perio ch 4 classifications of periodontal and peri-implant diseases and conditions and ch 5

how would you define the disease classification system?

grouping of similar entities based on certain differing characteristics; this provides tools to understand etiology, pathogenesis, and treatment

is the disease classification system expected to change over time?

yes; it evolves as new evidence-based knowledge develops

why is the periodontal classification system important?

provides information necessary for predicting treatment outcomes (prognosis) and for submitting info to insurance providers

what are the two organizations that develop new disease classification?

American Academy of Periodontology (AAP) and European Federation of Periodontology (EFP)

what are the three subcategories of gingivitis?

periodontal health and gingival health

dental biofilm-induced gingivitis

non dental biofilm-induced gingivitis

what is an example of something that causes nondental biofilm-induced gingivitis?

leukemia causes inflamed tissues

what are the three subcategories of periodontitis?

necrotizing periodontal disease

periodontitis

periodontitis as a manifestation of systemic disease

what is an example of periodontitis as a manifestation of systemic disease?

diabetes can fuel peridontitis

what are the five other conditions affecting the peridontium?

- systemic diseases or conditions affecting the periodontal supporting tissues

- periodontal abscesses and endodontic-periodontal lesions

- mucogingival deformities and conditions

- traumatic occlusal forces

- tooth and prothesis related factors

what are the four peri-implant conditions and diseases?

peri-implant health

peri-implant mucositis

peri-implantitis

peri-implant soft and hard tissue deficiencies

what is the most recent, internationally accepted classification system?

2017 AAP/EFP classification of periodontal and peri-implant diseases and conditions

what is the 2017 classifications based on?

the 1999 classification systems

the 1999 classification system previously grouped chronic vs aggressive forms of periodontitis, what is different in the current 2017 classification system?

the disease is known as "periodontitis" because there is little consistent evidence that "chronic" vs "aggressive" forms were different diseases

what is important about the multidimensional staging and grading system of the 2017 classification system?

allows provider to individualize pt-specific treatment, there is also a new classification category for peri-implant diseases and conditions

what is another update in the 2017 classification system?

includes case definition of "intact periodontium" vs "reduced periodontium"

what is the 2017 World Workshop definition of peridontal health?

state free from inflammatory periodontal disease that allows individual to function normally and avoid consequences (mental or physical) due to current or past diseases

list the characteristics of periodontal health

absence of...

bleeding on probing

erythema (redness)

edema (swelling)

attachment loss

bone loss

describe the color, contour, and consistency of periodontal health gingival tissue.

uniform pink color, pigmentation from melanin production is common

knife edge papilla

firm and stippled/smooth

what is the color of attached gingiva in health vs alveolar mucosa?

attached gingiva = coral pink

alveolar mucosa = dark red

what is the color of gingival tissue influenced by?

number/size of blood vessels, thickness of gingiva, and pt's complexion

what is the contour (size and shape) of peridontal health?

gingival margin = tightly encircles tooth's cervical region

CEJ = smoothly scalloped

gingival margin = tapered knife-edge meeting cervix of tooth, flat, or slightly rounded edge

gingival papilla = pyramidal/triangular appearance. flat in areas of no teeth contact, narrow in areas where teeth overlap

what is the consistency of attached gingiva in periodontal health?

keratinized and firmly bound to underlying cementum and bone

how is the periodontal tissue in health?

tissue firm and resilient on probing, stippling possibly present, gingival margin coincides with level of CEJ or is slightly coronal to CEJ (overlap), no bleeding

in chronic gingivitis, fibrotic stippling is present, so how would you confirm that this is gingivitis?

x-rays

in health, where is the margin for OMG?

overlapping or meeting (gap is not healthy)

if there is prior history of clinical attachment loss, but the periodontal tissue is considered healthy at a current appointment, what would the attachment loss present be an indicator of?

the previous disease activity

what is "intact periodontium"

no loss of periodontal tissue

what is "reduced periodontium"

preexisting loss of periodontal tissue but not currently undergoing loss of CT/alveolar bone

review: what is peridontal disease?

an umbrella term for periodontitis and gingivitis

what is dental biofilm induced gingivitis?

