AAP 2017 CLASSIFICATION OF PERIODONTAL DISEASE PART 1

latest classification of periodontal diseae

1. PROCEEDINGS OF THE WORLD WORKSHOP ON THE CLASSIFICATION OF PERIODONTAL AND PERI-IMPLANT DISEASES AND CONDITIONS CO-SPONSORED BY AMERICAN ACADEMY OF PERIODONTOLOGY (AAP) AND EUROPEAN FEDERATION OF PERIODONTOLOGY (EFP) November 9 to 11, 2017 1

2. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health. Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTIUM Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 2

3. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health. Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTIUM Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 3

4. 4 INTRODUCTION

5. To properly diagnose and treat patients. Investigate etiology, pathogenesis, natural history, and treatment. The authors were charged with updating the 1999 classification and developing similar scheme for periimplant diseases and conditions. To align and update the classification scheme to the current understanding. 5 Why we need of a classification?

6. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health. Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTIUM Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 6

7. 7 CLASSIFICATION - OVERVIEW

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9. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health . Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTIUM Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 9

10. PERIODONTAL HEALTH, GINGIVAL DISEASES AND CONDITIONS . PERIODONTAL DISEASES & CONDITIONS 10

11. PERIODONTAL HEALTH, GINGIVAL DISEASES AND CONDITIONS . 1. PERIODONTAL HEALTH AND GINGIVAL HEALTH . Clinical gingival health on an intact periodontium . Clinical gingival health on a reduced periodontium . Stable periodontitis patient. Non periodontitis patient. 2. GINGIVITIS DENTAL BIOFILM INDUCED Associated by dental biofilm alone. Mediated by systemic or local risk factors. Drug influenced gingival enlargement. 3. GINGIVAL DISEASES – NON DENTAL BIOFILM INDUCED Genetic/developmental disorders. Specific infections. Inflammatory and immune conditions. Reactive processes. Neoplasm. Endocrine, nutritional and metabolic diseases. Traumatic lesions. Gingival pigmentation. 11

12. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health. Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTIUM Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 12

13. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH, GINGIVAL DISEASES AND CONDITIONS . 1. PERIODONTAL HEALTH AND GINGIVAL HEALTH 13 intact periodontium

14. SPECTRUM OF CLINICAL PERIODONTAL HEALTH Absence of bleeding on probing, erythema and edema, patient symptoms and attachment and bone loss. Physiological bone level range from 1.0 to 3.0 mm apical to CEJ. Clinical gingival health is generally associated with an inflammatory infiltrate and a host response consistent with homeostasis. 14

15. 15 HEALTH DISEASE

16. 16 Patient with periodontal health Gingivitis Patient Periodontitis Patient Periodontal therapy Periodontitis Patient: Stable case of periodontal health Periodontitis Patient: Case with some gingival inflammation Periodontitis Patient: Unstable case of recurrent periodontitis SCENARIOS FOLLOWING TRANSITION FROM HEALTH

17. Assess gingival inflammation: BOP % - dichotomos yes/no Controlled force (0.25N) to apical end of sulcus @ 6 sites. LIMITATION : lack of standardized (Probe dimensions, taper), examiner variability (probe pressure, angle), patient related factors (biotype, medications etc.) and smoking. Periodontal health may exhibit one or two sites with some evidence of clinical gingival inflammation. Localized mild and delayed bleeding to probe at isolated site is ubiquitous, but may fall within the spectrum of clinical health. 17

18. ISO 21672 – global standard for probe Tip diameter 0.5mm Cylindrical tine structure Constant force limiter 0.25N 15 mm scale with precise individual or banded millimeter markings A taper of 1.75⁰ 18

19. GINGIVAL HEALTH ? <10% of sites BOP No probing depth of 4 mm or greater. (≤ 3mm) 19

20. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health. Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTITIS Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 20

21. PERIODONTAL HEALTH, GINGIVAL DISEASES AND CONDITIONS . 1. PERIODONTAL HEALTH AND GINGIVAL HEALTH 21 Reduced periodontium PERIODONTAL DISEASES & CONDITIONS A new classification scheme for periodontal and peri ‐implant diseases and conditions – Introduction and key changes from the 1999 classification Jack G. Caton1 | Gary Armitage2 |  Tord Berglundh3 | Iain L.C. Chapple4 |  Søren Jepsen5 | Kenneth S. Kornman6 | Brian L. Mealey7 |  Panos N. Papapanou8 |  Mariano Sanz9 | Maurizio S. Tonetti10 J Clin Periodontol . 2018;45:45( Suppl 20);S1–S8.

