Classifications Flashcards
1999 classifications (used)
Gingival diseases
II Chronic periodontitis
III Aggressive periodontitis
IV Periodontits as a manifestation of systemic diseases
V Necrotising periodontal diseases
VI Abscesses of the periodontium
VII Periodontitis associated with endodontic lesions
VIII Developmental or acquired deformities and conditions
- Problems
Ag P features vs chronic periodontitis - more likely to be genetic
often in young patients..
.. ’Usually affecting persons under 30 years of age, but patients may be older’ - etc - very woolly – room for interpretation
- Diagnosis of gingival health? If this case has one bleeding site is it a gingivitis case?
one bleeding site but overall in tact periodontium
diagnosis of gingival health
loss of inter-proximal attachment between incisors
no pockets
previous periodontitis
- no longer in tact periodontium but not active
aims of 2018 disease classifications (4)
Capture extent, severity
- Amount of periodontal tissue loss
Patient susceptibility
- Estimate by historical rate of progression
Current periodontal state
- Pocket depths/bleeding on probing
A system that can be future proofed for update with new biomarker information
- So don’t have to back date and rejig (e.g. salivary tests)
step 1 of 2018 classifications
What type of periodontal disease does the patient have
commonalities exist between
periodontitis in 2018 classification
Localised (less than or equal to 30% teeth)
Generalised (greater than 30% teeth)
Molar-incisor pattern
The term “aggressive periodontitis” was removed, creating a: staging and grading system for periodontitis that is based upon bone loss and classifies the disease into
4 stages based on severity (I, II, III or IV) BONE LOSS MAINLY
3 grades based on disease susceptibility (A, B or C).
staging perio
4 stages based on severity (I, II, III or IV) BONE LOSS MAINLY
Coronal third, middle third and apical third bone loss
Find worst site of interproximal bone loss and stage on that
Loss teeth due to perio = apical third of root thus stage 4
As long as can see bone level and no indication to take periapical and measure bone loss from CEJ
stage 1
early mild
<15% or 2mm interproximal bone loss
stage 2
moderate
coronal third of root interproximal bone loss
stage 3
severe (potential for additional tooth loss)
mid third of root interproximal bone loss
stage 4
very severe (potential for loss of dentition)
apical third of root interproximal bone loss
grading
captures progression
- A, B , C
Percent bone loss/age
- Worst site of bone loss - assign percentage (Apical third is greater than 60-70%)
- Need pt age
E.g
60 yo and 20% bone loss = slowly progressing
20yo and 60% (3 times age) clearly rapidly progressing -
grade A
slow progression
Percent bone loss/age
<0.5
- max bone loss less than half pt age
grade B
moderate progression
Percent bone loss/age
- 5-1.0
- everything else
grade C
rapid progression
Percent bone loss/age
>1.0
- max bone loss more than patient age
extent perio
Captures distribution
- Localised (<30% of teeth)
- Generalised (more than 30% of teeth)
- Molar incisor pattern
localised perio
<30% of teeth
generalised perio
more than 30% of teeth
BPE tool
screening
- employed to rapidly guide clinicians to arrive at a provisional diagnosis of periodontal health, gingivitis or periodontitis, irrespective of historical aHachment loss and bone loss (i.e., irrespective of staging and grading). As such, the BPE guides the need for further diagnos6c measures prior to establishing a defini6ve periodontal diagnosis and appropriate treatment planning.
How much more need to do and how much more diagnostic tools needed
- if they have interdental recession - they have perio - so want pocket chart
diagnostic pathway
Identify the type and extent of periodontal disease (if periodontitis then with staging and grading)
Identification of current health/disease status (PPD and BoP)
The final diagnosis includes these components in a “diagnostic statement”
action on BPE 3
Option 1 (BSP Guidelines) 0 If a sextant scores 3, this sextant should be reviewed AFTER initial treatment and a 6 point pocket completed for that sextant only (and only aeer treatment)
Option 2 (SDCEP - If a sextant scores 3, a 6 point pocket chart should be completed for that sextant BEFORE treatment and AFTER. ‘full periodontal examination of all teeth and root surface instrumentation where necessary (N.B. Where code 3 is observed in only one sextant, carry out full periodontal examination and root surface instrumentation of affected teeth in that sextant only)
diagnosis based on
Medical
Dental history
Oral examination
Further investigations
The diagnostic pathway
- Identify the type and extent of periodontal disease (if periodontitis then with staging and grading)
- Identification of current health/disease status (PPD and BoP)
The final diagnosis includes these components in a ‘diagnostic statement’
diagnostic pathway Qs
How extensive is the disease?
