New classification of the periodontal diseases

This persentation describes the new classification of periodontal diseases in details.

1. New Classification of Periodontal Diseases Dr. Diana Mostafa Abo El Ola

2. Periodontal diseases and conditions Periodontal health , gingival diseases and conditions Forms of Periodontitis Other conditions affecting periodontium I-Periodontal health and gingival health II-Gingivitis :Dental biofilm induced III-Gingival disease: Non dental- biofilm induced Necrotizing periodontal diseases Periodontitis Periodontitis as a manifestation of systemic diseases Systemic diseases & conditions affecting periodontal tissues Periodontal abscesses & endodontic- periodontal lesions Mucogingival deformities & conditions Traumatic occlusion Tooth & prothesis related factors 1-Clinical gingival health on intact periodontium 2- Clinical gingival health on reduces periodontium 1- Gingivitis associated with dental plaque alone 2- Gingival diseases mediated by systemic factors or risk local factors 3- Gingival diseases modified by medications: 1 -Gingival diseases of specific infections 2- Genetic /developmental disorder 3-Inflammatory/ immune conditions 4-Endocrine, nutritional & metabolic diseases 5-Traumatic lesions 6-Gingival pigmentation 7-Neoplasm 8- Reactive process 1-Necrotizing gingivitis 2- Necrotizing periodontitis 3- Necrotizing stomatitis 1-Based on severity and complexity of management -Stage I -Stage II -Stage III -Stage IV 2-According to evidence and risk of rapid progression -Grade A -Grade B -Grade c 3-According to extent and distribution -Localized -Generalized -Molar incisor distribution Hematologic disorders : -Acquired neutropenia -Leukemias. Genetic disorders : -Papillon- Lef ѐ vre syndrome. - Chédiak -Higashi syndrome. -Down syndrome. -Leukocyte adhesion deficiency -Familial & cyclic neutropenia -Histiocytosis syndrome -Glycogen Storage diseases -Infantile genetic agranulocytosis -Cohen syndrome -Ehlers-Danlos Syndrome -Hypophosphatasia 1-Systemic disorders that have a major impact on the loss of periodontal tissues by influencing periodontal inflammation 2-Other systemic disorders that influence the pathogenesis of periodontal diseases. 3-Systemic disorders that can result in loss of periodontal tissues independent of periodontitis 1-Periodontal abscesses 2-Endodontic periodontal lesions 1-Gingival phenotype 2-Gingival recession 3-Lack of Keratinized gingiva 4-Decrease vestibular depth 5-Aberrant frenum 6-Gingival excess 7-Abnormal color 8-Condition of the exposed root surface 1-Primary occlusal trauma 2-Secondary occlusal trauma 3-Orthodontic forces 1-Localized tooth related factor 2-Localized dental protheses- related factor

3. Healthy gingiva & Gingival diseases & conditions

4. 1- Periodontal health and gingival health A. Clinical gingival health on an intact periodontium. B. Clinical gingival health on a reduced periodontium. 2-Gingivitis , dental plaque biofilm-induced 3-Gingival diseases , nondental biofilm-induced A. Associated with dental biofilm only. B. Mediated by systemic or local risk factors. C. Drug-influenced gingival enlargement . A. Specific infection B. Genetic/developmental disorder C. Inflammatory and immune conditions D. Reactive processes E. Neoplasm F. Endocrine , nutritional, metabolic diseases G. Traumatic lesions H. Gingival pigmentation

5. I-Periodontal health and gingival health 1-Clinical gingival health on intact periodontium Stable periodontitis patient. Non periodontitis patient. 2-Clinical gingival health on reduced periodontium

6. II- Gingivitis :Dental biofilm induced 1- Gingivitis associated with dental plaque alone: Without other local contributing factors.(Bad Oral hygiene) 2- Gingival diseases mediated by systemic factors or risk local factors ↑ Gingival inflammation even with low amount of local factors. a)Defect in endocrine system: Puberty, menstrual cycle, pregnancy, and diabetes . (affects blood circulation and immunological function) b) Leukemia associated gingivitis and Vit C deficiency c) Risk local factors (that retain plaque microorganisms) e.g . restoration-caries-mouth breathing-ortho. Rx Vit . C deficiency

7. Gingivitis dt hormonal disturbance(puberty) 12 y old leukemic female Pyogenic granuloma, pregnancy tumor of pregnant woman Pregnancy ass. gingivitis Orthodontic Rx Gingivitis due to plaque acc.