- most COMMON periodontal disease

- does not directly cause tooth loss but must be managed as active disease process

= inflammatory response of gingival tissues by periodontal pathogens

what ages can dental biofilm induced gingivitis occur at?

all ages, but adults are more pronounced

what do these tissue color characteristics indicate?

red (erythematous), swollen (edematous), bleed easily, increase crevicular fluid, increased blood flow to the gingiva

*need to know this characteristics for exam

gingivitis

what can tissue contour show as in gingivitis?

bulbous papilla (edema causes enlargement of gingival tissues)

blunted papilla (interdental/embrasure space),

cratered papilla (with line of biofilm/plaque present)

how can the gingival margin appear in gingivitis?

rolled and thickened

what is the consistency of free gingiva in gingivitis?

soft, movable, easily retractable, spongy with light pressure, compressed air readily deflects gingival margin and papillae away from neck of tooth

what is the texture of tissue in gingivitis?

can appear smooth and very shiny from increased fluid, also has a "stretched" appearance, may lose gingival stippling

what is the appearance of the gingival margin in gingivitis?

may appear more coronal due to swelling and enlargement

what is the cause of the gingival margin being more coronal to the CEJ in gingivitis?

swelling!

what is the presence of bleeding in gingivitis?

occurs with gentle probing, epithelial lining of sulcus becomes ulcerated and blood vessels engorge, heavier bleeding as inflammation increases

what is the definition of the "extent" of dental biofilm induced gingivitis?

degree to what inflammation has spread

what does the percent of dental biofilm induced gingivitis have to be within the oral cavity for a pt to have "gingival health"?

less than 10%

what is the "distribution of inflammation"?

how spread-out inflammation is within the gingival

what is the distribution class if the gingival inflammation is only in the interdental papilla?

papillary gingivitis

what is the distribution class if the gingival inflammation is in the gingival margin and papilla?

marginal gingivitis

what is the distribution class if the gingival inflammation is in gingival margin, papilla, and attached gingiva?

diffuse gingivitis

what is "descriptive terminology"?

descriptive terms are combined to create a verbal picture of the gingiva

ex: "localized marginal inflammation in the mandibular anterior sextant"

what are the "extent" classes of gingival inflammation?

localized or generalized

what are the "distribution" classes of gingival inflammation?

papillary, marginal, diffuse

what is this clinical description of: pt presents with generalized healthy gingiva as evidenced by pink, firm, and knife-edge papilla

healthy gingiva color, contour, and consistency

what is this clinical description of: pt presents with generalized marginal plaque induced gingivitis as evidenced by red, bulbous papilla, and spongy tissue.

gingivitis

what does a clinical gingivitis description HAVE to include?

needs to include extent, distribution, plaque/non-plaque induced, AND color, contour, and consistency distributors

what are the treatment objectives for dental bio-film induced gingivitis?

remove etiologic factors

reinforce oral hygiene

avoid further loss of periodontal tissue

minimize risk of gingivitis converting into periodontitis

what will NOT be present on dental biofilm-induced gingivitis on a reduced periodontium after treatment?

presence of preexisting attachment loss

what is a pt with dental biofilm induced gingivitis on reduced periodontium at higher risk of after treatment?

periodontitis relapse

after treatment of gingivitis, can a pt revert to being classified as "dental biofilm-induced gingivitis on intact periodontium"?

no

what are systemic factors that could modify biofilm-induced gingivitis but are NOT considered diagnoses themselves?

sex and steroid hormones

puberty

menstrual cycle

pregnancy

oral contraceptives

(overall hormones)

what can cause exaggerated inflammation response to relatively little plaque biofilm?

increased steroid hormone levels

what is the level of inflammatory changes during ovulation?

only modest observable inflammatory changes

what are some signs seen with inflammation level on a pregnant pt with gingivitis?

increased gingival crevicular fluid flow from hormones

high inflammation to even minimal plaque biofilm AND

pregnancy associated pyogenic granuloma may form

a pt comes into the office with minimal plaque biofilm but has increased gingival crevicular fluid flow, inflammation, and a pyogenic granuloma, what most likely caused these increased responses?

pregnancy

what is a high concentration of glucose in circulating blood? this is especially seen in diabetes mellitus?

hyperglycemia

what does hyperglycemia cause with gingivitis pt?

exacerbated inflammatory response of gingival to plaque biofilm by high blood glucose levels

what is the cancer of body's blood-forming tissues?

leukemia

what can leukemia cause in terms of gingival inflammation?

exaggerated inflammatory response that causes bleeding and tissue enlargement, gingival tissue appears swollen, spongy, shiny, and red

"friable"?

term used to describe tissue in leukemia pts from bleeding with slight provocation

does biofilm have to be a prerequisite for gingivitis in pts with leukemia?

