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CLASSIFICATION OF PERIODONTAL DISEASES
Contents Introduction History Dominant Paradigms in the historical
development of classification systems Classification systems Conclusion References
Introduction Systematic arrangement into classes or
groups based on perceived common characteristics.
A means of giving order to a group of disconnected facts.
Need for classification Provides a framework for scientifically
studying Etiology Pathogenesis Treatment
To assess the prognosis, outcome and determine the treatment plan.
Advancing age and leads to progressive loosening and loss of teeth.
Very aggressive type that occurs in younger patients.
History Giralamo Cardono
Fauchard (1723) – ‘Scurvy’ of the gums
Early 19th century – Riggs Disease (John W Riggs 1811-1885)
1st to differentiate periodontal diseases
Gottlieb, 1920s Schmutz-Pyorrhoe Alveolar atrophy or Diffuse atrophy Paradental-Pyorrhoe Occlusal trauma Alveolar atrophy or Diffuse atrophy :
Accumulation of deposits, inflammation, shallow pockets, and resorption of the alveolar crest.
Non inflammatory disease - loosening of teeth,elongation,and wandering of teeth ,no dental deposits. Pockets are formed only in later stages
Paradental-Pyorrhoe:
Occlusal trauma :
Irregularly distributed pockets - shallow to extremely deep. May start as Schmutz-Pyorrhoe or as diffuse atrophy.
Physical overload which results in resorption of the alveolar bone and loosening of teeth.
McCall & Box : Periodontitis - those inflammatory diseases in which all three components of the periodontium
Periodontitis Simplex periodontitis Complex periodontitis
Dominant paradigms in the historical development of classification systems
1870–1920 The clinical features of the diseases
1920–1970 The concepts of classical pathology
1970–present Infectious etiology of the diseases
Clinical characteristics paradigm (1870-1920)
Local factors Black (1894), WD Miller (1890), Patterson (1885), Riggs(1882)
Systemic disturbances Peirce (1892), GA Mills (1881), LL Dunbar (1894)
Both local and systemic factors WD Miller (1890), Patterson (1885)
Classification of periodontal diseases
following the “Clinical characteristics”
paradigm
C.G. Davis (1879) Gingival recession with minimal or no inflammation.
Periodontal destruction secondary to ‘lime deposits’. Mechanical pressure → alveolar bone resorption
because of lack of nutrition.
Riggs’ Disease ‘... loss of alveolus without loss of gum.’ The
perceived problem was a ‘necrosed alveolus’ or death of the periodontal membrane.
G.V. Black (1886) Constitutional gingivitis A painful form of gingivitis Simple gingivitis Calcic inflammation of the peridental
membrane Phagedenic pericementitis (phagedenic =
spreading ulcer or necrosis) ‘Phagedenic pericementitis’ ‘Chronic
suppurative pericementitis’
Drawbacks/ Limitations: Little or no scientific evidence was used No accepted terminology or classification
system was adopted
Pyorrhea alveolaris
Phagedenic pericementitis
Calcic inflammation
of the peridental membrane
Riggs’ disease
Chronic suppurative
pericementitis
Classical pathology paradigm (1920-1970)
Gottlieb and Orban
All disease categories labeled as ‘dystrophic’, ‘atrophic’, or ‘degenerative.
Inflammatory Non- inflammatory
(degenerative/dystrophic)
Classification of periodontal diseases
following the “Classical pathology”
paradigm
INFLAMMATION1. Gingivitis (little or no pocket formation; can include
ulcerative form – Vincent’s) A. Local (calculus, food impaction, irritating
restorations, drug action etc) B. Systemic (Pregnancy, Diabetes, Other Endocrine
Dysfunctions, Tuberculosis, Syphilis, Nutritional Disturbances, Drug Action, Allergy, Hereditary, Idiopathic. Etc)
2. Periodontitis
A. Simplex– bone loss, pockets, abscesses can form, cases have calculus
B. Complex – etiologic factors similar to periodontitis, cases have little, if any calculus.
ORBAN 1942
DEGENERATION1. Periodontosis (attacks young girls and older men; often caries
immunity) A. Systemic disturbances (Diabetes, Endocrine dysfunctions, Blood
dyscrasias, Nutritional disturbance, Nervous disorders, infectious diseases)
B. Hereditary C. Idiopathic
2. Atrophy Periodontal atrophy (Recession. No inflammation no pockets;
osteoporosis) (Local trauma, Presenile, Senile, Disuse, Following inflammation,
Idiopathic)
3. Hypertrophy Gingival hypertrophy (Chronic irritation, Drug action, Idiopathic)
4. Traumatism (Periodontal traumatism, Occlusal trauma)
World workshop in Periodontics
(1966) •Periodontosis as a distinct disease entity ???????
