Periodontitis

Periodontitis is a chronic, slowly progressing disease which mainly results in the destruction of tooth supporting apparatus. Earlier it was classified as Chronic and Aggressive periodontitis with different clinical features and etiology. Current classification ( 2017) of periodontal disease involves periodontitis with is further divided into 4 stages and 3 grades depending on severity and rate of disease progression respectively. Diabetes meelitus and smoking are the validated risk factors for the progression of periodontitis.

1. PERIODONTITIS BY- DR. OINAM MONICA DEVI

2. Contents Definition Clinical features Changes in the nomenclature of case definition of Periodontitis Chronic Periodontitis Aggressive Periodontitis The most recent Case definition of Periodontitis References

3. Definition Clinical definition of periodontitis Periodontitis is a chronic multifactorial inflammatory disease associated with dysbiotic plaque biofilms and characterised by the progressive destruction of the tooth-supporting apparatus. Periodontitis is characterised by inflammation that results in the loss of periodontal attachment. While the formation of bacterial biofilm initiates gingival inflammation, the disease of periodontitis is characterised by three factors: The loss of periodontal-tissue support, manifested through clinical attachment loss (CAL) and radiographically assessed alveolar bone loss The presence of periodontal pocketing Gingival bleeding.

4. Signs and symptoms of periodontitis can include: Swollen or puffy gums Bright red, dusky red or purplish gums Gums that feel tender when touched Gums that bleed easily Pink-tinged toothbrush after brushing Spitting out blood when brushing or flossing your teeth Bad breath Pus between your teeth and gums

5. Armitage 1999 Chronic Periodontitis (A. Localized B. Generalized (> 30% of sites are involved) Aggressive Periodontitis (A. Localized B. Generalized (> 30% of sites are involved) Periodontitis as a Manifestation of Systemic Diseases A. Associated with hematological disorders B. Associated with genetic disorders C. Not otherwise specified Necrotizing Periodontal Diseases A. Necrotizing ulcerative gingivitis B. Necrotizing ulcerative periodontitis Periodontitis Associated With Endodontic Lesions A. Combined periodontic -endodontic lesions The classification to define Periodontitis used for the longest period was by American Academy of Periodontology (AAP) 1999

6. Chronic periodontitis has been defined as "an infectious disease resulting in inflammation within the supporting tissues of the teeth, progressive attachment loss , and bone loss.” Site-specific disease Slight (mild) periodontitis : No more than 1 to 2 mm of clinical attachment loss Moderate periodontitis : 3 to 4 mm of clinical attachment loss Severe periodontitis : 5 mm or more of clinical attachment loss Chronic Periodontitis

7. Clinical Diagnosis Detection of chronic inflammatory changes in the marginal gingiva Presence of periodontal pockets Loss of clinical attachment It is diagnosed radio graphically by: Localized or generalized loss of alveolar supporting bone, horizontal or vertical

8. Localized periodontitis : less than 30% of the sites demonstrate attachment loss and bone loss A. Clinical view of anterior teeth showing minimal plaque and inflammation B. Radiographs showing presence of localized, vertical, angular bone loss on the distal side of the maxillary left first molar C. Surgical exposure of the vertical, angular defect associated with the chronic plaque accumulation and Carranza, 11 th ed

9. Generalized periodontitis : less than 30% or more of the sites demonstrate attachment loss and bone loss A. Clinical view showing minimal plaque and inflammation B. Radiograph showing severe, generalized, horizontal pattern of bone loss Carranza, 11 th ed

10. Lang et al in 1999 defined aggressive periodontitis on the basis of: Aggressive Periodontitis

11. A striking feature is lack of clinical inflammation despite the presence of deep periodontal pockets and advanced bone loss. The plaque that is present forms a thin biofilm on the teeth and rarely mineralizes to form calculus. Rate of bone loss about three to four times faster than in chronic periodontitis . Localized Aggressive Periodontitis

12. Distolabial migration of the maxillary incisors with concomitant diastema formation. Increasing mobility of the first molars. Sensitivity of denuded root surfaces to thermal and tactile stimuli, and Deep, dull, radiating pain during mastication , probably because of irritation of the supporting structures. Other clinical features of localized aggressive periodontitis may include….

