Classifications of Periodontal Disease

Question 1

What are necrotising periodontal diseases?

Answer 1

A unique type of periodontal disease that involves tissue necrosis. They are non-contagious and occur in less than 1% of people in developed countries.

Question 2

What are the symptoms of necrotising periodontal disease?

Answer 2

• Painful bleeding gums
• Ulceration and necrosis of papilla
• ‘Punched out’ appearance of gums

Question 3

Categorise necrotising periodontal diseases into three broad types.

Answer 3

• Necrotising gingivitis (only gingival tissues affected)
• Necrotising periodontitis (progresses to PDL and alveolar bone)
• Necrotising stomatitis (progresses to deeper tissue beyond mucogingival line, including lip/cheek/tongue)

Question 4

What conditions predispose a patient to necrotising stomatitis?

Answer 4

Malnutrition and HIV

Question 5

What is cancrum oris?

Answer 5

Necrotising destructive infection of the mouth and face, not technically periodontal disease - but some evidence suggests it can develop from necrotising periodontal disease.

Question 6

What are the symptoms of necrotising gingivitis?

Answer 6

Ulcerated and necrotic papillae, ulcers are covered by yellow grey psudomembrane, that when removed causes bleeding.

Question 7

What is the psudomembrane of necrotising gingivitis made of?

Answer 7

A slime with no coherence, made of fibrin, necrotic tissue, leukocytes, erythrocytes, and a mass of bacteria.

Question 8

What are the symptoms of necrotising periodontitis?

Answer 8

Ulcerations similar to that of NG, but associated with deep pockets. Psudomembrane not obvious if present at all. Adenopathies are found in the most severe cases of the disease.

Question 9

What are the symptoms of necrotising stomatitis?

Answer 9

Disease develops through bone, causing necrotic tissue to form. Sequestrated bone may appear, with large areas of osteitis/OAF.

Question 10

Why is it difficult to test for NPD?

Answer 10

Histopathology is not pathognomic (not characteristic) for NPD - so biopsy isn’t able to confirm.

Microbiology is not characteristic either, as there are a large array of bacterial types which don’t necessarily indicate NPD.

Question 11

List five diseases that can be confused with NPD.

Answer 11

• Oral mucositis
• HIV associated periodontitis
• Herpes simplex virus (HSV)
• Scurvy
• Gingivostomatitis

Question 12

How can you differentiate between NPD and primary herpetic gingivostomatitis (PHG)?

Answer 12

NPD won’t have identifiable bacteria, will rarely appear outside the gingiva, and result in permanent destruction of periodontal tissue.

Question 13

What are the risk factors for NPD?

Answer 13

• Stress
• Sleep deprivation
• Poor OH
• smoking
• Immunosuppression
• Malnutrition

Question 14

What treatment is there for necrotising periodontal disease?

Answer 14

• Superficial debridement (PMPR) softly and under LA if required
• Tooth brushing discouraged as can interrupt healing
• Chlorhexidine mouthwash, 0.12-0.2% twice daily.
• If systemic symptoms unresolved consider antimicrobial prescription.

Question 15

What antibiotic and what dose should be recommended for a NPD patient who has not responded to initial treatment?

Answer 15

Metronidazole 400mg TID for 3 days

Question 16

Why should locally delivered antimicrobials not be recommended to treat NPD?

Answer 16

Not enough concentration of drug to deal with the high levels of bacteria, so they will be ineffective.

Question 17

How often should a patient be followed up with after presenting with NPD?

Answer 17

Daily if possible, and as signs and symptoms start to improve strict OH measures and PMPR should be used.

Question 18

What aesthetic consequence of NPD are most common?

Answer 18

Gingival craters

Question 19

How can you treat gingival craters?

Answer 19

• Gingivectormy
• Gingivoplasty
• PD flap surgery
• Regenerative surgery

Question 20

What should you advise the patient of, if they have no predisposing risk factors but present with NPD?

Answer 20

They may want to be screened for HIV, as it could be suggestive of a HIV infection.

Question 21

Why is the 4mm threshold for BPE critical for determining PD disease stability?

Answer 21

• A higher probing depth may not represent active disease.
• Probing depth may not recover quickly after therapy.

Question 22

What is the definition periodontal health?

Answer 22

• Patients with an intact periodontum
• Patients with a reduced periodontum not due to PD
• Patients with a reduced periodontum due to previous PD, but currently stable.

Question 23

Why may a BPE of 3/4 not necessarily indicate full periodontitis?

Answer 23

The gingiva may be severely inflamed, and no bone loss may be present. Can be inflamed by:

• Poor restoration margins
• Pregnancy (epulis- non plaque induced)
• Puberty induced
• Drug induced

Question 24

What non-plaque induced gingival diseases are there?

Answer 24

• Hereditary gingival fibromatosis
• Herpetic gingival stomatitis
• Lichen planus (immune reaction)
• Benign mucous membrane pemphigoid (immune reaction)
• Vit C deficiency

Question 25

What systemic diseases may manifest periodontal disease?

Answer 25

• Papillon Lefevre Syndrome
• Leukocyte Adhesion Deficiency
• Hypophosphatasia
• Down’s syndrome
• Ehlers-Danlo

Question 26

Under the 2017 periodontal disease classification system, what are the 10 different categories for periodontal disease?

Answer 26

1. Health
2. Plaque induced gingivitis
3. Non-plaque induced gingivitis
4. Periodontitis
5. Necrotising periodontal disease
6. Perio from systemic disease
7. Systemic diseases affecting PDL
8. Periodontal abscess
9. Periodontal endodontic lesions
10. Mucogingival deformities