Classification of Periodontal Diseases: Hayder Alwaeli: BDS, M.Sc. & J. Board

Classification of
Periodontal Diseases
Hayder Alwaeli: BDS, M.Sc. & J. Board
1
Gingiva
-Fibrous mucosa surrounding the teeth & covering the coronal of the
alveolar process Consists of 3 parts
1. Free Gingiva
2. Attached Gingiva
3. Interdental Gingiva
2
Clinical Features of Normal (Healthy) Gingiva
3
New Classification System
• 1999 International Workshop for the
Classification of Periodontal Diseases
4
Classification of Periodontal
Diseases
• American Academy of
Periodontology (AAP)
• The International
Workshop 1999
5
 Characteristics common to all gingival diseases
1. Signs & symptoms are confined to gingiva
2. The presence of dental plaque to initiate & / or exacerbte the severity
of the lesion
3. Clinically signs of inflammation:
• Enlarged gingival contour : edematous or fibrotic

• Red in color &/ or bluish red
• Bleeding upon stimulating
• ↑ gingival exudates
• Pathological ↑ in sulcular depth
• No radiographic evidence
4. Reversibility of the disease by removing the etiology (ies)

5. Possible role as a precursor to attachment loss around tooth
6
 Periodontitis
-An inflammatory disease of the supporting tissue of the teeth caused by specific
microorganisms or specific group, resulting in progressive destruction of
periodontal ligament & alveolar bone with pocket formation, recession, or both
- The primary clinical features of periodontitis
a. Clinical attachment loss
b. alveolar bone loss
c. periodontal pocketing
d. gingival inflammation( enlargement or recession )
e. increased mobility, drifting & / tooth exfoliation may occur
h. progress continuously as chronic inflammation or by burst of activity
-Several bacterial species associated with periodontitis
. P. gingivalis . T. denticola
. Actinobcillus actinomycetumcmitans . E. corrodens
. P. intermedia . E. nodatum
. C. rectus 7
8
9
Addition of a Section on “Gingival
Diseases”
I. Gingivitis associated with
dental plaque only
A. Without local
contributing factors
B. With local
contributing factors
10
II. Gingival diseases modified by
systemic factors
• A. Endocrine system
1. Puberty-associated
2. Menstrual cycle-associated
3. Pregnancy associated
a. Gingivitis
b. Pyogenic granuloma
4. Diabetes mellitus-associated
• B. Blood dyscrasias
1. Leukemia-associated
gingivitis
2. Other
11
systemic factors
a- Gingivitis
gingivitis
2. Other
12
systemic factors
a- Gingivitis
gingivitis
2. Other
13
systemic factors
a- Gingivitis
gingivitis
2. Other
14
systemic factors
a- Gingivitis
gingivitis
2. Other
15
systemic factors
a- Gingivitis
gingivitis
2. Other
16
systemic factors
a- Gingivitis
gingivitis
2. Other
17
Ill. Gingival diseases modified by
medications
1. Drug-influenced gingival
enlargements
a. Anticonvulsant
“Phenytoin”
b. Immunosupressent
“Cyclosporin A”
c. Calcium Channel Blockers

“Nifedipine, Verapamil, Diltiazem,
& Sodium Valporate”
2- Drug-influenced gingivitis
a. Oral contraceptive-associated
gingivitis
b. Other
18
Ill. Gingival diseases modified by
medications
1. Drug-influenced gingival
enlargements
a. Anticonvulsant
“Phenytoin”
b. Immunosupressent
“Cyclosporin A”
c. Calcium Channel Blockers

“Nifedipine, Verapamil, Diltiazem,
& Sodium Valporate”
2- Drug-influenced gingivitis
a. Oral contraceptive-associated
gingivitis
b. Other
19
IV. Gingival diseases modified by malnutrition
A. Ascorbic acid deficiency gingivitis
B. Other
20
Non-Plaque-Induced Gingival Lesions III. Gingival diseases of fungal
I- Gingival diseases of specific bacterial origin
origin A. Candida-species infections:
A. Neisseria gonorrhea Generalized gingival
B. Treponema pallidum candidosis
C. Streptococcal species
D. Other B. Linear gingival erythema
II. Gingival diseases of viral origin

