Classification of Periodontal Diseases Flashcards
What are the guidelines for treating periodontal disease during pregnancy
Treat periodontitis before patients get pregnant although this may not be possible
Provide non-surgical treatment in the second trimester
Avoid ‘traumatic’ procedures during pregnancy e.g RSD or perio surgery
What is the minimum treatment for those who are pregnant
supportive periodontal care
Why do we classify
- So we can properly diagnose and treat patients
- For research purposes so scientists can investigate aetiology, pathogenesis, natural history, treatment of diseases and conditions
What is periodontitis split into
localised
generalised
molar incisor pattern
What is localized periodontitis
less than 30% of teeth effected
What is generalized periodontitis
more than 30% of teeth are effected
What was aggressive periodontitis classification replaced with
a staging and grading system was created instead that is based upon bone loss and classifies disease
What are the stages and grades based on
○ 4 stages based on severity (I, II, III, or IV)
3 grades based on disease susceptibility (A, B or C)
What is staging based on
the severity of disease, complexity of management and the worst site of interproximal bone loss
What is stage 1 periodontitis
Early/mild severity
<15% or 2mm bone loss at worst site
What is stage 2 periodontitis
Moderate severity
Bone loss at worst site includes the coronal third of the root
What is stage 3 periodontitis
Severe (potential for additional tooth loss)
Bone loss at worst site includes mid third of the root
What is stage 4 periodontitis
Very severe (potential for loss of dentition) Bone loss at worst site includes apical third of root
How do we measure bone loss in staging
• Use bitewings to measure bone loss but if they aren’t available then measure from the CEJ
If someone is known to have lost teeth from perio what stage can we assign them to
can automatically be assigned to stage 4
When looking at severity in staging what do we look at
Inderdental clinical attachment loss at site of greatest loss
Radiographic bone loss
Tooth loss
When looking at complexity in staging what do we look at
○ What is the max probing depth? Larger the depth the more complex
○ Horizontal bone loss or vertical bone loss? Vertical is more complex
○ Furcation involvement? What class?
○ Ridge defect?
Bite defect?
What is grade A
Slow progression
Maximum bone loss is less than 50% of their age
What is grade B
Moderate progression
Maximum bone loss is between 50% and 100% of their age
What is grade C
Rapid progression
Maximum bone loss is greater than 100% of their age
When looking at progression what do we look at
direct evidence of progression
indirect evidence of progression
What determines staging
progression
bone loss in relation to age
risk factors
What is direct evidence of progression
§ Longitudinal date (radiographic bone loss or the clinical attachment loss) and over how long the bone loss has occurred
What is indirect evidence of progression
§ % bone loss/age
Case phenotype - is the destruction about right for the amount of biofilm?
What risk factors can modify the grade
○ Smoking - how many cigarettes?
Diabetes - well controlled?
