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 , various factors were considered when formulating the classification that is now accepted worldwide: World Worskshop in , 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 Plaque-induced only  No loss of Connective Tissue Attachment (CTA) or Alveolar  OH reinforcement Bone (AB)  review  Plaque present at  Redness  Oedematous  Increase in gingival exudates  Loss of stippling   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 and relief of pain using analgesia  Features– generalised pain in the gingival and ,  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 , 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  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 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 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 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 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 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