8. 3- Gingival diseases modified by medications: a) Drug-influenced gingival enlargements ( hyperplasia) . Anticonvulsant drugs Phenytoin Immunosuppressive drugs Cyclosporine Ca-channel blockers Nifedipine -Diltiazem-Na valproate. b) Drug-influenced gingivitis (oral contraceptives pills)due to elevation of hormones. GE in patient taking phenytoin Patient taking oral contraceptive pills

9. Patient under cyclosporine therapy Hypertensive patient under Ca channel blocker treatment

10. III-Gingival disease: Non dental- biofilm induced 1 - Gingival diseases of specific infections Bacterial origin: a) Treponema pallidum→ Syphilis b ) Neisseria gonorrhea→ Gonorrhea c) Streptococcal gingivitis( rare, diffuse, redness, swollen gingiva preceded by tonsillitis) Viral origin: a) Primary herpetic gingivostomatitis.(HSV) b) Varicella zoster infection.(HZV) Fungal origin: a) Candidiasis- Candida Albicans infection.(most common) Causes : topical steroids, decrease salivary flow(xerostomia), HIV(Linear gingival erythema) b) Histoplasmosis (fungus histoplasma)

11. Primary herpetic gingivostomatitis Pseudomembranous candidiasis in HIV patients Chronic erythematous candidosis Herps zoster with ulcers Gingival erythema Streptococcal gingivostomatitis Ruptured vesicles

12. 2- Genetic/developmental disorder: Hereditary gingival fibromatosis -Positive family history Gingival enlargement covers the teeth and delays eruption 3- Inflammatory/immune conditions : a) Mucocutaneous lesions( LP, EM, PV) have desquamative Gingiva. b) Allergic reactions(restorations- impression-toothpaste –mouth rinses, chewing gums) 4-Endocrine, nutritional & metabolic diseases Puberty, menstrual cycle, pregnancy, and Diabetes Mellitus. Leukemia associated gingivitis Vit C deficiency 5-Traumatic lesions: Habits, chemical(tobacco, aspirin, bleaching agent), mechanical(tooth brush-orthodontic bands- clamps-crown), or thermal injury. 6-Gingival pigmentation 7-Neoplasm 8- Reactive process Hereditary gingival fibromatosis Allergic reaction Gingival dehiscence via patient fingernail

13. Sever recession due to improper tooth brushing(unaffected IDP) Thermal burn due to hot coffee(erosions + petechiae) ERYTHEMA MULTIFORME (gingival erythema , ulcers and crusted lip). Gingival burn produced by with 20% H2O2. Aspirin burn Patient with LP(reticular , desquamative gingivitis)

14. Periodontitis

15. 1-Necrotizing Periodontal Diseases 2-Periodontitis 3- Periodontitis as a manifestation of systemic diseases A)Necrotizing gingivitis B) Necrotizing periodontitis C)Necrotizing stomatitis A)Based on severity and complexity of management (Stage I,II,III,VI) B)According to evidence and risk of rapid progression (Grade A,B,C) C)According to extent and distribution (localized, generalized, Molar incisor distribution ) A)Hematologic disorders Acquired neutropenia ,Leukemias , Others. B)Genetic disorders Papillon- Lef ѐ vre syndrome, Chédiak -Higashi syndrome, Down syndrome, Leukocyte adhesion deficiency syndrome, Familial & cyclic neutropenia, Histiocytosis syndrome, Glycogen Storage diseases, Infantile genetic agranulocytosis, Cohen syndrome, Ehlers-Danlos Syndrome, Hypophosphatasia, Others. C)Not otherwise specified

