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 Gingivitis
Plaque-induced only

Features
No loss of Connective Tissue Attachment (CTA) or Alveolar Bone (AB) Plaque present at gingival margin Redness Oedematous Increase in gingival exudates Loss of stippling Bleeding on probing Sulcular temperature change Reversible upon plaque removal Hormonal-increase in gingivitis during circumpubertal age, without simultaneous plaque increase diabetes Anti-convulsants-Phenytoin calcium channel blockers-Amlodipine Immunosuppressants-Cyclosporin Lack of vitamin c seen from their diet history

Treatment
OH reinforcement review

Modified by systemic conditions

Correct or reduce predisposing systemic factors (eg. Control diabetes, smoking cessation) OH reinforcement Review Attempt to change medication (discuss) with physician OH reinforcement review Review Diet Discuss diet supplements with physician OH reinforcement review OH reinforcement possibly with an antibacterial adjunct

Modified by medications

Modified by malnutrition

Non-plaque induced

Bacterial origin-N.gonorrhea, T.pallidum, Streptococci, Mycobacterium chelonae Features: fiery red, oedematous, painful ulceration (asymptomatic chancres, mucous patches or a typical nonulcerated highly inflamed gingivitis) Viral origin-herpetic ginigivostomatitis Features generalised pain in the gingival and oral mucosa, inflammation, ulceration of gingival and mucosa, lymphadenopathy, fever, malaise

Gentle debridement and relief of pain using analgesia Instruction in proper nutrition, appropriate fluid intake Reassurance that condition is self-limiting Antiviral adjunct Healing usually occurs within 1-2 weeks Soft/liquid diet Rest Atraumatic plaque removal CHX mouth rinses Antiviral adjunct

Viral origin-herpes zoster Features small ulcers on the tongue, mucosa and gingiva

Preyesh Patel and Alaa Guni, BDS 4 students

Diagnosis Gingivitis
Non-plaque induced

Features
Features pseudomembranous candido- sis may present as white lesions, chronic erythematous candidosis presents as redness along the gingival margins. Fungal origin-Candidosis

Treatment
Antifungal OH reinforcement review

Mucocutaneous disorders Oral Lichen Planus, Benign mucous membrane pemphigoid, pemphigus vulgaris, erythema multiforme Features desquamative lesions, gingival ulcerations Trauma traumatic brushing technique Features frictional keratosis

Topical ointments, steroids OH reinforcement Review

Instruction on atraumatic brushing technique

Periodontitis

Incidental attachment loss

Incipient chronic periodontitis

Loss of attachment doesnt fit into criteria of aggressive or chronic periodontitis Isolated areas of attachment loss in an other- wise healthy dentition associated with trauma, malpositioned tooth, impacted third molars, subginigival caries and endo infections May predispose to periodontitis Age of onset can be in adolescence (1314 years) Interproximal clinical attachment loss of 1 2 mm (commonly seen on maxillary first molars, mandibular incisors), associated with presence of plaque, subgingival calculus Pockets of 45 mm. Bone loss no more than 0.5 mm over an 18month period (bite-wing radiographs usually show horizontal bone loss).

Treat local defect OH reinforcement Review

OH reinforcement Non-surgical rsd Review

Preyesh Patel and Alaa Guni, BDS 4 students

Diagnosis Periodontitis
Chronic Periodontitis Mild 1-2mm cal, <25% Moderate 3-4mm cal, 25-50% bone loss Severe 5mm+ cal, >50% bone loss Localised <30% sites affected Generalised >30% sites affected

Features

Common, most prevalent in adults Amount of destruction consistent with presence of local factors Subgingival calculus frequent finding Slow to moderate rate of progression but have periods of rapid progression 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

Treatment

OH reinforcement Non-surgical rsd Review If treatment fails reassess and consider local antimicrobial adjunct.

Aggressive periodontitisLocalised: Circumpubertal onset restricted to interproximal areas (IP CAL is >3mm) of first molar and incisors. (arc shaped) involving no more than two teeth other than first molar or incisor Generalised Generalised Interproximal attachment loss affecting at least 3 teeth other than first molars and incisors (<30) Periodontitis as a manifestation of systemic conditions

Primary features:

Non-contributory medical history; Rapid attachment loss (3-4 times faster than chronic periodontitis) and bone destruction relative to age; Familial aggregation of disease.

OH reinforcement Non-surgical rsd Review If treatment fails reassess and consider local antimicrobial adjunct.

Secondary features: Amount of microbial deposits inconsistent with the severity of periodontal destruction Progression of attachment loss and bone loss may be self-arresting.

Papillon Lefevre Syndrome Chediak Higashi Syndrome Leucocyte Adhesion Deficiency

OH reinforcement Non-surgical rsd Review If treatment fails reassess and consider local antimicrobial adjunct.

Necrotising periodontal conditions

Spontaneously bleeding gum, red and very painful to touch Halitosis Patient may feel unwell generally Ulceration interproximally Yellow grey pseudomembraneous slough Exposed bone Smoking, poor OH, stress

Initially: Course of metronidazole (anti-bacterial) 200mg tds for 5 days , ensure no contraindication OH reinforcement including smoking cessation CHX mouthwash 0.2% x 10ml for 1 min twice daily Non-surgical rsd if allowed 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 Periodontitis
Abscesses (periodontal)

Features

Forms close to the gingival margin Tender to lateral percussion Pulp vital for true perio lesions

Treatment

Drainage (to relieve patient!) RSD if allowed Course of antimicrobials: Metronidazole (preffered as effective against anaerobic bacteria) or a mix of metronidazole and amoxicillin if cellulitis present Review

Perio-endo lesion -Primarily endodontic

History of trauma or pulpitis Heavily restored Fracture of tooth? Localised pockets and relatively healthy periodontium generally Non-vital TTP

Extraction or extirpate the pulp and monitor If improvement shown (reduction in symptoms and reduced lesion on LCPA) RCT followed by RSD

Perio-endo lesion -Primarily periodontic

History of periodontitis Vital/non-vital pulp upon testing Lack of restoration/fracture or history of trauma No history of pulpitis TTP

Extraction or extirpate the pulp and monitor If improvement shown (reduction in symptoms and reduced lesion on LCPA) RCT followed by RSD