Classification and clinical forms of periodontal diseases
I-Introduction:
Periodontal disease, due to the complexity of the biofilm and the bacteria that compose it and the numerous modifying and aggravating factors, are multifactorial diseases that make diagnosis more difficult.
Our therapeutic approach, guided by a classification of periodontal diseases and supported by a complete anamnesis and additional examinations, allows us to arrive at a diagnosis, a treatment plan and a prognosis specific to each clinical case.
II- Reminders
- The gingiva is firmly attached to the underlying structures
- Pale pink color
According to PAGE and SHROEIDER:
From a histological point of view, the connective tissues are infiltrated mainly by PN.
According to LISTGARDEN :
The microbial flora compatible with periodontal health is composed essentially of cocci and gram + aerobic filaments.
III- The objectives of the classification:
- Characterize and differentiate periodontal diseases according to:
⮲Their etiology ⮲ Their natural history ⮲ Their progression ⮲ Their response to treatment.
- Define the different clinical forms of periodontal diseases based on:
⮲ clinical elements ⮲ radiological elements ⮲ bacterial examinations ⮲ medical examinations
- It is essential for carrying out epidemiological or clinical studies by making the results comparable with each other.
IV -Classification criteria:
- Pathological process
Inflammatory: Periodontitis, Gingivitis
Degenerative: Periodontosis, Gingivosis
Neoplastic: Periodontoma, Gingivoma
- Evolutionary mode
a – Acute mode:
– Sudden and abrupt appearance
-Very painful
-Short duration
b- Chronic mode:
-Slow appearance
-No pain
-Low noise evolution
c- Sub-acute mode: warming of the chronic mode but less severe than the acute mode.
d- Recurrent mode: The lesion reappears after poor treatment; or treated successfully, but which, due to lack of supportive care, triggers a new process of destruction
e- Refractory mode: lesion does not respond to treatment
- The elementary lesion
a- Erythema: it corresponds to a change in color of the gum by vasodilation and capillary proliferation.
– Inflammation :
* Acute: Bright red color
* Chronicle: Appearance of a bluish component
b- Edema: increase in volume of the gum due to increase in capillary permeability with cup test (+).
c- Erosion: loss of substance affecting the epithelial tissue.
d- Ulceration: loss of substance that affects the connective tissue.
e- Gallbladder: hemispherical elevation filled with clear serous fluid with a diameter of < 3 mm.
f- Bubble: surface area larger than the vesicle.
g- Necrosis : mortification of a part of the gum.
h- Gangrene : mortification affecting the alveolar bone.
i- Hypertrophy : 🡭of volume by 🡭 of cell size.
j- Hyperplasia : 🡭 in volume by🡭 in the number of cells.
- Anatomical criteria
a- Headquarters:
Papillary
- Marginal Gingivitis
Attached
Superficial
- Deep periodontitis
Terminale
b- Scope:
- Localized: a tooth or group of teeth.
- Generalized: an arch or the oral cavity.
- Etiological factors : Weski triad.
- Local factors
- General factors
- Constitutional factors
- Depending on the state of the injury:
- Pure lesion
- Combined lesion: in the case of PCHA associated with hypertrophic gingivitis.
Classification and clinical forms of periodontal diseases
V-Classifications of periodontal diseases:
1-TECUCIANU classification: based on the classification criteria.
2-Classification of Page and Schroeder1982:
It includes the age, clinical, radiological, host response and microbiological aspects:
a-Dental disease with exclusive periodontal localization:
– Periodontitis
– Chronic periodontitis in adults
– Juvenile periodontitis
– Pre-pubertal periodontitis
– Rapidly progressive periodontitis
-PUN and GUN
b-Periodontal disease general disease symptoms:
– Butterfly Lefevre
– Hypophosphatasia
– Acatalasia
– DID
– Leukopenia
– Chidiak higashi
– Acrodynia
– Down syndrome
– Histiocytosis X
3-Classification of SUZUKI and Jacques CHARONE 1982:
Gingivitis:
– GUN
– G. associated with hormonal disorders
– G. associated with taking medication
– G. associated with nutritional disorders
– G. desquamative
Periodontitis
– PCHA
– Early onset P.: PPP; PJ; PPR
4- Classification American Academy of Periodontology 1986:
I- Juvenile periodontitis
- Pre-pubertal
- Juvenile located
- Juvenile generalized
II- Adult periodontitis
III- Gingivitis / ulcero-necrotic periodontitis
IV- refractory periodontitis
5-World workshop in clinical periodontics 1989
Gingivitis
– Inflammatory gingivitis of bacterial origin
– Gingivitis and hormonal changes
– Gingivitis and drug interference
– Desquamative gingivitis
– Gingivitis associated with systemic disease
Periodontitis
1-Adult periodontitis
2-Early periodontitis
- Prepubertal periodontitis
1-localized
2-generalized
B- juvenile periodontitis
1.localized
2.generalized
C- rapidly progressive periodontitis
III- periodontitis associated with systemic diseases
IV- ulcerative-necrotic periodontitis
V- refractory periodontitis
6- RANNEY 1992 classification
I- Adult periodontitis
- With systemic participation
- Without systemic participation
II- Early periodontitis
A. Localized (juvenile)
B. generalized (rapidly progressive)
C. associated with systemic diseases
III- Ulcerative-necrotic periodontitis
linked to the AIDS virus
related to nutritional disorders
Origin not yet specified
7- International workshop 1999 ARMITAGE:
In 1999, the AAP convened an international workshop and established a new classification including the following changes:
- It no longer takes into account the patient’s age
- Early-onset forms are now called aggressive periodontitis.