22. Reduced periodontium Stable periodontitis patient: successfully treated periodontitis patient Non periodontitis patient: ( e.g., recession, crown lengthening). In presence of reduced clinical attachment and bone level. Successfully treated, stable periodontitis patient remain at increased risk of recurrent progression. 22

23. VIEWS OF HEALTH Rational minority view Health: ≤ 3mm, no BOP – risk of recurrence. Counter majority view ≤ 3mm threshold rarely achieved, at 100% treated sites. Non bleeding sites > 3mm would not be classified as “health”. Lead to over treatment - further invasive treatment rather than monitoring and supportive care. 23 Periodontal health Niklaus P. Lang1 | P. Mark Bartold2 J Clin Periodontol . 2018;45( Suppl 20):S9–S16.

24. Successfully treated periodontitis patients Gingival bleeding – high risk of recurrence, progressive attachment loss. Bleeding at shallow site ≤3mm rather than ≤4mm (gingival health). When probing depth is 4mm or higher – no longer a closed pocket 24

25. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health. Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTITIS Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 25

26. PERIODONTAL HEALTH, GINGIVAL DISEASES AND CONDITIONS . 2. GINGIVITIS DENTAL BIOFILM INDUCED 26 PERIODONTAL DISEASES & CONDITIONS

27. 2. Gingivitis – dental plaque induced; intact periodontium : reduced periodontium in non periodontitis patient; reduced periodontium in successfully treated periodontitis patient. Associated with biofilm alone Mediated by systemic or local risk factors Systemic risk factors (modifying factors) Smoking Hyperglycemia Nutritional factors Pharmacological agents (prescription, non prescription, recreational) Sex steroid hormones Puberty Menstrual cycle Pregnancy Oral contraceptive Hematological conditions Local risk factors (predisposing) Dental plaque biofilm retention factors (prominent restoration margins) Oral dryness Drug influenced gingival enlargement 27

28. “an inflammatory lesion resulting from interactions between the dental plaque biofilm and the host’s immune inflammatory response, which remains contained within the gingiva and does not extend to periodontal attachment ( cementum , periodontal ligament and alveolar bone). Such inflammation remains confined to the gingiva and does not extend beyond the mucogingival junction and is reversible by reducing levels of dental plaque at and apical to the gingival margin” 28 DENTAL PLAQUE BIOFILM - INDUCED GINGIVITIS

29. Gingivitis on an intact periodontium . Gingivitis on a reduced periodontium in a non periodontitis patient ( e.g., recession, crown lengthening). Gingival inflammation on reduced peridontium in a successfully treated periodontitis patient (recurrent periodontitis cannot be ruled out). 29

30. DETERMINANTS OF THE RATE OF DEVELOPMENT OF GINGIVITS, SEVERITY AND EXTENT : Local risk factors (predisposing factors) encourage plaque accumulation – inhibiting its removal/creating a niche Retention factors (anatomy, subgingival restoration). Oral dryness – lack of salivary flow, reduced biofilm removal, anti parasymphatetic , sjogren , mouth breathing. Systemic risk factors(modifying factors) negatively influence the immune inflammatory response Smoking – microvascular vasoconstriction, fibrosis, mask. Metabolic factors - hyperglycemia – mitochondrial stress, AGE – activates proinflammatory signalling cascades. Nutritional factors - Scurvy – compromised antioxidant micronutrient defenses to oxidative stress. Pharmacological agents – saliva, endocrine, enlargement. Elevation in sex steroid hormones – puberty, pregnancy, contraceptives. Hematological conditions – leukemia, myelodisplasia , thrombocytopenia, clotting factor deficiency (bleeding inconsistent with level of dental plaque biofilm ). 30

31. DIAGNOSTIC CRITERIA FOR A GINGIVITIS CASE 6 to 94% - use of indices, site Vs whole mouth. 95% Mild localized inflammation – variation of normality – health rather than disease. More manifestations defined – lower prevalence. 31