16. A)Necrotizing gingivitis Sudden onset. The lesions appear punched out and crater-like, papilla necrosis ; the necrotic tissue separates from the healthy gingiva, forming a gray pseudomembrane ; and the gingiva shows linear erythema (redness) Causes: stress-smoking-malnutrition-immunosuppression. Rx: antimicrobial therapy + plaque removal + OHI. B) Necrotizing periodontitis When bone loss occurs NG becomes NP C)Necrotizing stomatitis 1-Necrotizing Periodontal Diseases:

17. 2-Periodontitis How to diagnose and classify the periodontitis???? Dentification of CAL in more than two non-adjacent teeth The attachment loss should be related only to periodontitis while other etiologies such as recession, root fracture & defective restorations should be excluded. Identification of the form of periodontitis e.g. Necrotizing, Manifestation of systemic conditions, or Periodontitis. Description of the presentation Based on the newly introduced staging & grading system.

18. Steps for diagnosis & treatment Step 1: ( Initial overview of the case) Screen full mouth radiographs, probing depths and missing teeth. Step 2: ( Determine stage ) Determine maximum CAL or radiographic bone loss and bone loss pattern (horizontal/angular) → Stages I/II. Check for tooth loss & determine case complexity (probing depths, furcation involvements, occlusion/function, need for extensive rehabilitation) → Stages III and IV. Step 3: ( Determine grade ) History/risk of progression/age, risk factors and medical status and systemic inflammatory consideration. Response to SRP and plaque control assessments. Step 4: ( Treatment plan) If stages I/II → standard periodontal treatment. If stages III/IV → complex or multidisciplinary treatment.

19. Based on severity and complexity of management Stage I: Initial periodontitis (CAL=1-2mm, RBL <15% of root, no mobility) Stage II : Moderate periodontitis (CAL=3-4mm, RBL =15-33% of root, no mobility) Stage III: Sever with potential for additional bone loss (CAL>5mm,RBL middle to apical third of the root, mobility in 4 teeth or less) Stage IV: Sever periodontitis with potential for loss of the dentition (CAL>5mm, RBL middle to apical third of the root, mobility in 5 teeth or more)

20. According to evidence and risk of rapid progression Grade A: slow rate of progression Grade B: moderate rate of progression Grade C: rapid rate of progression Anticipated treatment response depend on case phenotype , smoking & hyperglycemia .

21. 3-According to extent and distribution Localized (less than 30% involved teeth) Generalized (more than 30% involved teeth) Molar incisor distribution Generalized bone loss Molar incisor distribution

22. Hematologic disorders: Acquired neutropenia Leukemias. Others Genetic disorders: Papillon-Lef ѐ vre syndrome. Chédiak -Higashi syndrome. Down syndrome. Leukocyte adhesion deficiency syndrome. Familial & cyclic neutropenia Histiocytosis syndrome Glycogen Storage diseases Infantile genetic agranulocytosis Cohen syndrome Ehlers-Danlos Syndrome Hypophosphatasia Others Not otherwise specified 3- Periodontitis as a manifestation of systemic diseases: Down’s syndrome patient LAD syndrome Chédiak -Higashi syndrome. Hyperkeratosis in Papillon- Lefevre syndrome

23. Other conditions affecting the periodontal supporting tissues

24. 1- Systemic diseases & conditions affecting the periodontal tissues 2-Periodontal abscess and endodontic periodontal lesions 3-Mucogingival deformities and conditions around teeth 4-Traumatic occlusal forces 5-Prostheses and tooth related factors that modify or predispose to plaque induced gingival disease/ periodontitis

25. 1- Systemic diseases & conditions affecting the periodontal tissues. 1- Systemic disorders that have a major impact on the loss of periodontal tissues by influencing periodontal inflammation. 2- Other systemic disorders that influence the pathogenesis of periodontal diseases. 3-Systemic disorders that can result in loss of periodontal tissues independent of periodontitis.