C. Histoplasmosis
A. Herpesvirus infections
1. Primary herpetic gingivostomatitis
2. Recurrent oral herpes D. Other
3. Varicella zoster
B. Other
21
IV- Gingival lesions of genetic origin B. Allergic reactions
A. Hereditary gingival fibromatosis 1. Dental restorative materials
(mercury, acrylic, nickel)
B. Other 2. Reactions attributable to
a- tooth pastes
V. Gingival manifestations of systemic b- mouth washes
conditions c- chewing gum
A. Mucocutaneous lesions d- foods and additives
1. Lichen planus
2. Pemphigoid VI: traumatic lesions:
3. Pemphigus vulgaris “Factitious, Iatrogenic, & Accidental”
4. Erythema multiforme A- chemical injury
B- physical injury
5. Lupus erythematosus
C- thermal injury
6- Drug induced
7. Other VII: Foreign body reactions
VIII: not otherwise specified
22
Hereditary Gingival Fibromatosis
Clinical Features:
• no sex predilection
• apparent when the teeth are erupting,
usually enlargement begins in puberty
• gingival overgrowth, gingiva may cover the
teeth possibly completely
• more common in posterior mandibular areas
• pink, firm, smooth and uniform
• asymptomatic, nonhemorrhagic,
nonexudative
• possible apparent delay in dental eruption
• malpositioning of teeth, retention of
deciduous teeth, esthetic and functional
problems
23
Classification of Periodontal
Diseases
• American Academy of
Periodontology (AAP)
• The International
Workshop 1999
24
Periodontitis
The Old Classifications
25
World Workshop in Clinical Periodontics (1989)
Form of Priodontitis Basic Characteristics

Adult Periodontitis  >35 years
 Slow rate of progression
 No defects in host defenses
Early onset Periodontitis  < 35 years
- Prepubertal  Rapid rate of progression
- Juvenile  Defects in host defenses
- Rapidly progressive Associated with specific microflora
Periodontitis associated with Systemic diseases that predispose to
systemic diseases rapid rates of destruction (e.g.
Diabetes)
Necrotizing Ulcerative Similar to NUG but with clinical
26
Periodontitis attachment loss
European Classification (1993)
Adult Periodontitis  4th decade
Early onset Periodontitis  Prior to 4th decade
- Rapidly progressive
Diabetes)
Necrotizing Ulcerative Tissue necrosis with clinical
Periodontitis attachment loss & bone loss 27
Drawbacks of the old classifications
Considerable
systemic diseases overlap inrates
rapid disease categories
of destruction (e.g.
Diabetes)
Necrotizing Ulcerative Tissue necrosis with attachment
Periodontitis clinical attachment & bone loss 28
Absence
systemic diseases of a gingival
rapiddisease component
rates of destruction (e.g.
Diabetes)
PeriodontitisInappropriate
associated with emphasis
Systemic diseases
on agethat predispose
of to
onset of disease and rates of progression
Diabetes)
Inadequate
systemic diseases or inappropriate classification
rapid rates criteria
of destruction (e.g.
Diabetes)
Periodontitis
• Chronic
• Aggressive
• Periodontitis as a manifestations of
systemic diseases
32
Chronic periodontitis
• The most prevalent form in adults
• Amount of destruction consistent with local factors
• Associated with a variable microbial pattern
• Subgingival calculus frequently found
• Slow to moderate rate of progression
• Possibly modified by or associated with the following:
Systemic diseases
Local factors predisposing factors
Environmental factors
33
Chronic periodontitis
Localized form: <30% of sites involved

Generalized form: >30% of sites involved
Slight: 1-2 mm of clinical attachment loss

Moderate: 3-4 mm of clinical attachment loss
Severe: ≥5 mm of clinical attachment loss
34
Generalized Severe Chronic Periodontitis
35
36
37
38
Aggressive Periodontitis
Primary Features
• Except for the presence of periodontitis, patients
are otherwise clinically healthy
• Rapid attachment loss and bone destruction
• Familial aggregation
39
Aggressive
Secondary Features
Periodontitis
• Amounts of microbial deposits are inconsistent with the
severity of periodontal tissue destruction
• Elevated proportions of Aa and, in some populations, P.