32. CLINICAL, RADIOLOGICAL AND BIOLOGICAL SIGNS AND SYMPTOMS Gingivitis is a clinical diagnosis – microbiological, molecular, pathophysiology – not sufficient to supersede parameters. Clinical signs of inflammation – erythema , edema, pain (soreness), heat and loss of function. May manifest as swelling – blunting of papilla bleeding on gentle probing redness discomfort on gentle probing Symptoms the patient may report include: bleeding gums (metallic/altered taste) pain (soreness) halitosis difficulty eating Appearance (swollen red gums) Reduced oral health – related quality of life 5. Radiographs cannot be used to diagnose gingivitis. 32

33. Should we classify ? No objective clinical criteria To communicate (mild, moderate, severe) No robust evidence to clearly differentiate Remains a matter of professional opinion Defining percentages mild <10 %, moderate 10 – 30 %, severe >30 % sites. Grading ( grade 1 to 5 in 20 % quintiles for %sites BOP) ≥10% bleeding sites, Probing depth ≤3mm. Localized gingivitis 10-30% bleeding sites. Generalized >30% bleeding sites. 33

34. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health . Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTITIS Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 34

35. PERIODONTAL HEALTH, GINGIVAL DISEASES AND CONDITIONS . 3. GINGIVAL DISEASES NON DENTAL PLAQUE INDUCED 35 PERIODONTAL DISEASES & CONDITIONS

36. 3. Gingival diseases – non dental plaque induced Genetic/developmental factors Hereditary gingival fibromatosis * Specific infections Bacterial origin Neisseria gonorrhoeae * Treponema pallidum * Mycobacterium tuberculosis* Streptococcal gingivitis Viral origin Coxsackie virus (hand-foot and mouth disease)* Herpes simplex I &II (primary or recurrent)* Varicella zoster (chicken pox & shingle – V nerve)* Molluscum contagiousum * Human papilloma virus ( squamous cell papilloma ; condyloma acuminatum ; verruca vulgaris ; focal epithelial hyperplasia) Fungal origin Candidosis Other mycoses e.g., histoplasmosis , aspergillosis 36

37. Inflammatory and immune conditions Hypersensitivity reactions Contact allergy* Plasma cell gingivitis* Erythema multiformae * Autoimmune diseases of skin and mucous membranes Pemphigus vulgaris * Pemphigoid * Lichen planus * Lupus erythematosus * Systemic Discoid Granulomatous inflammatory lesions crohn’s disease* Sarcoidosis * Reactive processes Epulides Fibrous epulis Calcifying fibroblastic granuloma Vascular epulis Peripheral giant cell granuloma * 37

38. Neoplasms Premalignancy Leukoplakia Erythroplakia Malignancy Squamous cell carcinoma* Leukemic cell infiltration* Lymphoma* Hodgkin Non hodgkin Endocrine, nutritional & metabolic diseases Vitamin deficiencies * Vitamin C deficiency (scurvy) Traumatic lesions Physical/ mechanical trauma Frictional keratosis Mechanically induced gingival ulceration Factitious injury (self harm) Chemical (toxic) burn 38

39. Thermal insults Burns to gingiva Gingival pigmentation Melanoplakia * Smoker’s melanosis Drug induced pigmentation ( antimalarials , minocycline ) Amalgam tattoo ……………………………“Precision dental medicine” 39

40. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health . Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTITIS Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 40

41. PERIODONTITIS 41 PERIODONTAL DISEASES & CONDITIONS Periodontitis : Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and PeriImplant Diseases and Conditions Panos N. Papapanou1 | Mariano Sanz2 |  Nurcan Buduneli3 | Thomas Dietrich4 |  Magda Feres5 | Daniel H. Fine6 | Thomas F. Flemmig7 | Raul Garcia8 |  William V. Giannobile9 |  Filippo Graziani10 | Henry Greenwell11 | David Herrera2 |  Richard T. Kao12 | Moritz Kebschull1,13 | Denis F. Kinane14 | Keith L. Kirkwood15 |  Thomas Kocher16 | Kenneth S. Kornman9 |  Purnima S. Kumar17 | Bruno G. Loos18 |  Eli Machtei19 |  Huanxin Meng20 | Andrea Mombelli21 | Ian Needleman22 |  Steven Offenbacher23 | Gregory J. Seymour24 | Ricardo Teles14 | Maurizio S. Tonetti7 . J Clin Periodontol . 2018;45( Suppl 20):S162–S170.