World workshop in Periodontics
(1977)
•No scientific basis for retaining the concept : non-inflammatory or degenerative forms of destructive periodontal disease.
Periodontosis - Infection
Juvenile periodontitis
Infection/ host response Paradigm (1970- present)
Robert Koch (1876) - The germ theory of disease
W.D. Miller - Early proponent of the infectious nature of periodontal diseases
Pyorrhea alveolaris: Predisposing circumstances Local irritation Bacteria (not specific, but various)
Systemic conditions
Reluctance to accept Degenerative nature of periodontal
diseases (i.e. domination of the ‘Classical Pathology’ paradigm).
Microbiological studies
Harald Löe (1965-1968) - classical ‘experimental gingivitis’
Infection/Host Response Paradigm - Dominant
paradigm
Classification of periodontal diseases
following the “Infection / Host
response” paradigm
GINGIVITIS Chronic Marginal Gingivitis
Acute Necrotizing Ulcerative Gingivitis (ANUG)
PERIODONTITIS Juvenile Periodontitis Rapidly Progressive Periodontitis Adult Type Periodontitis
PAGE AND SHROEDER 1982
Suzuki, 1988 Modification of Page & Schroeder 1982
3 plausible hypothesis for the
pathogenesis of the disease: Direct tissue destruction by bacteria &
metabolic products Immune hyper-responsiveness Immune deficiencies involving neutrophil
function (chemotaxis and phagocytosis)
Adult Periodontitis > 35 yrs
Rapidly Progressing Periodontitis Type A 14 - 26 yrs
Type B >26 yrs
Post juvenile Periodontitis 26 – 35 yrs
Juvenile Periodontitis 12 – 26 yrs
Prepubertal Periodontitis < 14 yrs
SUZUKI 1988
Modifications : Subdivisions to rapidly progressive
periodontitis Post- juvenile periodontitis
Advantages : Short and Easy
Shortcomings : Does not include all criteria and conditions
like gingival conditions
I. Adult Periodontitis
II. Early Onset Periodontitis A. Prepubertal Periodontitis 1. Generalised 2. Localised B. Juvenile Periodontitis 1. Generalised 2. Localised C. Rapidly Progressive Periodontitis
III. Periodontitis Associated With Systemic Diseases Downs syndrome, Diabetes, Papillon-Lefevre syndrome,
HIV, others
IV. Necrotising Ulcerative Periodontitis
V. Refractory Periodontitis
WORLD WORKSHOP IN CLINICAL PERIODONTITIS, 1989
Merits: Inclusion of ‘Periodontitis Associated with
Systemic Disease’
Inclusion of ‘Refractory periodontitis’
Critical evaluation Depended heavily on the age of the affected
patients Baab DA(1986), Page RC (1983) and the rates of progression Page RC (1983).
The dividing line between adult and early onset categories -35 years.
