broad spectrum antibiotics.• The most common oral fungal infection is candidiasis caused by infection with candida albicans which also can be seen under prosthetic devices the individuals using topical steriods and in individuals with decreased salivary flow increased salivary glucose, or decreased salivary pH.
  29. 29. • A generalized candidal infection may manifest as white patches on the gingiva, tongue or oral mucous membrane than can be removed with a gauze leaving a red, bleeding surface.• In HIV infected individuals candidal infection may present as erythema of attached gingiva and has been referred to as linear gingival erythema or HIV associated gingivitis.
  30. 30. Gingival Disease of Genetic Origin• One of the most clinically evident conditions is hereditary gingival fibromatosis that exhibits autosomal dominant or (rarely) autosomal recessive modes of inheritance.• The gingival enlargement may completely cover the teeth, delay eruption and present as an isolated finding or be associated with several more generalized syndromes.
  31. 31. Gingival Manifestations of Systemic Conditions• It may appear as desqumative lesions, ulceration of gingiva or both.• Allergic reactions that manifest with gingival changes are uncommon but have been observed in association with several restorative materials, tooth pastes, mouth washes, chewing gum and foods.
  32. 32. Traumatic Lesions Traumatic lesions may be factitial (produced by artificalmeans; unintentionally produced) as in the case of tooth brushtrauma resulting in gingival ulceration, recession or both;iatrogenic (trauma to the gingiva induced by the dentist orhealth professional) as in the case of preventive or restorativecare that may lead to traumatic injury of the gingiva; oraccidental as in the case of damage to the gingiva throughminor burns from hot food and drinks.
  33. 33. Foreign Body Reactions• Foreign body reactions lead to localized inflammatory conditions of the gingiva and are caused by the introduction of foreign material into the gingival connective tissues through breaks in epithelium• Eg. Introduction of amalgam into gingiva during the placement of restoration or an extraction of a tooth leaving an amalgam tatoo or the introduction of abrasives during polishing procedures.
  34. 34. CHRONIC PERIODONTITIS It is a common plaque induced periodontal infection that is major cause of tooth loss throughout the world. Its important clinical features are• Most prevalent in adults but can occur in children and adolescents.• Amount of destruction is consistent with the presence of local factors.• Associated with a variable microbial pattern• Slow to moderate rate of progression but may have periods of rapid progression.• Can be associated with local predisposing factors.• May be modified by or associated with systemic disease• Can be modified by or factors other than systemic disease such as cigarette smoking and emotional stress.
  35. 35. AGGRESSIVE PERIODONTITIS• Aggressive periodontitis is much less common than chronic periodontitis and affects a narrower range of younger patients.• It occurs in localized and generalized forms and the two forms differ in many respects with regard to their etiology and pathogenesis.• LAP and GAP were once called localized and generalized juvenile periodontitis respectively.• However these terms were replaced with LAP and GAP terminology because they do not depend on questionable age based classification criteria.
  36. 36. Both forms of aggressive periodontitis share the following common features.• Expect for the presence of periodontitis patients are otherwise clinically healthy• Rapid attachment loss and bone destruction• Familial aggregation
  37. 37. Some of the important secondary features of both forms of aggressive periodontitis are• Amount of microbial deposits are inconsistent with the severity of periodontal tissue destruction.• Increased proportions of Actinobacillus actino – mycetemcomitans and in some populations, Porphyromonas gingivalis may increased.• Phagocyte abnormalities• Hyper responsive macrophage phenotype, including increased levels of prostaglandin E2 and inter leukin – 1 β• Progression of attachment loss and bone loss may be self arresting
  38. 38. Specific features of localized and generalized aggressive periodontitis.Localized Aggressive Periodontitis• Circum Pubertal onset• Robust serum antibody to infecting agents• Localized first molar / incisor 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.
  39. 39. Generalized Aggressive Periodontitis• Usually affecting individuals less than 30 years but patients may be older• Poor serum antibody response to infecting agents• Pronounced episodic nature of the destruction of attachment and alveolar bone• Generalized interproximal attachment loss affecting at least three permanent teeth other than first molars and incisors.
  40. 40. Periodontitis as a manifestation of systemic diseases There are two general catogories of systemic disease that have periodontitis as a frequent manifestation1. Certain hematologic disorders (eg acquired neutropenia, leukemia) and2. Some genetic disease (eg. Familial / cyclic neutropenia, down syndrome, leucocyte adhesion deficiency syndromes, papillon lefevre syndrome).
  41. 41. NECROTIZING PERIODONTAL DISEASE• Necrotizing periodontal infections include necrotizing ulcerative gingivtis (NUG) and necrotizing ulcerative periodontitis (NUP).• In both the condition there is a rapid onset of pain associated with development of necrotic and ulcerative lesions of marginal gingiva, particularly involving interproximal sites.