42. FORMS OF PERIODONTITIS 1. NECROTIZING PERIODONTAL DISEASES Necrotizing gingivitis Necrotizing periodontitis Necrotizing stomatitis 2. PERIODONTITIS AS MANIFESTATION OF SYSTEMIC DISEASES Classification of theses conditions should be based on the primary systemic disease according to the international statistical classification of diseases and related health problems(ICD) codes 3. PERIODONTITIS STAGES : Based on severity and complexity of management Stage I: initial periodontitis Stage II: Moderate periodontitis Stage III: Severe periodontitis with potential for additional tooth loss Stage IV: Severe periodontits with potential for loss of the dentition EXTENT AND DISTRIBUTION : Localized; Generalized; Molar-Incisor distribution GRADES : Evidence or risk of rapid progression, anticipated treatment resonse Grade A: Slow rate of progression. Grade B: Moderate rate of progression. Grade C: Rapid rate of progression. 42

43. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health . Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS . Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTITIS Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 43

44. FORMS OF PERIODONTITIS 44 PERIODONTAL DISEASES & CONDITIONS NECROTIZING PERIODONTAL DISEASE

45. Necrotizing periodontal disease - distinct? Ulcer within stratified squamous epithelium, superficial connective tissue. Non specific acute inflammatory infiltrate. ZONES: Superficial bacterial zone. Neutrophil rich zone. Necrotic zone. Spirochetal /bacterial invasion zone. 45 Papilla necrosis, Bleeding, Pain

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47. Mean plasma and serum concentrations of retinol, ascorbic acid, zinc, albumin markedly reduced. Saliva levels of albumin, cortisol (plasma) increased. 47

48. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health . Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTITIS Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 48

49. FORMS OF PERIODONTITIS 49 PERIODONTAL DISEASES & CONDITIONS PERIODONTITIS

50. PERIODONTITIS 1989 – recognised distinct clinical presentations, different age of onset and rates of progression. Prepubertal , juvenile (localized and generalized), adult, rapidly progressive. 1993 – European workshop – adult, early onset. 1996 – insufficient new evidence to change the classification. 1999 – chronic, aggressive (localized and generalized), necrotizing and as a manifestation of sytemic disease, Periodontal abscess…………..17 years.( overlap, pathology, imprecision) 2017 - Consistent with current knowledge of pathophysiology – 3 forms Multidimensional grading system that could be adapted over time. 50

51. Staging – severity, complexity of management. CAL, bone loss, PD, angular defect, furcation , mobility, tooth loss. Grading – feature, history, rate, risk of further progression. general health status, exposures – smoking, metabolic control. Allows clinician to incorporate individual patient factors into diagnosis. 51

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53. STAGING 53

54. Periodontitis stage Stage 1 Stage 2 Stage 3 Stage 4 Interdental CAL at the site of greatest loss 1 to 2mm 3 to 4mm ≥ 5mm ≥ 5mm Severity Radiographic bone loss Coronal third <15% Coronal third 15 to 33% Extending to middle or apical third of the root Extending to middle or apical third of the root Tooth loss No tooth loss Perio due to dontitis Tooth losss due to periodontits of ≤ 4 teeth Tooth loss due to periodontits of ≥ 5mm teeth Complexity Local Maximu m probing depth ≤ 4 mm Mostly horizontal bone loss Maximu m probing depth ≤ 5 mm Mostly horizontal bone loss In addition to stage 2complexity: Probing depth ≥ 6mm Vertical bone loss ≥ 3mm Furcation involvement of Class 2 or 3 Moderate ridge defect In addition to stage 3 complexity: Need for complex rehabilitation due to: Masticatory dysfunction Secondary occlusal trauma (tooth mobility degree ≥ 2) Severe ridge defect Bite collapse, drifting, flaring, less than 20 remaining teeth ( 10 opposing pairs) Extent and distribution Add to stage as descriptor For each stage, describe extent as localized (<30% of teeth involved), generalized, or molar/incisor pattern. 54

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58. Initial stage determined using CAL. Tooth loss – modify stage. Complexity factor shifts stage – high mobility. POST TREATMENT PATIENTS : CAL, RBL, complexity factor eliminated – not retrogress – consider always in maintanence . 58

