Preyesh Patel and Alaa Guni, BDS 4 students
Classification of periodontal diseases-the eternal quest
Classifying and grouping entities is integral to human nature. It enforces a sense of belonging so much so, that the entire human species is subdivided into various races, religions and castes. It would be interesting to see if this phenomenon is reciprocated amongst animals.
When it came to tackling the age old concern of classifying periodontal disease, various factors were considered when formulating the classification that is now accepted worldwide: World Worskshop in Periodontology, 1999. These factors included: Aetiology, clinical presentation as well as prognosis/outcome.
As a dental student appreciation of these finely tuned (so far) classifications can be difficult. However, after sifting through many resources, we have formulated a table of our own. A summary of the classifications of the periodontal diseases coupled with its appropriate management. This will serve as a quick and simple tool when revising for exams or even as a reference when in practice.
Preyesh Patel and Alaa Guni, BDS 4 students Diagnosis Features Treatment Gingivitis Plaque-induced only No loss of Connective Tissue Attachment (CTA) or Alveolar OH reinforcement Bone (AB) review Plaque present at gingival margin Redness Oedematous Increase in gingival exudates Loss of stippling Bleeding on probing Sulcular temperature change Reversible upon plaque removal Modified by systemic conditions Hormonal-increase in gingivitis during circumpubertal age, Correct or reduce predisposing systemic factors without simultaneous plaque increase (eg. Control diabetes, smoking cessation) diabetes OH reinforcement Review Modified by medications Anti-convulsants-Phenytoin Attempt to change medication (discuss) with calcium channel blockers-Amlodipine physician Immunosuppressants-Cyclosporin OH reinforcement review Modified by malnutrition Lack of vitamin c seen from their diet history Review Diet Discuss diet supplements with physician OH reinforcement review Non-plaque induced Bacterial origin-N.gonorrhea, T.pallidum, Streptococci, Myco- OH reinforcement possibly with an antibacte- bacterium chelonae rial adjunct
Features: fiery red, oedematous, painful ulceration (asymptomatic chancres, mucous patches or a typical non- ulcerated highly inflamed gingivitis) Viral origin-herpetic ginigivostomatitis Gentle debridement and relief of pain using analgesia Features– generalised pain in the gingival and oral mucosa, Instruction in proper nutrition, appropriate fluid inflammation, ulceration of gingival and mucosa, lymphade- intake nopathy, fever, malaise Reassurance that condition is self-limiting Antiviral adjunct
Viral origin-herpes zoster Healing usually occurs within 1-2 weeks Soft/liquid diet Features– small ulcers on the tongue, mucosa and gingiva Rest Atraumatic plaque removal– CHX mouth rinses Antiviral adjunct
Preyesh Patel and Alaa Guni, BDS 4 students
Diagnosis Features Treatment Gingivitis Non-plaque induced Viral origin-herpetic ginigivostomatitis Antifungal OH reinforcement Features– pseudomembranous candido- review sis may present as white lesions, chronic erythematous candidosis pre- sents as redness along the gingival mar- gins.
Mucocutaneous disorders– Oral Lichen Topical ointments, steroids Planus, Benign mucous membrane OH reinforcement pemphigoid, pemphigus vulgaris, ery- Review thema multiforme
Features– desquamative lesions, gingi- val ulcerations
Trauma– traumatic brushing technique Instruction on atraumatic brushing tech- nique Features– frictional keratosis
Periodontitis Incidental attachment loss Loss of attachment doesn’t fit into criteria Treat local defect of aggressive or chronic periodontitis OH reinforcement Isolated areas of attachment loss in an other- Review wise healthy dentition associated with trauma, malpositioned tooth, impacted third molars, subginigival caries and endo infec- tions May predispose to periodontitis
Incipient chronic periodontitis Age of onset can be in adolescence (13–14 OH reinforcement years) Non-surgical rsd Interproximal clinical attachment loss of 1– Review 2 mm (commonly seen on maxillary first molars, mandibular incisors), associated with presence of plaque, subgingival calcu- lus Pockets of 4–5 mm. Bone loss no more than 0.5 mm over an 18- month period (bite-wing radiographs usually show horizontal bone loss).
Preyesh Patel and Alaa Guni, BDS 4 students
Diagnosis Features Treatment Periodontitis Chronic Periodontitis Common, most prevalent in adults OH reinforcement Mild 1-2mm cal, <25% Amount of destruction consistent with presence of local factors Non-surgical rsd Moderate 3-4mm cal, 25-50% bone loss Subgingival calculus frequent finding Review Severe 5mm+ cal, >50% bone loss Localised <30% sites affected Slow to moderate rate of progression but have periods of rapid progres- If treatment fails reassess and consider local antimicro- Generalised >30% sites affected sion bial adjunct. Apical migration of epithelial attachment Loss of alveolar bone and connective tissue Severity modified by smoking, diabetes, stress and HIV May present with moderately severe gingival inflammation
Aggressive periodontitis- Primary features: OH reinforcement Localised: Non-surgical rsd Circumpubertal onset Non-contributory medical history; Review restricted to interproximal areas (IP Rapid attachment loss (3-4 times faster than chronic periodontitis) and If treatment fails reassess and consider local antimicro- CAL is >3mm) of first molar and bone destruction relative to age; bial adjunct. incisors. (arc shaped) Familial aggregation of disease. involving no more than two teeth other than first molar or incisor Secondary features: Generalised- Generalised Interproximal attach- Amount of microbial deposits inconsistent with the severity of ment loss affecting at least 3 teeth periodontal destruction other than first molars and incisors (<30) Progression of attachment loss and bone loss may be self-arresting.
Periodontitis as a manifestation of sys- Papillon Lefevre Syndrome OH reinforcement temic conditions Chediak Higashi Syndrome Non-surgical rsd Leucocyte Adhesion Deficiency Review If treatment fails reassess and consider local antimicro- bial adjunct.
Necrotising periodontal conditions Spontaneously bleeding gum, red and very painful to touch Initially: Halitosis Course of metronidazole (anti-bacterial) 200mg tds for 5 Patient may feel unwell generally days , ensure no contraindication Ulceration interproximally OH reinforcement including smoking cessation Yellow grey pseudomembraneous slough CHX mouthwash 0.2% x 10ml for 1 min twice daily Exposed bone Non-surgical rsd if allowed Smoking, poor OH, stress Review Long term: OH reinforcement +smoking cessation Dietary advice Surgery involving gingivectomy or flap surgery may be considered to correct any deformities present to improve aesthetics and cleaning If necrotising periodontitis: Consider also discussion with physician as can be HIV related.
Preyesh Patel and Alaa Guni, BDS 4 students
Diagnosis Features Treatment
Periodontitis Abscesses (periodontal) Forms close to the gingival margin Drainage (to relieve patient!) Tender to lateral percussion RSD if allowed Pulp vital for true perio lesions Course of antimicrobials: Metronidazole (preffered as effective against anaerobic bacteria) or a mix of met- ronidazole and amoxicillin if cellulitis present Review
Perio-endo lesion -Primarily endodontic History of trauma or pulpitis Extraction or extirpate the pulp and monitor Heavily restored If improvement shown (reduction in symptoms and re- Fracture of tooth? duced lesion on LCPA) à RCT followed by RSD Localised pockets and relatively healthy periodontium generally Non-vital TTP
Perio-endo lesion -Primarily periodontic History of periodontitis Extraction or extirpate the pulp and monitor Vital/non-vital pulp upon testing If improvement shown (reduction in symptoms and re- Lack of restoration/fracture or history of trauma duced lesion on LCPA) à RCT followed by RSD No history of pulpitis TTP