what disease is it?
how severe is the disease? (stage)
is the disease uncontrolled/active or controlled?
what is the rate and risk of disease progression? (grade)
what is the pt risk profile?
diagnose
58 years old Non smoker Fit and well 25% BOP Probing pocket depths all <4mm
Yes there is interproximal
- Had/has periodontitis
60% bone loss
- so stage 3
Grade B
- on the line as patient 58 so below or above 60%
Generalised
Unstable
- as 25% BOP
diagnose
24 years old Non smoker Fit and well 85% BOP BPE 4/4/4 4/4/4 Full pocket chart – probing pocket depths greater than 6mm at all sites Radiographs taken
Stage 3 / 4
Grade C
Generalised
Perio
Unstable
No obvious risk
A 49 year old female patient who had recently moved into the area, presented in good general health. Specifically, she had not been diagnoses with diabetes mellitus, was not taking any medications regularly, reported a healthy diet and low stress levels, and was never a smoker. She reported a history of several courses of periodontal treatment by her previous GDP. Clinical examination revealed overt interproximal recession/clinical attachment loss
deep pockets (>5mm) on seven teeth with pocket
Interproximal attachment loss so periodontitis
Rather clean teeth currently - so OH seems adequate, maybe more likely genetic cause
Stage 4 - into apical third
C - more bone loss that 49%
Pocket chart - Unstable
Generalised - more than 60%
No risk factors from history
BPE use in diagnosis of perio
of limited value in patients who have already been diagnosed with periodontitis.
- Interproximal attachment loss - do 6PPC
- BPE doesn’t help in perio already
how long a perio pt
successfully treated periodontitis patient remains a periodontitis patient for life - the disease may progress at any timeme if periodontal maintenance is sub-optimal and risk factors are not controlled.
At any given time following therapy a periodontitis patient may represent a case of
- health in a successfully treated patient (stable)
- recurrent gingival inflammation (BoP ≥10%) at sites with PPD < 3mm and no PPD > 4mm (disease remission)
- recurrent periodontitis, bleeding sites ≥ 4mm or any PPD ≥ 5mm (unstable)
4mm cut off complexity
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 judgments when considering the need or lack of need for additional treatment such as reinstrumentation or surgery for such sites.
4mm threshold determines disease stability at nonbleeding sites
- No bleeding plaque control good and recent RSD might just be site needs longer to heal
Think of all previous treatment in context pt pocket depths
bleeding at 4mm site in perio
assume on way to recurrent perio - thus unstable
pockets larger than 4mm
4mm pt cant clean into it - less stable greater risk of progression than 4mm of less
gum health states
intact periodontium
reduced periodontium
- see gingival interdental recession due to cause other than periodontits e.g. crown lengthening surgery, defect left on distal of 7 after wisdom tooth extraction
3 definitions of periodontal health
Patients with an intact periodontium,
patients with a reduced periodontium due to causes other than periodontitis, and
patients with a reduced periodontium due to periodontitis
gingival health
Clinical gingival health on an intact periodontium is characterized by the absence of bleeding on probing, erythema and edema, patient symptoms, and attachment and bone loss. Physiological bone levels range from 1.0 to 3.0 mm apical to the cemento-enamel junction. (parameters of health)
For an intact periodontium and a reduced and stable periodontium, gingival health is defined as < 10% bleeding sites with probing depths ≤3 mm.
plaque induced gingivitis (localised/generalised gingivitis)
- Intact periodontium
- Reduced periodontium
Associated with dental biofilm alone
Mediated by systemic or local risk factors
Drug influenced gingival enlargement
modifying factors for plaque induced gingivitis
Sex steroid hormones Hyperglycaemia Leukaemia Smoking Drug induced Malnutrition poor restorative margins
hormones effect on gingivitis
- Modified by puberty
- Mestural cycle
- pregnancy
- Oral contraceptive
Hormonal change by itself will not cause gingivitis – plaque causes it and changes in hormones exaggerate the response
pregnancy epulis
considered a mucogingival deformity)
- No radiological bone loss
- No interdental recession
drugs that can modify gingivitis
drug influenced gingival enlargement
- Ca channel blockers
- Cyclosporin immunosuppressants
Enlargement of papilla – distinctive
non plaque induced gingival diseases and conditions
rare, seek specilalist help to get diagnosis (BIPSY)
genetic/developmental disorders
- e.g hereditary gingival fibromatosis, Doesn’t recur after surgical reception
specific infections
- e.g. herpetic gingival stomatitis, Candida albicans
- common in children, red inflammation of gingivae, antibiotics no help
inflammatory and immune conditions (lichen planus)
reactive processes neoplasms endocrine, nutritional and metabolic diseases traumatic lesions gingival pigmentation
nutritional deficiency effect on gingiva
vitamin C deficiency
rare
e.g. clean teeth but inflammation of gingiva persisting
necrotising periodontal diseases
necrotising gingivitis
necrotising periodontitis
necrotising stomatitis
necrotising gingivitis
necrosis and ulcer in the interdental papilla (94–100%)
gingival bleeding (95– 100%)
pain (86–100%)
pseudomembrane formation (73–88%)
halitosis (84–97%).