59. GRADING 59

60. Periodontitis grade Grade A: slow rate of progression Grade B: Moderate rate of progression Grade C: Rapid rate of progression Direct evidence of progression Longitudinal data (radiographic bone loss or CAL) Evidence of no bone loss over 5 years <2mm over 5 years ≥2mm over 5 years Primary criteria Indirect evidence of 1. % bone loss/age <0.25 0.25 to 1.0 >1.0 Progression 2. Case phenotype Heavy biofilm deposits with low level of destruction Destruction commmensurate with biofilm deposits Destruction exceeds expectation given biofilm deposits; specific clinical patterns suggestive of periods of rapid proression and /or early onset disease (e.g., molar/incisor pattern; lack of expected response to standard bacterial control therapies) Grade modifiers Risk factors Smoking Non smoker smoker < 10 cigarettes/day smoker ≥10 cigarettes/day Diabetes Normoglycemic /no diagnosis of diabetes HbA1c <7.0% in patients with diabetes HbA1c ≥7.0% in patients with diabetes 60

61. Initially assume grade B Seek evidence to shift. Modified based on presence of risk factors. 61

62. 62 Grade B

63. 63

64. HOW DO WE DEFINE A PERIODONTITIS CASE? 64

65. Differences in etiology and pathogenesis are required. Case definition : Interdental CAL - ≥ 2 non adjacent teeth. Buccal CAL ≥ 3mm with pocketing 3mm at ≥ 2 teeth Non periodontitis cause : Gingival recession of traumatic origin. Dental caries extending in cervical area of tooth. Presence of CAL on distal aspect of second molar with malposition /extraction of 3 rd molar Endodontic lesion draining through marginal periodontium Vertical root fracture 65

66. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health . Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTITIS Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 66

67. OTHER CONDITIONS AFFECTING PERIODONTIUM 67 PERIODONTAL DISEASES & CONDITIONS

68. PERIODONTAL MANIFESTATION OF SYSYTEMIC DISEASES AND DEVELOPMENTAL AND ACQUIRED CONDITIONS 1. SYSTEMIC DISEASES OR CONDITIONS AFFECTING THE PERIODONTAL SUPPORTING TISSUES 2. OTHER PERIODONTAL CONDITIONS Periodontal abscesses Endodontic periodontal lesions 3. MUCOGINGIVAL DEFORMITIES AND CONDITIONS AROUND TEETH Gingival phenotypes Gingival/soft tissue recession Lack of gingiva Decreased vestibular depth Aberrant frenum /muscle position Gingival excess Abnormal color Conditions of the exposed root surface 4. TRAUMATIC OCCLUSAL FORCES Primary occlusal forces Secondary occlusal forces Orthodontic forces 5. PROSTHESES AND TOOTH RELATED FACTORS THAT MODIFY OR PREDISPOSE TO PLAQUE INDUCED GINGIVAL DISEASES/ PERIODONTITIS Localized tooth related factors Localized dental prosthesis related factors. 68

69. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health . Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTITIS Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 69

70. OTHER CONDITIONS AFFECTING PERIODONTIUM 70 PERIODONTAL DISEASES & CONDITIONS PERIODONTAL ABSCESS Periodontitis : Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and PeriImplant Diseases and Conditions Panos N. Papapanou1 | Mariano Sanz2 |  Nurcan Buduneli3 | Thomas Dietrich4 |  Magda Feres5 | Daniel H. Fine6 | Thomas F. Flemmig7 | Raul Garcia8 |  William V. Giannobile9 |  Filippo Graziani10 | Henry Greenwell11 | David Herrera2 |  Richard T. Kao12 | Moritz Kebschull1,13 | Denis F. Kinane14 | Keith L. Kirkwood15 |  Thomas Kocher16 | Kenneth S. Kornman9 |  Purnima S. Kumar17 | Bruno G. Loos18 |  Eli Machtei19 |  Huanxin Meng20 | Andrea Mombelli21 | Ian Needleman22 |  Steven Offenbacher23 | Gregory J. Seymour24 | Ricardo Teles14 | Maurizio S. Tonetti7 . J Clin Periodontol . 2018;45( Suppl 20):S162–S170.