26. A) Genetic disorders Diseases associated with immunological disorder Down syndrome- Leukocyte adhesion deficiency syndrome-Papillon Lefevre syndrome-Haim Munk syndrome- Chediak Higashi syndrome- Neutropenia- Primary immunodeficiency diseases- Chronic granulomatous disease- Hyperimmunoglobulin E syndrome- Cohen syndrome. Diseases affecting the oral mucosa Epidermolysis bullosa- Kindler syndrome- Plasminogen deficiency. Diseases affecting the connective tissue Ehler Danlos syndrome(type IV, VIII)- Angioedema (C 1 inhibitor deficiency)- Systemic lupus erythematosus. Metabolic & endocrine disorders Glycogen storage disease- Gaucher disease- Hypophosphatasia – Hypophosphatemic rickets- Hajdu Cheney syndrome. B)Acquired immunodeficiency diseases Acquired neutropenia- HIV infection C)Inflammatory diseases Epidermolysis bullosa acquista - inflammatory bowel disease. 1- Systemic disorders that have a major impact on the loss of periodontal tissues by influencing periodontal inflammation

27. 2-Other systemic disorders influence the pathogenesis of periodontal diseases Diabetes Mellitus- Obesity- Osteoporosis – Arthritis – Emotional stress – Smoking - Medications 3-Systemic disorders that can result in loss of periodontal tissues independent of periodontitis A)Neoplasm Primary neoplastic diseases of periodontium Oral squamous cell carcinoma Odontogenic tumors Other primary metastatic neoplasms of the periodontal tissues Secondary metastatic neoplasms of the periodontal tissues B)Other disorders that may affect the PD tissues Granulomatosis with polyangiitis Langerhans cell histiocytosis Giant cell granuloma Hyperparathyroidism Systemic sclerosis (scleroderma) Vanishing bone disease

28. Mainly rare diseases…… Papillon Lefevre , Leukocyte adhesion deficiency & hypophosphatasia . Mainly common diseases……. Diabetes Miletus. Mainly rare conditions independent of dental plaque biofilm-induced inflammation ……… squamous cell carcinoma , Langerhans cell histiocytosis .

29. 2-Periodontal abscess and endodontic periodontal lesions Periodontal abscesses: Acute lesions with localized accumulation of pus within the gingival wall of periodontal pocket /sulcus and rapid tissue destruction. Associated with risk of systemic dissemination. The primary detectable signs/symptoms associated with a periodontal abscess may involve ovoid elevation in the gingiva along the lateral part of the root and bleeding on probing.

30. Endodontic periodontal lesions • Causes: lateral canals-exposed DT-vertical fracture. -Is a pathological communication between the pulpal and periodontal tissues. -Acute or chronic form. -It is classified according to signs & symptoms that have direct impact on their prognosis and treatment (i.e., presence or absence of fractures and perforations, and presence or absence of periodontitis).

31. 3-Mucogingival deformities and conditions around teeth Gingival phenotype Gingival/soft tissue recession Lack of Keratinized gingiva Decrease vestibular depth Aberrant frenum/muscle position Gingival excess Abnormal color Condition of the exposed root surface

32. 4-Traumatic occlusal forces Primary occlusal trauma is caused by excessive and non-physiological forces exerted on teeth with a normal, healthy periodontium ( no CAL). Secondary occlusal trauma It results from reduced ability of the tissues to resist the occ. F. causing damage to periodontium.(attachment loss present) Orthodontic forces

33. 5-Prostheses and tooth related factors that modify or predispose to plaque induced gingival disease/periodontitis . 1- Localized tooth related factor Tooth anatomic factors. Root fractures. Crevicular root resorption , cemental tear. Root proximity. Altered passive eruption. 2- Localized dental protheses- related factor Restoration margin placed within the supracrestal attached tissues. Clinical procedures related to the fabrication of indirect restoration. Hypersensitivity /toxicity reactions to dental materials.