How is extent of periodontitis determined
• Localised (less than 30% of teeth effected)
• Generalised (more than 30% of teeth effected)
Molar incisor pattern (more seen in younger px)
If a patient gets BPE code 0/1/2 what should next be investigated
bleeding on probing - the diagnosis is split on:
<10%
10-30%
>30%
What is <10% BOP for codes 0-2
clinical gingival health
What is 10-30% BOP for codes 0-2
localized gingivitis
What is >30% BOP for codes 0-2
generalized gingivitis
If there is a code 3 after BPE what should be done
appropriate radiographic assessment
initial periodontal therapy and review in 3 months with localized 6PPC in involved sextants
If there is a code 4 what should be done
appropriate radiographic assessment
full periodontal assessment
After staging and grading what should be assessed
current perio status
risk factor assessment
What determines currently stable periodontitis
BOP <10%
PPD <=4mm
No BOP at 4mm sites
What determines currently in remission periodontitis
BOP >=10%
PPD <=4mm
No BOP at 4mm sites
What determines currently unstable periodontitis
PPD >= 5mm or PPD>=4mm and BOP
What is the diagnosis statement
extent, periodontitis, stage, grade, stability, risk factors
What are the two options for BPE 3
○ Option 1 = if a sextant scores a 3 then this sextant should be reviewed after initial treatment and a 6 point pocket chart completed for that sextant only
○ Option 2 = if a sextant scores 3, a 6 point pocket chart should be completed for that sextant before and after treatment (full perio examination of all teeth and RSD)
When a code 3 is only observed in one sextant, carry out full periodontal exam and RSD in that sextant only
What is required to come to a diagnosis
To come to a diagnosis the following is required • Medical • Dental history • Oral examination Further investigations
What questions do we ask in diagnostic pathway
what disease does the px have how extensive is the disease is the disease active or controlled how severe is the disease what is the patients risk profile what is the rate and risk of disease progression
What are limitations of BPE
• It is a screening tool employed to rapidly guide clinicians to arriving at a provisional diagnosis of periodontal health, gingivitis or periodontitis irrespective of historical attachment loss and bone loss (irrespective of staging and grading)
Therefore the BPE guides the need for further diagnostic measures prior to establishing a definitive periodontal diagnosis and appropriate treatment planning
What may a perio patient represent a case of following therapy
○ Health in a successfully treated patient (stable)
○ Recurrent gingival inflammation (BOP equal to or greater than 10%) at sites with PPD < 3mm and no PPD > 4mm (disease remission)
○ Recurrent periodontitis, bleeding sites >= 4mm or any PPD >= 5mm (unstable)
Does 4mm mean active disease
- The 4mm threshold is critical as it determines periodontal disease stability at non-bleeding sites following successful periodontal therapy
- A higher probing depth of 5mm or 6mm in the absence of bleeding may not always represent active disease - in particular soon after periodontal treatment.
- Therefore clinicians need to exercise clinical judgements when considering the need or lack of need for additional treatment such as re-instrumentation or surgery for such sites
Why may there be a reduced periodontium other than periodontitis
○ An example of other things that cause loss of attachment are crown lengthening surgery or wisdom tooth extraction that leaves a defect on the distal of the 7
What is clinical gingival health on an intact periodontium characterized by
○ The absence of bleeding on probing
○ Erythema and oedema
○ Patient symptoms
○ Attachment and bone loss
What do physiological bone levels range from
1.0 to 3.0mm apical to the CEJ
For an intact periodontium and a reduced stable periodontium, what is gingival health defined as
○ <10% bleeding sites
No pockets exceeding 3mm depth
Can gingivitis only be on an intact periodontium
• You can have gingivitis on an intact or reduced periodontium (not periodontitis cause)
What is gingivitis associated with
dental biofilm alone
What is gingivitis mediated by
systemic or local risk factors (e.g medical conditions or overhanging restorations)
What is the difference between health and gingivits for an intact periodontium
only difference is gingivitis, BOP >10%
What is the difference between health and gingivitis for a reduced periodontium (non perio px)
only difference is gingivitis, BOP >10%
bone loss may be seen in both healthy and gingivitis patients
What are modifying factors
systemic conditions
oral factors enhancing plaque accumulations
What are systemic conditions that can make perio disease worse
sex steroid hormones hyperglycaemia leukemia smoking malnutrition
What are the sex steroid hormones that can impact perio