13. Vertical loss of alveolar bone around the first molars and incisors, beginning around puberty in otherwise healthy teenagers. Radiographic findings may include an “arc-shaped loss of alveolar bone extending from the distal surface of the second premolar to the mesial surface of the second molar”. Radiographic Findings

14. Usually affects individuals <30 yrs; may be older. A poor antibody response to the pathogens present. “Generalized interproximal attachment loss affecting at least three permanent teeth other than first molars and incisors”. Periods of advanced destruction followed by stages of quiescence of variable length (weeks to months or years). Two types of gingival responses seen: Destructive Stage Quiescence Stage Generalized Aggressive Periodontitis

15. Patients often have small amounts of bacterial plaque . inconsistent with the amount of periodontal destruction. Qualitatively, P. gingivalis , A. actinomycetemcomitans , and Bacteriodes forsythus frequently are detected in the plaque. Generalized juvenile periodontitis (emphasis on a possible relationship with LAP) 2. Severe periodontitis (emphasis on the advanced destruction in comparison with patient age) 3. Rapidly progressing periodontitis (emphasis on the fast rate of progression of lesions in these forms). GAP represents the most heterogeneous group and includes the most severe forms of periodontitis . They comprise forms originally described as:

16. Can range from severe bone loss associated with minimum number of teeth to advanced bone loss affecting the majority of teeth in the dentition. Radiographically

17. American Academy of Periodontology Task Force Report on the Update to the 1999 Classification of Periodontal Diseases and Conditions This update addresses specific areas of concern with the current classification: 1. Attachment level, 2. Localized versus generalized periodontitis. 1. Use of attachment levels in diagnosis of periodontitis In clinical practice, measurement of CAL is challenging, and time consuming. Measuring the location of CEJ when the gingival margin is located coronal to the CEJ is difficult and may involve some guesswork when the CEJ is not readily evident via tactile sensation. The clinician may chart probing depths alone or probing depths with a single recession measure at the mid-facial or mid-lingual and only when recession is actually present. American Academy of Periodontology Task Force Report on the Update to the 1999 Classification of Periodontal Diseases and Conditions. J Periodontol 2018; 86 ( 7), 835–38 .

18. Another common error occurs when gingival margin measures are charted as ‘‘0 mm ’’ when in fact the gingival margin is not right at the level of the CEJ, resulting in attachment levels that are incorrectly charted as being equal to probing depth. In general, a patient would have periodontitis when one or more sites had bleeding on probing, radiographic bone loss, and increased probing depth or clinical attachment loss. American Academy of Periodontology Task Force Report on the Update to the 1999 Classification of Periodontal Diseases and Conditions. J Periodontol 2018; 86 (7), 835–38.

19. The New Classification from the 2017 World Workshop on Periodontal and Periimplant Disease and Conditions (“the World Workshop”) reviewed the scientific evidence and reached four main conclusions: 1. There is no evidence of a specific pathophysiology that enables the differentiation of cases as “aggressive” or “chronic” periodontitis or provides guidance for different kinds of intervention. 2. There is little consistent evidence that aggressive and chronic periodontitis are different diseases. But there is evidence that multiple factors, and the interactions between them, influence clinically observable disease outcomes (phenotypes) at the individual level. 3. On a population basis, the average (mean) rates of periodontitis progression are consistent across all observed populations in the world. However, there is evidence that specific segments of the population exhibit different levels of disease progression. 4. A classification system based only on disease severity fails to capture important dimensions of an individual’s disease, including complexity and risk factors.

20. Classification of periodontitis based on stages defined by severity Papapanou et al., 2018

21. Borderland between gingivitis and periodontitis . Represents the early stages of attachment loss. Patients with stage I periodontitis , if they show a degree of clinical attachment loss at a relatively early age, may have heightened susceptibility to disease onset. Early diagnosis may be a challenge in general dental practice: periodontal probing to estimate early clinical attachment loss – the current gold standard for defining periodontitis – may be inaccurate. Assessment of salivary biomarkers and/or new imaging technologies may increase early detection of stage I periodontitis .