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72. CLINICAL FEATURES Localized accumulation of pus located within the gingival wall of the periodontal pocket resulting in a significant tissue breakdown. Ovoid elevation in gingiva along the lateral part of the root and BOP. Pain, suppuration, deep pocket, increased tooth mobility. 72

73. PATHOPHYSIOLOGY OF ABSCESS 73

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75. OUTLINE INTRODUCTION. CLASSIFICATION – OVER VIEW. PERIODONTAL DISEASES & CONDITIONS PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS. Periodontal health and gingival health . Gingivitis: Dental Biofilm Induced. Gingivitis: Non Dental Biofilm Induced. PERIODONTITIS. Necrotizing Periodontal Diseases. Periodontitis . Periodontal manifestation of systemic diseases and conditions. OTHER CONDITIONS AFFECTING PERIODONTITIS Systemic diseases or conditions affecting periodontal supporting tissues. Periodontal abscess and endodontic periodontal lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth and prosthesis related factors. PERI-IMPLANT DISEASES AND CONDITIONS. Peri implant health Peri implant Mucositis Peri implantitis Peri implant soft and hard tissue deficiencies KEY CHANGES. 75

76. OTHER CONDITIONS AFFECTING PERIODONTIUM 76 PERIODONTAL DISEASES & CONDITIONS ENDODONTIC PERIODONTAL LESIONS

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78. Endo - perio lesion Pathologic communication between the pulpal and periodontal tissues at a given tooth may be triggered by a carious, traumatic lesion affect pulp, secondarily affect periodontium , root canal or by concomitant presence of both. Do Endo - perio lesion have a distinct pathophysiology ? NO evidence . Communication complicates the management. 78

79. CLINICAL FEATURES Deep pocket to apex Negative pulp vitality Bone loss – apical/ furcation Pain on palpation/ percussion Purulent exudate /suppuration Tooth mobility Sinus tract/fistula Crown/gingival color alteration. 79

80. 80

81. 81 KEY CHANGES

82. Identifying difference bw presence of gingival inflammation at one or more sites and the definition of gingivitis. Periodontal health in reduced periodontium . Non plaque induced gingival diseases – primary etiology. Multidimensional staging and grading system for periodontitis . Periodontitis as a manifestation of systemic disease – primary systemic disease. Eg Papillon Lefevre Syndrome. 82

83. Systemic diseases or conditions affecting the periodontal supporting tissues – independent of plaque induced periodontitis . ( Neoplastic ) Uncontrolled Diabetes- modify, descriptor – severity, response, no unique pathophysiology . Periodontal phenotype (Biotype). Traumatic occlusal force. Supracrestal attached tissues (Biological width). A new classification system for perimplant diseases and conditions. 83

84. References 84 A new classification scheme for periodontal and peri ‐implant diseases and conditions – Introduction and key changes from the 1999 classification Jack G. Caton1 | Gary Armitage2 |  Tord Berglundh3 | Iain L.C. Chapple4 |  Søren Jepsen5 | Kenneth S. Kornman6 | Brian L. Mealey7 |  Panos N. Papapanou8 |  Mariano Sanz9 | Maurizio S. Tonetti10 J Clin Periodontol . 2018;45:45( Suppl 20);S1–S8. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium : Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri ‐Implant Diseases and ConditionsIain L.C. Chapple1 | Brian L. Mealey2 | Thomas E. Van Dyke3 | P. Mark Bartold4 |  Henrik Dommisch5 | Peter Eickholz6 | Maria L. Geisinger7 | Robert J. Genco8 |  Michael Glogauer9 | Moshe Goldstein10 | Terrence J. Griffin11 |  Palle Holmstrup12 |  Georgia K. Johnson13 | Yvonne Kapila14 |  Niklaus P. Lang15 |  Joerg Meyle16 |  Shinya Murakami17 | Jacqueline Plemons18 | Giuseppe A. Romito19 |  Lior Shapira10 |  Dimitris N. Tatakis20 |  Wim Teughels21 | Leonardo Trombelli22 | Clemens Walter23 |  Gernot Wimmer24 |  Pinelopi Xenoudi25 |  Hiromasa Yoshie2 J Clin Periodontol . 2018;45( Suppl 20):S68–S77. Periodontal health Niklaus P. Lang1 | P. Mark Bartold2 J Clin Periodontol . 2018;45( Suppl 20):S9–S16. Periodontitis : Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and PeriImplant Diseases and Conditions Panos N. Papapanou1 | Mariano Sanz2 |  Nurcan Buduneli3 | Thomas Dietrich4 |  Magda Feres5 | Daniel H. Fine6 | Thomas F. Flemmig7 | Raul Garcia8 |  William V. Giannobile9 |  Filippo Graziani10 | Henry Greenwell11 | David Herrera2 |  Richard T. Kao12 | Moritz Kebschull1,13 | Denis F. Kinane14 | Keith L. Kirkwood15 |  Thomas Kocher16 | Kenneth S. Kornman9 |  Purnima S. Kumar17 | Bruno G. Loos18 |  Eli Machtei19 |  Huanxin Meng20 | Andrea Mombelli21 | Ian Needleman22 |  Steven Offenbacher23 | Gregory J. Seymour24 | Ricardo Teles14 | Maurizio S. Tonetti7 . J Clin Periodontol . 2018;45( Suppl 20):S162–S170.