□ Puberty
□ Menstrual cycle
□ Pregnancy - can get pregnancy epulis (considered a mucogingival deformity)
□ Oral contraceptives
What are oral factors that enhance plaque accumulated,ation
§ Prominent subgingival restoration margins
§ Hyposalivation
What can non plaque induced gingival disease be due to
genetic developmental disorders specific infections inflammatory and immune conditions reactive processes nutritional deficiency neoplasms endocrine nutritional and metabolic disease traumatic lesions gingival pigmentation
What are genetic/developmental disorders that cause non plaque induced gingival disease and conditions
hereditary gingival fibromatosis
What are specific infections that can result in gingival disease
Herpetic gingival stomatitis
□ Common in children
□ Presents with red inflammation of the gingivae
□ Child is usually taken to the GP who gives antibiotics but doesn’t do anything
What are immune and inflammatory conditions that can cause gingival disease
§ E.g lichen planus
§ E.g benign mucous membrane pemphigoid
What are the 3 types of necroticising periodontal disease
necrotising gingivits
necrotising periodontitis
necrotising stomatitis
What is necrotising gingivitis
○ It is necrosis and ulcers in the interdental papilla
○ There is gingival bleeding
○ Pain
○ Pseudo membrane formation
○ Bad breath (halitosis)
○ Extra oral symptoms too - regional lymphadenopathy (44-61%)/fever (20-39%)
○ In children, pain and halitosis is less frequent whereas fever, lymphadenopathy and sialorrhea were more frequent
What is necrotising periodontitis
○ In addition to the signs and symptoms of NG the following is seen
§ Periodontal attachment and bone destruction
§ Frequent extra-oral signs
§ In severely immune compromised patients, bone sequestrum may occur
What is necrotising stomatitis
○ Bone denudation extended through alveolar mucosa
Larger areas of osteitis and bone sequestrum
What results in periodontitis as a manifestation of systemic disease
• It is mainly rare diseases that affect the course of periodontitis resulting in the early presentation of severe periodontitis ○ Papillion lefevre syndrome ○ Leucocyte adhesion deficiency ○ Hypophosphatasia ○ Down's syndrome ○ Ehlers danlos
What are systemic diseases or conditions that affect periodontal tissues
• Mainly rare conditions affecting the periodontal supporting tissues independently of dental plaque biofilm-induced inflammation
• This is a more heterogenous group of conditions which result in breakdown of periodontal tissues and some of which may mimic the clinical presentation of periodontitis
Examples include squamous cell carcinoma and Langerhans cell histiocytosis
What is the effect of diabetes on perio
• Common systemic diseases such as uncontrolled diabetes mellitus have variable effects on the course of periodontitis which appear to be part of the multifactorial nature of complex diseases such as periodontitis and are included in the new clinical classification of periodontitis as a descriptor in the staging and grading process
Which patients get perio abscesses
• The majority of patients with periodontal abscesses already have periodontal diseases
What can the causes of a periodontal abscess be split into
periodontal abscess in periodontitis patients (in a pre-exisitng periodontal pocket)
periodontal abscess in non-periodontitis pocket (not mandatory to have a pre-exisitng periodontal pocket)
What can result in a periodontal abscess in a perio patient
§ Acute exacerbation § After treatment □ Post surgery □ Post scaling Post medication
What can result in a periodontal abscess in a non perio patient
§ Impaction § Harmful habits (wire or nail biting) § Orthodontic factors/forces § Gingival overgrowth § Alteration of root surface
Classify periodontal-endodontic lesions
Can be with or without root damage
What can periodontal-endodontic lesions with root damage be due to
○ Root canal fracture or cracking
○ Root canal or pulp chamber perforation
○ External root resorption
What can periodontal-endodontic lesions without root damage be due to
○ Endo-periodontal lesion in periodontitis patients
○ Endo-periodontal lesion in non-periodontitis patients
What are mucgongival deformities and conditions
• Mucogingival deformities and conditions around teeth lack of keratinised gingiva/aberrant frenal attachment
What is gingival recession split into
RT1
RT2
RT3
What is RT1 gingival recession
gingival recession with no loss of interproximal attachment. Interproximal CEJ is clinically not detectable at both the mesial and distal aspects of the tooth
What is RT2 gingival recession
gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss is less than or equal to the buccal attachment loss
What is RC3 gingival session
gingival recession associated with loss of interproximal attachment. Amount of attachment loss is greater than the buccal attachment loss