- Adult periodontitis is now called chronic periodontitis.
- Refractory periodontitis disappears as an entity
- It specifies the class of “gum diseases”
- It develops and better identifies the characteristics of periodontitis associated with systemic diseases
- She introduced the term “necrotizing periodontal diseases”
- Periodontal abscess appears in the classification
- Endo-periodontal lesions are also part of the classification
- Some conditions are classified as “innate or acquired unfavorable conditions” in which mucogingival defects are taken into account.
I – GINGIVAL DISEASES
a- Plaque-induced gingival disease
– Plaque-associated gingivitis alone
– Gingival diseases modified by general factors
– Endocrine disorders
– Hematopathological diseases
– Drug-induced gingival diseases
– Gingival diseases modified by malnutrition
b- Non-plaque-induced gingival disease
– Specific bacterial gingival disease
– Viral gingival disease
– Fungal gingival disease
– Genetic gingival disease
– Gingival manifestation of systemic conditions
– Cutaneo-mucosal syndrome
– Allergies
– Traumatic injuries
– Foreign body reaction
– Without other specificity
II – CHRONIC PERIODONTITIS
– Localized
– Generalized
III – AGGRESSIVE PERIODONTITIS
– Localized –
Generalized
IV – PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASE
– Associated with hematological disorders
– Associated with genetic disorders
– Without other specificity
V- NECROTIC PERIODONTAL DISEASES
– Ulcerative necrotic gingivitis
– Ulceronecrotic periodontitis
VI- PERIODONTAL ABSCESS
– Gingival abscess
– Periodontal abscess
– Pericoronary abscess
VII- PERIODONTITIS ASSOCIATED WITH ENDODONTIC LESIONS VIII- INGENIOUS OR ACQUIRED DEFECTS a- Modifying or predisposing dental factors b- Mucogingival defects – Gingival recessions – Absence of keratinized gingiva – Decreased depth of the vestibule – Aberrant position of a frenum – Excess gingival tissue – Abnormal color c – Defect of edentulous ridges d – Occlusal trauma
8- International workshop March 2018:
The aim of this workshop was to align and update the classification system for the current understanding of periodontal and peri-implant diseases and conditions.
Since the 1999 workshop, important new information has emerged from population studies, basic science investigations, and evidence from prospective studies leading to the 2017 workshop.
Classification and clinical forms of periodontal diseases
- In 2018, periodontitis is part of a chapter entitled “Periodontitis”
- Are classified into different stages and different grades
Four main categories should be remembered:
– healthy periodontium and gum diseases;
– periodontitis;
– other periodontal disorders;
– healthy and pathological peri-implant conditions.
VI-Clinical forms of periodontal diseases:
- According to Page and Schroeder
A/ Periodontal disease with exclusive periodontal localization:
1- Periodontitis: According to Chaput: it is a parallel atrophy of all the elements of the periodontium
Clinically: -It is rare in its pure form.
-Affects adults and the elderly.
-Absence of inflammatory signs.
-Bare roots with regular horizontal alveolysis generalized over the entire set of teeth
2-Periodontitis:
A- Chronic habitual periodontitis in adults (PCHA):
Settles slowly, occurs around 30 to 35 years of age, can be shallow or deep. Evolves irregularly with a succession of remission phases and active phases
- Clinical and radiological aspect:
-Dark red or purplish gum with 🡭volume (edema)
-Periodontal pockets, more or less deep, sometimes suppurative.
-Secondary recessions, mobilities and migrations (depending on the degree of bone lysis).
-Inflammation is related to the amount of PB and tart ( correlation between the amount of PB and inflammation).
-Horizontal alveolysis (simple periodontitis), vertical (complex periodontitis).
- Etiology: Bacterial plaque and cofactor
- Microbiology: (a polymorphic flora) The bacterial population according to LINDHE 1980 is:
-28.4% cocci and filaments.
