Classifications

Question 1

1999 classifications (used)

Answer 1

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?

Question 2

one bleeding site but overall in tact periodontium

Answer 2

diagnosis of gingival health

Question 3

loss of inter-proximal attachment between incisors

no pockets

Answer 3

previous periodontitis

- no longer in tact periodontium but not active

Question 4

aims of 2018 disease classifications (4)

Answer 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)

Question 5

step 1 of 2018 classifications

Answer 5

What type of periodontal disease does the patient have

commonalities exist between

Question 6

periodontitis in 2018 classification

Answer 6

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).

Question 7

staging perio

Answer 7

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

Question 8

stage 1

Answer 8

early mild

<15% or 2mm interproximal bone loss

Question 9

stage 2

Answer 9

moderate

coronal third of root interproximal bone loss

Question 10

stage 3

Answer 10

severe (potential for additional tooth loss)

mid third of root interproximal bone loss

Question 11

stage 4

Answer 11

very severe (potential for loss of dentition)

apical third of root interproximal bone loss

Question 12

grading

Answer 12

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 -

Question 13

grade A

Answer 13

slow progression

Percent bone loss/age
<0.5
- max bone loss less than half pt age

Question 14

grade B

Answer 14

moderate progression

Percent bone loss/age

0. 5-1.0
   - everything else

Question 15

grade C

Answer 15

rapid progression

Percent bone loss/age
>1.0
- max bone loss more than patient age

Question 16

extent perio

Answer 16

Captures distribution

• Localised (<30% of teeth)
• Generalised (more than 30% of teeth)
• Molar incisor pattern

Question 17

localised perio

Answer 17

<30% of teeth

Question 18

generalised perio

Answer 18

more than 30% of teeth

Question 19

BPE tool

Answer 19

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

Question 20

diagnostic pathway

Answer 20

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”

Question 21

action on BPE 3

Answer 21

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)

Question 22

diagnosis based on

Answer 22

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’

Question 23

diagnostic pathway Qs

Answer 23

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?

Question 24

diagnose

58 years old 
Non smoker
Fit and well 
25% BOP 
Probing pocket depths all <4mm

Answer 24

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

Question 25

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 ```

Answer 25

Stage 3 / 4 Grade C Generalised Perio Unstable No obvious risk

Question 26

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

Answer 26

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

Question 27

BPE use in diagnosis of perio

Answer 27

of limited value in patients who have already been diagnosed with periodontitis. - Interproximal attachment loss - do 6PPC - BPE doesn’t help in perio already

Question 28

how long a perio pt

Answer 28

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)

Question 29

4mm cut off complexity

Answer 29

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

Question 30

bleeding at 4mm site in perio

Answer 30

assume on way to recurrent perio - thus unstable

Question 31

pockets larger than 4mm

Answer 31

4mm pt cant clean into it - less stable greater risk of progression than 4mm of less

Question 32

gum health states

Answer 32

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

Question 33

3 definitions of periodontal health

Answer 33

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

Question 34

gingival health

Answer 34

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.

Question 35

plaque induced gingivitis (localised/generalised gingivitis)

Answer 35

- Intact periodontium - Reduced periodontium Associated with dental biofilm alone Mediated by systemic or local risk factors Drug influenced gingival enlargement

Question 36

modifying factors for plaque induced gingivitis

Answer 36

``` Sex steroid hormones Hyperglycaemia Leukaemia Smoking Drug induced Malnutrition poor restorative margins ```

Question 37

hormones effect on gingivitis

Answer 37

- 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

Question 38

pregnancy epulis

Answer 38

considered a mucogingival deformity) - No radiological bone loss - No interdental recession

Question 39

drugs that can modify gingivitis

Answer 39

drug influenced gingival enlargement - Ca channel blockers - Cyclosporin immunosuppressants Enlargement of papilla – distinctive

Question 40

non plaque induced gingival diseases and conditions

Answer 40

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 ```

Question 41

nutritional deficiency effect on gingiva

Answer 41

vitamin C deficiency rare e.g. clean teeth but inflammation of gingiva persisting

Question 42

necrotising periodontal diseases

Answer 42

necrotising gingivitis necrotising periodontitis necrotising stomatitis

Question 43

necrotising gingivitis

Answer 43

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

Question 44

necrotising periodontitis

Answer 44

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

Question 45

necrotising stomatitis

Answer 45

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

Question 46

how to deal with necrotising periodontal diseases

Answer 46

``` figure out what is causing the necrotising disease in patient - stress - malnourished - underlying viral infection immunosuppressant ``` control underlying causes

Question 47

periodontitis as a manifestation of systemic disease

Answer 47

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

Question 48

systemic diseases or conditions affecting the periodontal tissues

Answer 48

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.

Question 49

periodontal abscesses

Answer 49

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)

Question 50

periodontic- endodontic lesion

Answer 50

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

Question 51

periodontic- endodontic lesion - 2 types

Answer 51

With root damage Endo-periodontal lesion without root damage

Question 52

mucogingival deformities and conditions

Answer 52

around teeth lack of keratinised gingiva/aberrant frenal attachment Type of recession dictates what Tx can be done - 1, 2, 3

Question 53

recession type 1

Answer 53

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

Question 54

recession type 2

Answer 54

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

Question 55

recession type 3

Answer 55

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

Question 56

categories in 207/8 disease classifications

Answer 56

1. health 2. plaque induced gingivitis (localised/generalised gingivitis) 3. non plaque induced gingival disease and conditions 4. periodontitis (localised, generalised, molar incisor) 5. necrotising periodontal diseases 6. periodontitis as a manifestation of systemic diseases 7. systemic diseases or conditions affecting periodontal tissues 8. periodontal abscesses 9. periodontal-endodontic lesions 10. mucogingival deformities and conditions