‘Rapidly Progressive’ and ‘pre-pubertal periodontitis’ - not a single entity
Periodontitis
Overlap exists among different diagnostic categories and cases did not clearly fit into any single category’
Considerable ‘heterogeneity’ existed within the Refractory Periodontitis
KS Kornman (1996) Loe (1993) Choi J-I (1990), Lee et al(1995),
Magnusson(1991)
I. Periodontitis In Adults
II. Periodontitis In Juveniles Localized Form Generalized Form
III. Periodontitis With Systemic Involvement Primary Neutrophil Involvement Disorders Secondary/Associated Neutrophil
Impairment Other Systemic Diseases
IV. Miscellaneous Conditions
GENCO, 1990
Shortcomings: Onset, duration of diseases not considered Gingival diseases not considered
I. Gingivitis Gingivitis, Plaque Bacterial Non - Aggravated Systemically Aggravated Related To Sex Hormones Related To Drugs Related To Systemic Diseases Necrotising Ulcerative Gingivitis Systemic Determinants Unknown Related To HIV Gingivitis, Non-Plaque Associated With Skin Disease Allergic Infectious
RANNEY, 1993
II. Periodontitis Adult Periodontitis Non-Aggravated Systemically Aggravated
Neutropenia, Leukemias, Lazy Leukocyte Syndrome, AIDS, Diabetes Mellitus
Early Onset Periodontitis Localised Early Onset Periodontitis Neutrophil Abnormality
Generalised Early Onset Periodontitis Neutrophil Abnormality, Immunodeficient
Early Onset Periodontitis Related To Systemic DiseaseLAD, Papillon-Lefevre Syndrome,Chediak Higashi
Syndrome, AIDS, Diabetes Mellitus Type I, Trisomy 21,
Early Onset Periodontitis, Systemic Determinants Unknown
Necrotising Ulcerative PeriodontitisSystemic Determinants UnknownRelated To HIVRelated To Nutrition
Periodontal Abscess
Modifications: Elimination of the ‘Refractory Periodontitis’
category - heterogeneous group
Elimination of the ‘Periodontitis Associated with Systemic Disease’ category
Shortcomings: Lenghty
AMERICAN ACADEMY OF PERIODONTOLOGY, 1999
GINGIVAL DISEASES Dental plaque induced Non plaque induced
CHRONIC PERIODONTITIS Localised Generalised
AGGRESSIVE PERIODONTITIS Localised Generalised PERIODONTITIS AS MANIFESTATION SYSTEMIC DISEASES Associated with hematological disorders Associated with genetic disorders Not otherwise specified
NECROTIZING PERIODONTAL DISEASES Necrotizing Ulcerative gingivitis Necrotizing Ulcerative periodontitis ABSCESSES OF THE PERIODONTIUM Gingival abscess Periodontal abscess Periocoronal abscess PERIODONTITIS ASSOCIATED WITH ENDODONTIC LESIONS Endodontic –periodontal lesion Periodontal – endodontic lesion Combined lesion DEVELOPMENTAL OR ACQUIRED DEFORMITIES OR CONDITIONS Localized tooth related Mucogingival deformities around teeth Mucogingival deformities in edentulous area Occlusal trauma
GINGIVAL DISEASES Dental plaque induced gingival diseases:
1) Gingivitis associated with plaque only: Without local contributing factors With local contributing factors
2) Gingival diseases modified by systemic factorsPuberty associated gingivitisMenstrual cycle associated gingivitisPregnancy associated gingivitisDiabetes mellitus associated gingivitis
3) Associated with blood dyscrasiasLeukemia associated gingivitisOthers
4) Gingival diseases modified by medicationsDrug influenced gingival enlargementsDrug induced gingivitis
5) Gingival diseases modified by malnutrition
Non-Plaque-Induced Gingival Lesions
1. Gingival diseases of
bacterial origin• Neisseria
gonorrhea-associated lesions
• Treponema pallidum-associated lesions
• Streptococcal species-associated lesions
• Other
2. Gingival diseases of viral
origin• Primary
herpetic gingivostomatitis
• Recurrent oral herpes
• Varicella-zoster infection
• Other
3. Gingival diseases of
fungal origin• Candida-
species infections
• Histoplasmosis
• Other
4. Gingival lesions of genetic origina. Hereditary gingival fibromatosisb. Other
5. Gingival manifestations of systemic conditions A) Mucocutaneous disorders i) Lichen planus
ii) Pemphigoidiii) Pemphigus vulgarisiv) Erythema multiforme v) Lupus erythematosusvi) Drug inducedvii) Other
B) Allergic reactions
Dental restorative materials
• Mercury• Nickel• Acrylic• Other
Reactions attributable to
• Toothpastes/Dentifrices
• Mouthrinses/Mouthwashes
• Chewing gum additives
• Foods and additives• Others
6. Traumatic lesions
7. Foreign body reactions
8. Not otherwise specified (NOS)
Physical injury
Chemical injury
Thermal injury
CHRONIC PERIODONTITIS Localised Generalised
Clinical features and characteristics of Chronic Periodontitis are:
Most prevalent in adults
Amount of destruction is consistent with the presence of local factors
Subgingival calculus is a frequent finding
Variable microbial pattern
Slow to moderate rate of progression
Sub classifications:
Extent
Localised (<30%)
Generalised
(>30%)
Severity Slight
(1-2mm)
Moderate(3-4 mm)
Severe (≥ 5mm)
Can be modified by :
Local factors
Environmental factors (smoking,
stress)
Systemic factors
(diabetes mellitus, HIV)
AGGRESSIVE PERIODONTITIS
Localised Generalised
Common features of localized and generalized forms of Aggressive Periodontitis are: Patients are otherwise clinically healthy
Rapid attachment loss and bone destruction
Familial aggregation.
