Periodontal Diseases Classification I

Lecture given 10/7/2025

*what are the characteristics of initial gingivitis?

2-4 days

dilation of blood vessels

infiltration of PMNs in the sulcular/junctional epithelium

PMNs are the predominant immune cells

perivascular loss of collagen

low gingival fluid

*what are the characteristics of early gingivitis?

4-7 days

proliferation of blood vessels

infiltration of PMNs in the sulcular/junctional epithelium

lymphocytes are the predominant immune cells

increased loss of collagen

erythema, BOP

what are the characteristics of established gingivitis?

14-21 days

proliferation of blood vessels

more advanced infiltration of PMNs in the sulcular/junctional epithelium

plasma cells are the predominant immune cells

continuous loss of collagen

change in color, texture, and size

what are the characteristics of advanced gingivitis aka periodontitis?

timeline of transition to disease is unknown

proliferation of blood vessels

pockets in the sulcular/junctional epithelium

plasma cells are the predominant immune cells (>50%)

continous loss of collagen, lesion extends to PDL

pocket formation, CAL bone loss

chronic periodontitis

most common form of periodontitis in adults, can also be seen in adolescents

characterized by CAL, bone loss, pocket formation, and recession

prevalence, extent, severity, and rate of progression are variable and my be influenced by various periodontal risk factors

microbial plaque is the key etiological factor

what are clinical/radiographic/microbial features of chronic periodontitis?

interproximal clinical attachment loss, true pocket formation >= 4mm, typically there is a horizontal pattern of bone loss on radiographs, vertical (infrabony) bone loss may be present on some sites, poor plaque control, supragingival and subgingival calculus

possible/variable presence of drifting of teeth, mobility, recession, furcation defects, suppuration, halitosis

variable subgingival plaque microflora

t/f chronic periodontitis progression is consistent, linear, and equal everywhere in the mouth

false- usually progression is slow to moderate with phases of exacerbations and remission

destruction is consistent with the presence of plaque and calculus- modifying local and systemic factors can exacerbate

what are risk factors for chronic periodontitis?

tobacco smoking, stress, and poorly controlled diabetes mellitus

what are general clinical findings of chronic periodontitis?

gingival inflammation, bleeding on probing, gingival edema, pocket formation, clinical attachment loss, recession of the free gingival margin, alveolar bone loss, furcation exposure, increased teeth mobility, drifting and/or exfoliation of teeth

how is the extent of chronic periodontitis determined according to the 2017 updates?

localized- <30% of sites affected

generalized- >30% of sites affected

how is the severity of chronic periodontitis determined?

mild/slight- 1-2mm CAL

moderate- 3-4mm CAL

severe- >= 5mm CAL

what was aggressive periodontitis previously known as?

early-onset periodontitis, juvenile periodontitis

what are common features of aggressive periodontitis?

patients are healthy except for periodontitis, there is rapid attachment loss and bone destruction, familial aggregation

what are secondary features of aggressive periodontitis?

inconsistent amounts of microbial deposits with the severity of periodontal tissue destruction, elevated proportions of A.a. and in some populations levels of P.g. may be raised, phagocyte abnormalities are found, hyperresponsive macrophage phenotype including elevated levels of PGE and IL-1beta, the progression of attachment loss and bone loss may be self limiting

localized aggresive periodontitis

circumpubertal onset, robust serum antibody response to the infecting agent A.a.

localized first molar/incisor presentation- interproximal attachment loss on at least 2 permanent teeth, one of which is a first molar, and involving no more than two teeth other than first molars and incisors

generalized aggressive periodontitis

usually affects people younger than 30 years but they may be older, there is a poor serum antibody response to infecting agents, there is a pronounced episodic nature of the destruction of periodontal attachment and alveolar bone, generalized interproximal attachment loss affects at least 3 permanent teeth other than first molars and incisors

what are the systemic disease categories that may manifest as periodontitis?

associated with hematological disorders, associated with genetic disorders, not otherwise specified

what disorders that manifest as periodontitis are associated with hematological disorders?

acquired neutropenia, leukemias, other

acquired neutropenia

ulceration and necrosis of the marginal gingiva, bleeding and occasional involvement of the attached gingiva, deep periodontal pockets and extensive/generalized bone loss involving the permanent dentition

leukemia

acute or chronic, generalized gingival enlargement, gingival swelling due to infiltration by leukemic cells, gingival bleeding

what genetic disorders is periodontitis associated with?

familia and cyclic neutropenia, down syndrome, leukocyte adhesion deficiency syndromes, papillon-lefevre syndrome, chediak-higashi syndrome, histiocytosis syndrome, glycogen storage disease, infantile genetic agranulocytosis, cohen syndrome, ehlers-danlos syndrome (type IV and VIII), hypophosphatasia, other

familial and cyclic neutropenia

<2000 cells/mm3 (neutrophils), oral mucosa ulcerations, severe gingivitis and periodontitis that can affect both the primary and permanent dentition leading to premature exfoliation of teeth

*down syndrome (trisomy 21)

generalized early periodontitis (deciduous teeth), high prevalence and severity of periodontal disease, the most frequent sites of periodontal destruction are around the incisor and molar teeth, the roots of the lower incisors are characteristically short, premature loss of these teeth

leukocyte adhesion deficiency syndrome

a rare autosomal recessive disease, commonly fatal, inflammatory periodontal disease in young patients, severe periodontal infections