  42. 42. NECROTIZING ULCERATIVE GINGIVITIS The two most significant criteria used for the diagnosis of NUG are 1. Presence of interproximal necrosis and ulceration 2. A histroy of rapid onset of gingival soreness and pain.• The interproximal necrosis and ulceration take the form of eroded crater like depressions of one or more interproximal gingival papillae sometimes referred to as having “ Punched Out” appearance.• Marked halitosis is present in most patients with NUG.• Some patients have a pseudomembrane covering the ulcerated areas of the gingiva.
  43. 43. It is a heterogenous film composed of fibrin, bacteria,sloughed epithelial cells and other debris. It can be easilyremoved or wiped of by frictional forces of eating and istherefore frequently absent. NUG are occasionally associatedwith lymphadenopathy, increased salivation, fever, malaviseand anorexia. Predisposing factors for NUG in adult patients fromNorth America and Europe include. 1. Emotional stress 2. Heavy cigarette somking 3. Lack of sleep 4. Poor dietary habits 5. Immunosuppression.
  44. 44. • In children from underdeveloped countries, NUG appears to be associated with malnutrition or the debilitating and immunosuppressive effects of viral or parasitic infection.• The common features of all the predisposing factors of NUG is that they decrease host resistance to periodontal infections.• In every immunosuppressed children, NUG is believed to be the first stage of noma or cancrum oris, a severe necrotic infection that caused massive destruction of the tissues of the oral cavity and the face.
  45. 45. Necrotizing Ulcerative Periodontitis• Compared to NUG, NUP always involves considerable loss of periodontal attachment and alveolar bone.• The term necrotizing ulcerative periodontitis did not appear in classification systems for periodontal disease until the later 1980s at the peak of the AIDS epidemic.• It was added to the classification systems primarily because of the increasing appearance of a rapidly destructive and intensely painful form of in HIV infected patients.
  46. 46. • In some patients with NUP there were exposure and sequestration of alveolar bone.• Severe immuno suppression from other sources such as cancer chemotherapy and advanced protein energy malnutrition also can lead to the development of NUP.
  47. 47. ABSCESSES OF PERIODONTIUM An abscess is a circumscribed collection of pus. Factors that predispose to abscess formation are1. Deep periodontal pockets.2. Incomplete removal of sublingival calculus during scaling and root planing3. Occlusion of the pocket orifice by foreign bodies4. Administration of antibiotics to patients with periodontitis in the absence of mechanical therapy
  48. 48. Periodontitis Associated with Endodontic Leisions• Infections of periapical tissues caused by the pulpal death (i.e endodontic lesions) can often locally join with separate infections emenating from periodontal pockets.• This coalescence of endodontic and periodontal infections has termed combined periodontal– endodontic lesions.
  49. 49. Developmental or Acquired Deformities and Conditions• There are many developmental or acquired deformities and conditions of periodontal tissues that technically are not disease.• They are included in most classifications of periodonatl disease because they may be important modifiers of susceptibility to periodontal infections or can dramatically influence treatment outcomes.
  50. 50. Localized tooth related factors that modify or predispose to plaque induced periodontal diseases.• Tooth related factors that can be associated with an increased risk for development of plaque induced periodontal disease include, cervical enamel projections, enamel pearls, furcation anatomy, tooth position, root proximity and anamalous grooves in roots.• Defect in dental restorations such as poor contours and marginal discrepancies can increase the risk of periodontal infections.
  51. 51. Mucogingival Deformities and conditions around Teeth Mucogingival deformities refer to a group of congenital,developmental, or acquired defects in the normal relation betweenkeratinized gingival tissues and nonkeratinized alveolar mucous. Thesedeformities are1. Gingival/soft tissue recession - Facial or lingual surfaces - Inter proximal (papillary)2. Lack of keratinzed gingiva3. Decreased vestibular depth4. Aberrant frenum/muscle position5. Gingival excess - Pseuodpockets - Inconsistent gingival margin - Excessive gingival display - Gingival enlargement6. Abnormal
  52. 52. Mucogingival Deformities and Conditions on Edentulous Ridges.There are:• Vertical and/or horizontal ridge deficiency• Lack of gingival /keratinized tissue• Gingival / soft tissue enlargement• Aberrant frenum /muscle position• Decreased vestibular depth• Abnormal color.
  53. 53. Occlusal Trauma:Damage to periodontal tissues can occur during avariety of conditions involving occlusal loads andforces that exceed the capacity of the periodontium towith stand them eg: Primary occlusal trauma Secondary occlusal trauma
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