22. Stage II represents established periodontitis in which a carefully performed clinical periodontal examination identifies the characteristic damages that periodontitis has caused to tooth support. At this stage of the disease process, however, management remains relatively simple for many cases as application of standard treatment principles. Careful evaluation of the stage II patient's response to standard treatment principles is essential, and the case grade plus treatment response may guide more intensive management for specific patients.

23. At stage III, periodontitis has produced significant damage to the attachment apparatus. In the absence of advanced treatment, tooth loss may occur. The stage is characterized by the presence of deep periodontal lesions that extend to the middle portion of the root. Management is complicated by the presence of deepintrabony defects, furcation involvement, history of periodontal tooth loss/exfoliation, and presence of localized ridge defects that complicate implant tooth replacement. In spite of the possibility of tooth loss, masticatory function is preserved. Treatment of periodontitis does not require complex rehabilitation of function.

24. Periodontitis causes considerable damage to the periodontal support and may cause significant tooth loss, and this translates to loss of masticatory function. In the absence of proper control of the periodontitis and adequate rehabilitation, the dentition is at risk of being lost. This stage is characterized by the presence of Deep periodontal lesions that extend to the apical portion of the root History of multiple tooth loss Tooth hypermobility due to secondary occlusal trauma & the sequelae of tooth loss Posterior bite collapse Drifting Case management requires stabilization/restoration of masticatory function.

25. Classification of periodontitis based on grades Papapanou et al., 2018

26. Grading a periodontitis patient involves estimating the future risk of periodontitis progression and the likely responsiveness to standard therapeutic principles. This estimate guides the intensity of therapy and secondary prevention after therapy. Grading adds another dimension and allows the rate of progression to be considered, using direct and indirect evidence.

27. Direct evidence is based on the available longitudinal observation: for example, in the form of older diagnostic-quality radiographs. Indirect evidence is based on the assessment of bone loss at the worst-affected tooth in the dentition as a function of age. The periodontitis grade can then be modified by the presence of risk factors. Clinicians should approach grading by assuming a moderate rate of progression (grade B) and look for direct and indirect measures of whether there is a higher disease progression that would justify the application of grade C. Grade A is applied once the disease is arrested.

28. Risk Factors Currently validated risk factors for Periodontitis include Smoking Diabetes Smoking and Diabetes are termed as Grade modifiers since they are considered to influence the rate of progression of Periodontitis . Emerging risk factors like obesity, specific genetic factors, physical activity, or nutrition may one day contribute to assessment of Periodontitis .

29. Papapanou et al., 2018 Classification of necrotizing periodontal diseases (NPD)

30. Classification of periodontal abscesses based on the etiologic factors involved Papapanou et al., 2018

31. The main features to identify periodontitis Loss of periodontal tissue support due to inflammation is the primary feature of periodontitis . A threshold of interproximal , CAL of ≥2 mm or ≥3 mm at ≥2 non‐adjacent teeth Presence of interproximal tissue loss through radiographic assessments of bone loss Clinically meaningful descriptions of periodontitis should include the proportion of sites Bleed on probing The number and proportion of teeth with probing depth over certain thresholds (commonly ≥4 mm and ≥6 mm) Teeth with CAL of ≥3 mm and ≥5 mm

32. Definition of a periodontitis case In the context of clinical care, a patient is a “ periodontitis case” if: 1. Interdental CAL is detectable at ≥2 non‐adjacent teeth 2. Buccal or oral CAL ≥3 mm with pocketing ≥3 mm is detectable at ≥2 teeth The observed CAL cannot be ascribed to non‐ periodontitis ‐related causes such as: 1) Gingival recession of traumatic origin 2) Dental caries extending in the cervical area of the tooth 3) The presence of CAL on the distal aspect of a second molar and associated with malposition or extraction of a third molar 4) An endodontic lesion draining through the marginal periodontium 5) the occurrence of a vertical root fracture