*papillon lefevre syndrome

autosomal recessive inheritance, presence of hyperkeratotic skin lesions, diffuse palmar-plantar keratosis, severe generalized periodontitis, early onset in puberty, early tooth loss

chediak-higashi syndrome

autosomal recessive inheritance, abnormal neutrophil chemotaxis and bactericidal functions, severe periodontitis

histiocytosis syndrome

necrotic ulcers with considerable granulation tissue, tissue necrosis, and marked bone loss

may clinically resemble NUP

diagnose with hematological and immunological tests; biopsy of the granulation tissue

glycogen storage disease

autosomal recessive condition, faulty carbohydrate metabolism, association with low neutrophil numbers and impaired neutrophil function, association with periodontal disease

infantile genetic agranulocytosis

a very rare autosomal recessive disorder, severe neutropenia, has been associated with periodontitis resembling the early onset form

cohen syndrome

autosomal recessive, non-progressive mental and motor retardation, obesity, dysmophia, and neutropenia

more frequent and extensive alveolar bone loss than matched mentally retarded control

*ehlers- danlos syndrome

a group of connective tissue disorders, defective collagen synthesis, autosomal dominant, classified into 10 types on the basis of inheritance and clincal symptoms, mainly affects the joints and skin, fragile oral mucosa and blood vessels and severe generalized periodontitis (resembling early onset periodontitis), premature loss of permanent teeth

types IV and VIII have an increased susceptibility to periodontitis

hypophosphatasia

decreased serum alkaline phosphatase, severe bone loss, premature loss of the deciduous teeth, particularly anteriorly 

what diseases fall into the necrotizing periodontal diseases category?

necrotizing ulcerative gingivitis and necrotizing ulcerative periodontitis

t/f NUG and NUP are possibly the same infection, just different stages

true

necrotizing ulcerative gingivitis (NUG)

fetid breath, pain, interdental necrosis, bleeding, pseudomembrane formation

fusiform bacteria, prevotella intermedia, and spirochetes have been associated with the gingival lesions

infection characterized by gingival necrosis presenting as punched out papillae, with gingival bleeding and pain

what are predisposing factors for NUG?

emotional stress, poor diet, cigarette smoking, HIV infection

necrotizing ulcerative periodontitis (NUP)

bone loss, CAL, deep pockets, soft tissue necrosis

most commonly observed in individuals with systemic conditions including but not limited to HIV infection, severe malnutrition, and immunosuppression

infection characterized by necrosis of gingival tissues, periodontal ligament, and alveolar bone

abscesses of the periodontium

gingival absecess, periodontal abscess, and pericoronal abscess

more common in untreated than treated patients, can be caused by incomplete calculus removal during periodontal treatment, impaction of food/foreign bodies, frequently found in furcations, association with systemic antibiotics in untreated periodontitis (superinfection with opportunistic organisms), association in patients with uncontrolled diabetes, tooth related factors like developmental anomalies and enamel pearls, trauma, or endodontic perforation

what are the clinical signs and symptoms of abscesses of the periodontium?

swelling, suppuration, visible redness, extrusion of the tooth involved, loosening, tenderness to even slight percussion

gingival abscess

a localized purulent infection that involves the marginal gingiva or interdental papilla

localized, painful, rapidly expanding lesion, involves marginal gingiva/interdental papilla, acute inflammatory response to foreign bodies, red swelling with a smooth/shiny surface

periodontal abscess

a localized purulent infection within the tissues adjacent to the periodontal pocket that may lead to the destruction of periodontal ligament and alveolar bone

associated with pockets, furcation involvment, or intrabony defects

calculus is often detected on root surface, acute or chronic, drainage through fistula or periodontal pocket, red/smooth/shiny surface, suppuration through pocket upon pressure, pressure in the gingiva, increased tooth mobility

periodontal abscess in non-periodontitis patients

impaction of foreign bodies like dental floss, orthodontic elastic, toothpick, rubber dam, or popcorn hulls

harmful habits

orthodontic factors

gingival enlargement

alterations to the root surface (anatomic, iatrogenic, root damage like vertical root fracture or external resporption)

periodontal abscess in periodontitis patients

acute exacerbation in untreated periodontitis, acute exacerbation in refractory periodontitis, after scaling and root planing, after periodontal surgery, systemic antimicrobial intake without subgingival debridement, use of other drugs

signs and symptoms of periodontal abscess

usually average pain, swelling at the base of the pocket, drainage usually through pocket, swelling and then pain, palpation and percussion responses are within normal limits, have pockets, not necessarily related to trauma/caries/restorations, usually positive pulp vitality test, crestal bone loss on radiograph

signs and symptoms of periapical abscess

severe pain, periapical swelling, drainage usually through sinus tract, pain and then swelling, palpation and percussion responses are intense, usually no pockets, usually related to trauma/caries/restorations, usually negative pulp vitality test (multirooted teeth), periapical radiolucency on radiograph

pericoronal abscess

usually in mandibular 3rd molars, red and swollen gingival flap, pain, difficulty swallowing, severity of pericoronitis associated with increasing proportions of gram- anaerobic pathogens

a localized purulent infection within the tissue surrounding the crown of a partially erupted tooth

how do we define a patient as a periodontitis case?

interdental CAL is detectable at >= 2 non-adjacent teeth, buccal or oral CAL >= 3mm with pocketing >= 3mm is detectable at >= 2 teeth but the observed CAL cannot be ascribed to non-periodontitis related causes

which different forms of periodontitis are recognized in the present revised classification system?

necrotizing periodontitis, periodontitis as a direct manifestation of systemic disease, and periodontitis

learn the periodontitis grading and staging for the 2017 updates- no way that was all getting typed out sorry

:(

what are the main changes from the 1999 classification that were made in the 2017 classification? 

the 2017 classification… (finish the sentence)

added a periodontal/gingival health category

changed chronic/aggressive periodontitis to periodontitis with grading/staging

changed excessive occlusal forces to traumatic occlusal forces

changed biologic width to supracrestal supporting tissues

changed necrotizing ulcerative periodontal diseases to necrotizing periodontal diseases

changed periocoronal abscess to periodontal abscess