Amount of microbial deposits inconsistent with disease severity
Common characteristics, but not universal: Diseased sites infected with A.a
Abnormalities in phagocyte function
Hyper-responsive macrophages producing elevated levels of PGE2 and IL-1β
Self-arresting disease progression
Sub classifications
Localised • Circumpubertal
onset• Robust serum
antibody response• Localised proximal
attachment loss on at least two permanent teeth, one of which is first molar
Generalised • Usually , < 30
years• Poor serum
antibody response• Generalised
proximal attachment loss affecting at least three teeth other than first molar and incisor
PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASE
Hematologic • Neutopenias • Leukemias• Others
Genetic • Cyclic
neutropenia• Down syndrome• LAD syndrome• Chediak –
Higashi Syndrome
• Papillon- lefevre syndrome
NECROTIZING PERIODONTAL DISEASE
Necrotizing ulcerative gingivitis (NUG) Necrotizing ulcerative periodontitis (NUP)
Necrotizing ulcerative gingivitis
NUGBacterial etiology?
Necrotic lesion
Pre disposing factors
(stress, smoking, immunosuppresi
on)
Contributing factor
Malnutrition
Necrotizing ulcerative periodontitis NUP + HIV : 20.8 times more likely to have
CD4+ cell counts below 200 cells/mm3
Probability of death within 24 months : 72.9%
ABSCESSES OF THE PERIODONTIUM
Gingival abscess Periodontal abscess Pericoronal abscess
• A localized purulent infection that involves the marginal gingiva or interdental papilla.
• Trauma, Foreign body impaction etc
Gingival
•A localized purulent infection located contiguous to the periodontal pocket that leads to destruction of periodontal ligament and alveolar bone
•Moderate to deep pockets, Incomplete calculus removal etc
Periodontal
•A localized purulent infection within the tissue surrounding the crown of a partially erupted tooth.
• Retention of debris, plaque etc beneath the operculum
Pericoronal
PERIODONTITIS ASSOCIATED WITH ENDODONTIC LESION
Endodontic – Periodontal Lesion Periodontal – Endodontic Lesion Combined Lesion
Endodontic – Periodontal L esion
Periapical lesion Accessory canals
Periodontal ligament PDL / Furcation
Clinical attachment and
bone loss
Pulpal infection
PERIODONTITIS ASSOCIATED WITH ENDODONTIC LESION
Endodontic – Periodontal Lesion Periodontal – Endodontic Lesion Combined Lesion
DEVELOPMENTAL OR ACQUIRED DEFORMITIES OR CONDITIONS
Localized tooth related Mucogingival deformities around teeth Mucogingival deformities in edentulous
area Occlusal trauma
Localized tooth related factors
1)Tooth anatomic factors2)Dental restorations/appliances3)Root fractures 4)Cervical root resorption and cemental tears
• Cervical enamel projections and enamel pearls
• Palatogingival grooves, proximal root groove
•Open contacts
Tooth anatomic factors
•Impingement of biologic width•Rough surfacesDental
restorations
•Apical migration of plaque along fracture lineRoot
fractures
B) Mucogingival deformities and conditions around teeth
1) Gingival/soft tissue recession
2) Lack of keratinized gingiva
3) Decreased vestibular depth
4) Aberrant frenum / muscle position
5) Gingival excessa. Pseudopocketb. Inconsistent gingival marginc. Excessive gingival displayd. Gingival enlargement
6) Abnormal color
Mucogingival deformities and conditions on edentulous ridges
1) Vertical and/or horizontal ridge deficiency2) Lack of gingival/keratinized tissue3) Gingival/soft tissue enlargement4) Aberrant frenum/muscle position5) Decreased vestibular depth6) Abnormal color
Occlusal trauma 1) Primary occlusal trauma 2) Secondary occlusal trauma
1989 1999
1. Addition of a Section on "Gingival Diseases“
Clinical expression of gingivitis can be substantially modified by: 1) systemic factors 2) medications, and 3) malnutrition
Non-plaque induced gingival lesions includes a wide range of disorders that affect the gingiva.