extraoral - regional lymphadenopathy (44–61%) / fever (20-39%)
In children, pain and halitosis less frequent, whereas fever, lymphadenopathy, and sialorrhea were more frequent.
White grey fibrin coating of interdental papilla
Sloughing
necrotising periodontitis
in addition to the signs and symptoms of NG
periodontal attachment and bone destruction
frequent extraoral signs
In severely immune-compromised patients, bone sequestrum may occur
Visible ulceration
Sloughing
Most severe at papilla (start point) spread into necks of papilla
necrotising stomatitis
bone denudation extended through the alveolar mucosa
- lose chunks of bone from alveolar process
larger areas of osteititis and bone sequestrum,
Creator type defect
Dramatic loss of bone and tissue – aesthetic compromise
Can happen quickly
how to deal with necrotising periodontal diseases
figure out what is causing the necrotising disease in patient - stress - malnourished - underlying viral infection immunosuppressant
control underlying causes
periodontitis as a manifestation of systemic disease
Classification is based on the primary systemic disease
Mainly rare diseases that affect the course of periodontitis resulting in the early presentation of severe periodontitis.
- Papillon Lefevre Syndrome
- Leucocyte adhesion deficiency
- Hypophosphatasia
- Down’s syndrome
- Ehlers-Danlos
process is similar but presents earlier
systemic diseases or conditions affecting the periodontal tissues
Mainly rare conditions affecting the periodontal supporting tissues independently of dental plaque biofilm-induced inflammation.
This is a more heterogeneous group of conditions which result in breakdown of periodontal tissues and some of which may mimic the clinical presentation of periodontitis.
- Squamous cell carcinoma
- Langerhans cell histiocytosis
Get a biopsy if radiograph doesn’t look right – could be cancer
Common systemic diseases, such as uncontrolled diabetes mellitus, with variable effects that modify the course of periodontitis 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.
periodontal abscesses
common
pus draining through pocket or sinus
think of cause
- In periodontitis patients in a pre-existing pocket
- In non-periodontitis patients (not needed to have a pre-existing pocket)
(Ligature of rubber dam, chewing on something etc)
periodontic- endodontic lesion
Mindful of what is the cause of source of pus draining
With root damage
- Root fracture/cracking
- Root canal or pulp chamber perforation
- External root resorption
Endo-periodontal lesion without root damage
- Endo-periodontal lesions in periodontitis patients
- Endo-periodontal lesions in non-periodontitis patients
periodontic- endodontic lesion - 2 types
With root damage
Endo-periodontal lesion without root damage
mucogingival deformities and conditions
around teeth lack of keratinised gingiva/aberrant frenal attachment
Type of recession dictates what Tx can be done
- 1, 2, 3
recession type 1
Gingival recession with no loss of inter- proximal attachment. Interproximal CEJ is clinically not detect- able at both mesial and distal aspects of the tooth.
Interproximal attachment is mainly in tact, narrow localised recession defect
- Surgical intervention can help – increase width of keratinised tissue so easier to clean
recession type 2
Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss (measured from the interproximal CEJ to the depth of the interproximal sulcus/pocket) is less than or equal to the buccal attachment loss (measured from the buccal CEJ to the apical end of the buccal sulcus/pocket).
Little bit of attachment but apical extent is still greater than interproximal
- Little you can do – may or may not work
recession type 3
Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss (measured from the interproximal CEJ to the apical end of the sulcus/pocket) is greater than the buccal attachment loss (measured from the buccal CEJ to the apical end of the buccal sulcus/pocket).
Papilla is completely gone, nothing left interdentally
- Not able to do anything to improve appearance
categories in 207/8 disease classifications
- health
- plaque induced gingivitis (localised/generalised gingivitis)
- non plaque induced gingival disease and conditions
- periodontitis (localised, generalised, molar incisor)
- necrotising periodontal diseases
- periodontitis as a manifestation of systemic diseases
- systemic diseases or conditions affecting periodontal tissues
- periodontal abscesses
- periodontal-endodontic lesions
- mucogingival deformities and conditions