85. PART 2 85

86. PERI-IMPLANT DISEASES AND CONDITION 86 PERI- IMPLANT DISEASES & CONDITIONS

87. PERI-IMPLANT DISEASES AND CONDITION 1. PERI-IMPLANT HEALTH 2. PERI-IMPLANT MUCOSITIS 3. PERI-IMPLANTITIS 4. PERI-IMLANT SOFT AND HARD TISSUE DEFICIENCY 87

88. PROSTHESIS AND TOOTH RELATED FACTORS The section on prostheses related factors was expanded in the new classification. Clinical procedures involved in the fabrication of indirect restorations was added Because of new data indicating - procedures may cause recession, CAL. 88

89. PERIODONTAL MANIFESTATION OF SYSYTEMIC DISEASES AND DEVELOPMENTAL AND ACQUIRED CONDITIONS 89

90. SYSTEMIC DISEASE Papillon Lefevre syndrome result in early presentation of severe periodontitis . Classification should be based on primary systemic disease. Neoplastic diseases, affects independent of plaque. Diabetes – modify course, multifactorial , DESCRIPTOR in staging, grading. Current evidence- no unique pathophysiology . 90

91. CHANGES IN THE CLASSIFICATION OF PERIODONTAL DEVELOPMENTAL AND ACQUIRED DEFORMITIES AND CONDITIONS MUCOGINGIVAL CONDITIONS The new case definitions related to treatment of gingival recession are based on interproximal loss of clinical attachment and also in corporate the assessment of the exposed root and CEJ . The consensus report presents a new classification of gingival recession that combines clinical parameters including gingival phenotype as well as characteristics of the exposed root surface . Periodontal biotype replaced by periodontal phenotype . 91

92. OCCLUSAL TRAUMA AND TRAUMATIC OCCLUSAL FORCES. Traumatic occlusal force , replacing the term excessive occlusal force, is the force that exceeds the adaptive capacity of the periodontium and/or the teeth. Result in occlusal trauma and excessive wear or fracture of the teeth. There is lack of evidence from human disease implicating occlusal trauma in the progression of attachment loss in periodontitis . 92

93. A NEW CLASSIFICATION FOR PERI-IMPLANT DISEASES AND CONDITIONS 93

94. PERI IMPLANT HEALTH : Absence of visual signs of inflammation and bleeding on probing. Can exist around implant with normal or reduced bone support. It is not possible to define a range of probing depths compatible with periimplant health. 94

95. PERI-IMPLANT MUCOSITIS : Bleeding on probing and visual signs of inflammation. Strong evidence that peri -implant mucositis is caused by plaque Little evidence for non plaque induced peri -implant mucositis . Can be reversed. 95

96. PERI – IMPLANTITIS : Plaque associated pathological conditions occuring in tissues around dental implants, inflammation in the periimplant mucosa, progressive loss of supporting bone. Periimplant mucositis assumed to precede. Onset of periimplantitis may occur early following implant placement as indicated by radiographic data. Absence of treatment, progress in a non linear, accelerating pattern. 96

97. HARD AND SOFT TISSUE IMPLANT SITE DEFICIENCIES: Severe loss of periodontal support, extraction trauma, endodontic trauma, endodontic infection, root fractures, thin buccal plates, poor tooth position, injury and pneumatization of the maxillary sinuses. Medications and systemic diseases reducing the amount of naturally formed bone, tooth agenesis, pressure from prosthesis. 97

98. 98