gingivalis may be elevated
• Phagocyte abnormalities
• Hyper-responsive macrophage phenotype, including

elevated levels of PGE2 and IL-1β
• Progression of attachment loss and bone loss may be self-

arresting
40
Localized Aggressive Periodontitis
• Circumpubertal onset of disease
• Localized presentation with

interproximal attachment
loss on at least two
permanent teeth, one of
which is a first molar, and
involving no more than two
teeth other than first molars
and incisors
• Robust serum antibody response

to infecting agents
41
Localized Aggressive Periodontitis
42
Generalized Aggressive Periodontitis
• Usually affects persons under 30
years of age
• Generalized proximal attachment

loss affecting at least three teeth
other than first molars and incisors
• Pronounced episodic nature of

periodontal destruction
• Poor serum antibody response to

infecting agents
43
Generalized Aggressive Periodontitis
44
Periodontitis as a Manifestation of Systemic Diseases
1. Hematologic disorders 2. Genetic disorders
a. Acquired neutropenia a. Familial and cyclic neutropenia

b. Leukemias b. Down syndrome
c. Other c. Leukocyte adhesion deficiency
syndromes
d. Papillon-Lefevre syndrome
e. Chediak-Higashi syndrome
f. Histiocytosis syndromes
g- Glycogen storage disease
h. Infantile genetic agranulocytosis
i. Cohen syndrome
j. Ehlers-Danlos syndrome
k. Hypophosphatasia
l. Other
3. Not otherwise specified

45
Hematologic disorders
• Agranulocytosis
• Neutropenia
46
Genetic disorders
47
Necrotizing Periodontal Diseases
• Necrotizing ulcerative gingivitis
• Necrotizing ulcerative periodontitis
48
Abscesses of the periodontium
• Gingival
• Periodontal
• Pericoronal
49
Periodontitis associated with
endodontic lesions
• Combined perio-endo lesions
50
Developmental or acquired
deformities and conditions
A. Localized tooth-related factors that modify or predispose to
plaque-induced gingival diseases/periodontitis
1. Tooth anatomic factors
a. Enamel Pearls; Associated with attachment loss
specially in furcation areas
b. Cervical Enamel Projections;
found 15 % to 24 % of mandibular molars
found 9 % to 25 % of maxillary molars
2. Dental restorations/appliances
3. Root fractures
4. Cervical root resorption and cemental tears
51
B. Mucogingival deformities and conditions around teeth
1. Gingival/soft tissue recession
A. facial or lingual surfaces
B. interproximal (papillary)
2. Lack of keratinized gingiva
3. Decreased vestibular depth
4. Aberrant frenum/muscle position
5. Gingival excess
A. pseudopocket
B. inconsistent gingival margin
C. excessive gingival display
D. gingival enlargement
E. Abnormal color
52
C. Mucogingival deformities and conditions on
edentulous ridges
1. Vertical and/or horizontal ridge deficiency
2. Lack of gingiva/keratinized tissue
3. Gingival/soft tissue enlargement
4. Aberrant frenum/muscle position
5. Decreased vestibular depth
6. Abnormal color
D. Occlusal trauma
1. Primary occlusal trauma
2. Secondary occlusal trauma 53
FINALLY ,,
Please read;
• Chapter 4
pages; 64 – 72
Classification of Diseases
and Condition Affecting
the Periodontium
54

Classification of Periodontal Diseases: Hayder Alwaeli: BDS, M.Sc. & J. Board

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Classification of Periodontal Diseases: Hayder Alwaeli: BDS, M.Sc. & J. Board

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Classification of

• Enlarged gingival contour : edematous or fibrotic

4. Reversibility of the disease by removing the etiology (ies)

c. Calcium Channel Blockers

c. Calcium Channel Blockers

A. Ascorbic acid deficiency gingivitis

II. Gingival diseases of viral origin

VIII: not otherwise specified

Form of Priodontitis Basic Characteristics

Localized form: <30% of sites involved

Slight: 1-2 mm of clinical attachment loss

• Rapid attachment loss and bone destruction

• Elevated proportions of Aa and, in some populations, P.

• Hyper-responsive macrophage phenotype, including

• Progression of attachment loss and bone loss may be self-

• Circumpubertal onset of disease

• Localized presentation with

• Robust serum antibody response

• Generalized proximal attachment

• Pronounced episodic nature of

• Poor serum antibody response to

a. Acquired neutropenia a. Familial and cyclic neutropenia

3. Not otherwise specified

• Combined perio-endo lesions

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