33. Diagnosis of Periodontitis A periodontitis diagnosis for an individual patient should encompass three dimensions: 1. Definition of a periodontitis case based on detectable CAL loss at two non‐adjacent teeth 2. Identification of the form of periodontitis : necrotizing periodontitis , periodontitis as a manifestation of systemic disease or periodontitis 3. Description of the presentation and aggressiveness of the disease by stage and grade

34. Characterization of periodontitis by stage and grade Stage is largely dependent upon the severity of disease at presentation Staging, further includes a description of extent and distribution of the disease in the dentition. Grade provides supplemental information about biological features of the disease including A history‐ based analysis of the rate of periodontitis progression Assessment of the risk for further progression; Analysis of possible poor outcomes of treatment Assessment of the risk that the disease or its treatment may negatively affect the general health of the patient.

35. Different forms of periodontitis Based on pathophysiology , three clearly different forms of periodontitis have been identified: (A) Necrotizing periodontitis (B) Periodontitis as a direct manifestation of systemic diseases (C) Periodontitis Differential diagnosis is based on history and the specific signs and symptoms of necrotizing periodontitis , or the presence or absence of an uncommon systemic disease that alters the host immune response. The remaining clinical cases of periodontitis which do not have the local characteristics of necrotizing periodontitis or the systemic characteristics of a rare immune disorder with a secondary manifestation of periodontitis should be diagnosed as “ periodontitis ” and be further characterized using a staging and grading system.

36. Difference between acute periodontal lesions and other forms of periodontitis Periodontal abscesses, lesions from necrotizing periodontal diseases and acute presentations of endo ‐periodontal lesions, share the following features that differentiate them from periodontitis lesions: Rapid‐onset, Rapid destruction of periodontal tissues, underscoring the importance of prompt treatment (3) Pain or discomfort, prompting patients to seek urgent care.

37. Difference in the pathophysiology between periodontal abscesses and other periodontitis lesions The first step in the development of a periodontal abscess is bacterial invasion or foreign body impaction in the soft tissues surrounding the periodontal pocket. Pathophysiologically , this lesion differs in that the low pH within an abscess leads to rapid enzymatic disruptionof the surrounding connective tissues and, in contrast to a chronic inflammatory lesion, has a greater potential for resolution if quickly managed.

38. Difference in the pathophysiology between necrotizing periodontal diseases and other periodontitis lesions. Yes. Necrotizing gingivitis lesions are characterized by the presence of ulcers within the stratified squamous epithelium and the superficial layer of the gingival connective tissue, surrounded by a non‐specific acute inflammatory infiltrate. Necrotizing periodontal diseases are strongly associated with impairment of the host immune system, as follows (1) In chronically, severely compromised patients (2) in temporarily and/or moderately compromised patients

39. Difference in the pathophysiology between endo ‐periodontal lesions and other periodontitis or endodontic lesions. The term endo ‐periodontal lesion describes a pathologic communication between the pulpal and periodontal tissues at a given tooth that may be triggered by a carious or traumatic lesion that affects the pulp and, secondarily, affects the periodontium ; by periodontal destruction that secondarily affects the root canal; or by concomitant presence of both pathologies. No distinct pathophysiology between an endo ‐periodontal and a periodontal lesion has been identified. The communication between the pulp/root canal system and the periodontium complicates the management of the involved tooth.

40. References Newman, Takei, Klokkevold , Carranza. Carranza’s, clinical periodontology , 10th ed ; 632-34. Newman, Takei, Klokkevold , Carranza. Carranza’s, clinical periodontology , 13th ed ; 1880-1916. Papapanou , P. N., Sanz , M., Buduneli , N., Dietrich, T., Feres , M., Fine, D. H., … Tonetti , M. S. Periodontitis : Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri -Implant Diseases and Conditions. J Periodontol 2018;89: S173-82.   American Academy of Periodontology Task Force Report on the Update to the 1999 Classification of Periodontal Diseases and Conditions. J Periodontol 2015; 86 (7), 835–38. Sanz M, Tonetti M. New classification of periodontal and peri-implant diseases. EFP 2019. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis : Framework and proposal of a new classification and case definition. J Clin Periodontol 2018 ;89:S159-72.

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