2. Replacement of "Adult Periodontitis" With "Chronic Periodontitis“
The age-dependent nature – diagnostic dilemma
A nonspecific term : "Chronic Periodontitis" – more accurate
Substitute terminologyPeriodontitis-Common
Form
Type II Periodontiti
s
Chronic Periodontiti
s
3. Replacement of "Early-Onset Periodontitis" With "Aggressive Periodontitis"
Wise to discard classification terminologies that were age-dependent or required knowledge of rates of progression
4. Elimination of a Separate Disease Category for “Refractory Periodontitis”
"Refractory Periodontitis" – not a single disease entity.
Small percentage of cases of all forms of periodontitis might be non responsive to treatment.
The "refractory" designation - applied to all forms of periodontitis in the new classification system (e.g., refractory chronic periodontitis, refractory aggressive periodontitis, etc.
5. Clarification of the Designation “Periodontitis as a Manifestation of Systemic Diseases”
Retained in the new classification since it is clear that destructive periodontal disease can be a manifestation of certain systemic diseases.
It should be noted that diabetes mellitus is not on this list.
6. Replacement of “Necrotizing Ulcerative Periodontitis” With “Necrotizing Periodontal Diseases”
Both clinical conditions under the single category of "Necrotizing Periodontal Diseases."
Inclusion of "Necrotizing Periodontal Diseases" as a separate category is that both NUG and NUP might be manifestations of underlying systemic problems such as HIV infection.
7. Addition of a Category on "Periodontal
Abscess”
8. Addition of a Category on "Periodontic-Endodontic Lesions”
9. Addition of a Category on "Developmental or Acquired Deformities and Conditions”
MERITS: A gingivitis or gingival disease category Heterogeneous disease categories of
prepubertal, refractory and rapidly progressive periodontitis eliminated.
Criteria of age and rate of progression removed
The reasons for these changes - not arbitrary, but based on available data and understanding of the nature of periodontal infections
Critical evaluation Complex classification as numerous disease
categories are listed
Diabetes associated gingivitis and not Diabetes associated periodontitis
Developmental/ acquired deformities – Inappropriate to include it
Removal of localized juvenile periodontitis – retrograde step, most well defined of all periodontal diseases and with a large body of research
Term ‘chronic’ as a replacement for ‘adult’ – inappropriate
Not based on the microbiological features or genetic factors that control the clinical expression of these diseases
Chronic Periodontitis’ - polymicrobial and polygenic, are altered by important environmental and host-modifying conditions.
Hence, possible to subclassify the multiple forms of ‘Chronic Periodontitis’ into discrete microorganism/host genetic polymorphism groups
Extent Severity Age
Clinical characteris
tics
VAN DER VELDEN, 2005
Parameters are set in the following order: extent, severity, clinical characteristics and age
Examples for diagnoses are: Generalized severe refractory post
adolescent periodontitis, Localized minor prepubertal periodontitis, Localized severe adult periodontitis.
Demerits Refractory periodontitis
Modification by Systemic factors
Gingival diseases
Conclusion Classification systems for periodontal
diseases have evolved based on the understanding of the nature of these diseases
Although classification systems for periodontal diseases currently in use are based on, the Infection/Host Response paradigm, some features of the older paradigms are still valid and have been retained.
The new system is not perfect and will need to be modified
References Gary C. Armitage, Classifying periodontal
diseases – a long standing dilemma., Periodontology 2000, Vol. 30, 2002, 9–23
Gary C. Armitage, Periodontal diagnosis and classification of periodontal diseases. Periodontology 2000, Vol 34, 2004, 9-21
Gary C. Armitage, Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1-6.
Ubele Van Der Velden, Purpose and problems of periodontal disease classification. Periodontology 2000, Vol. 39, 2005, 13–21
Newman, Takei, Klokkevold, Carranza. 10th edition. Carranza’s Clinical Periodontology. W. B. Saunders Company.
Angelo Mariotti. Dental Plaque-Induced Gingival Diseases. Ann Periodontol 1999;4:7-17.
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