NO

in leukemia, plaque biofilm doesn't have to be present for gingivitis to occur, for hormones, is this the same cause?

no, hormones have an exaggerated response to plaque biofilm, but an inflammation response won't occur if plaque isn't present

what lifestyle risk commonly causes gingival fibrosis? (=formation of abnormal amount of fibrous tissue)

smoking

why do smokers have fewer clinical signs, symptoms of gingival inflammation?

because of constricted blood flow

gingivitis is associated with malnutrition but the precise relationship is not fully understood, what vitamin deficiency can cause scurvy (delay healing)?

this vitamin is responsible for collagen and fibrous tissue for normal intercellular matrices in teeth, bone, cartilage, CT, and skin. it is also responsible for structural integrity of capillary walls.

vitamin C

what oral factor enhances plaque biofilm from low saliva causing progressive caries, taste disorders, halitosis, and inflammation of the oral mucosa?

hyposalivation

what are some drugs that can influenced gingival enlargements? (this doesn't occur in all pts taking these meds, enlargement usually occurs within 3 months of medication use

anticonvulsants

calcium channel blocking agents (hypertension)

immunosuppressants

drug-induced gingival enlargements have a higher prevalence in younger age groups, what tissue sextant is most commonly affected by this?

characterized by:

increased flow of crevicular fluid from sulcus and probing bleeding with no attachment loss

anterior sextant

a pyogenic granuloma is associated with what?

pregnancy

a pt presents with gingivitis and no bone loss or clinical attachment loss, what does the pt classify as?

gingivitis on intact periodontium

what is the less common class of gingival disease where plaque is NOT the primary etiologic factor, can be painful, and pts are more likely to notice?

non-dental biofilm induced gingival disease

what are the types of non dental biofilm induced gingival diseases and conditions?

genetic/developmental disorders

specific infections

inflammatory and immune conditions and lesions

reactive processes

neoplasms

endocrine, nutritional, and metabolic diseases

traumatic lesions

gingival pigmentation

how do genetic/developmental abnormalities affect the gingiva?

= hereditary gingival fibromatosis; slow progressive enlargment of attached gingiva

what do specific infections caused by specific bacterium not commonly found in typical bacterial plaque biofilm manifest as?

ulcerations, chancres, or mucous patches

what intraoral reactions called that are often caused by flavoring agents, history of allergic conditions, and manifest as diffuse fiery red gingivitis, sometimes with ulcerations?

hypersensitivity reactions

how might you recognize an allergic reaction from the gingiva?

may suspect if pt has good self-care and history of healthy gingiva

advise pt to change brands or flavors of gum, toothpaste, or mouthwash

can confirm with biopsy if needed

what is an uncommon acute inflammatory disorder that causes large, symmetrical erythematous papules resembling target in circular pattern on skin.... cause unknown?

erythema multiforme

the "T" in target can hint at...

erythema mulTiforme

what is a COMMON inflammatory condition that can affect the skin, hair, nails, and mucous membranes and is characterized by purplish, itchy, flat-topped bumps on the skin, lacy white patches, sometimes painful sores, in mouth and other areas?

- requires a biopsy for diagnosis

- increases risk of oral cancer

oral lichen planus

the "L" in lacy white patches can hint at...

oral Lichen planus

During the assessment of the periodontium, you note

the following: bleeding, redness, and swelling of the

tissue; abundant plaque biofilm, no apical migration of

the JE, and no attachment loss. The patient's medical

history is normal; he takes no medications. According

to the 2017 disease classification, would this patient

be classified as healthy, having gingivitis, periodontitis,

or periodontitis as a manifestation of systemic disease, and why?

gingivitis bc no PDL or alveolar bone loss but inflammation present paired with plaque

During the assessment of the periodontium, you note

the following: no bleeding or signs of inflammation, no

apical migration of the JE, and no attachment loss.

The patient's medical history is normal; he takes no

medications. According to the 2017 disease

classification, would this patient be classified as

healthy, having gingivitis, periodontitis, or periodontitis

as a manifestation of systemic disease, and why?

healthy

A patient new to your dental office has an appointment

with you for a dental prophylaxis. The patient has just

relocated to your town. The patient tells you that he

saw a dentist just before moving who told him that he

has gingivitis. During your discussion with the patient,

he asks if there is some way he can tell at home if he

has gingivitis. How might you reply to this patient's

question?

gingivitis

Let him know the healthy characteristics of gingiva
Gum tissue should appear as a light pink
- Gum tissue should tightly fit around the tooth.

A few things to look at home: let him know that Healthy gums do not bleed!
- Gums bleeding during brushing
- Lifting your lip to see redness in your gums
- Does the tissue in between your teeth seem puffy or loose