-5.9% fusiform.
-17.6% curved and mobile sticks.
-55.3% spirochetes.
- Its evolution:
Cyclic: alternation of rest periods of variable duration and phases of acute exacerbation.
B-JUVENILE PERIODONTITIS (PJ): First described by GOTTLIEB 1923 under the name “diffuse alveolar atrophy”. – CHAPUT 1967: speaks of desmodontosis or Periodontitis. Acute juvenile.
Occurs in adolescents aged 12 to 26, the onset is insidious and often goes unnoticed, reaches a peak at puberty, there are two forms:
B-1 Localized juvenile periodontitis (LJP):
- Occurs in healthy adolescents aged approximately 12 to 26 years with the presence of hereditary notions.
- Affects the molars and/or incisors symmetrically (notion of preferred seat)
- Pink gum free from inflammation
- Low plaque and tartar and Low cavities
– deep periodontal pockets
– Rapidly evolving vertical alveolysis at the level of the incisors and/or the (1st) molars giving a mirror image. Destruction unrelated to the amount of PB (non-correlation)
- Recessions, dental mobility, secondary migrations
- Microbiology: AAC (ACTINOBACILLUS ACTINOMYCETEM COMITANS)
-Gram (-) anaerobic bacilli form 59% of the specific flora
- Its evolution: the evolution takes place according to several patterns
-spontaneous remission
– localized form continuing to evolve until the teeth concerned fall out
– evolution towards the generalized form.
B-2 Generalized juvenile periodontitis (GJP):
– intense gingival inflammation
– Large amount of PB
– Rapidly developing alveolysis at the level of the incisors and the (1st) molars with involvement of the other teeth
– Bone lysis is more advanced at the level of the incisors and (1st) molars compared to the other teeth
MICROBIOLOGY: Predominance of PORPHYROMONAS GINGVALIS and EIKENELLE CORRODENS
C- rapidly progressive periodontitis: PPR
Occurs most often in young adults aged 20-25, sometimes earlier post-puberty or later at the age of 30-35,
- Clinically: intense gingival inflammation, raspberry-colored.
-spontaneous gingival bleeding and suppuration.
-amount of PB is important
-deep periodontal pockets
– dental mobility.
– severe and rapid bone destruction, deep and generalized and irregular
-all teeth are affected without any predilection.
- Microbiology: dominated by:
-porphyromonas gingivales -bacteroides forsythus Spirochetes and filaments and fusiforms
- Evolution: cyclical with phases of activity that can continue until tooth loss. The rest phases are shorter and vary from one individual to another.
D-Pre-pubertal periodontitis (PPP)
Appears during or immediately after the eruption of primary teeth and may occur at age 4 to 5 years.
It is more common in girls, there is a family predisposition (hereditary concept).
There are two forms:
-localized form
– affects certain teeth without a preferred seat
– discreet inflammation
Bacteriology: PREVOTELLA INTERMEDIA, CAPNOCYTOPHAGA
– generalized form
– damage to temporary and/or permanent teeth as soon as they erupt
-severe gingival inflammation with spontaneous hemorrhages
-Periodontal recession
-Very rapid generalized irregular bone resorption
– frequent infections of the respiratory tract and ears (general disorders)
- Microbiology : it is rich in very pathogenic germs: AAC, PI (PREVOTELLA INTERMEDIA), Pg (porphyromonas gingivalis), FN (fusobacterium nucleatum), Bacilli G- -anaerobic
B-Periodontal disease symptom of general diseases: a certain number of general diseases are accompanied by periodontal lesions, in certain cases these signs can be revealing and allow the diagnosis of the disease.
1-Papillon Lefèvre syndrome (palmoplantar hyperkeratosis): This is a recessive genotypic condition, characterized by:
Keratoderma of the palms of the hands and soles of the feet with severe periodontal destruction,After the eruption of the temporary teeth, the gum is erythematous and edematous, there are deep periodontal pockets, suppuration, halitosis, significant alveolysis. From the age of 4 to 5 years ⇨ total loss of teeth
Permanent teeth are expelled according to the chronology of their eruption ⇨around 15 years old, the child is toothless
8- acrodynia: this is a rare disease, generally occurring in children before the age of 2, due to mercury poisoning. Hypersalivation is noted
The gum becomes painful; sometimes ulcerated, loss of tooth
The skin of the hands, feet, nose, ears, cheeks becomes red, cold to the touch
Presence of pruritus and arthralgia
9- leukopenia: number of leukocytes < 4000 /mm3 Severe ulcerations
Perhaps hereditary, infectious or due to bone marrow failure.
Classification and clinical forms of periodontal diseases
- CLINICAL FORMS ACCORDING TO ARMITAGE IN 1999:
I-Gum diseases:
1-Gum diseases induced by dental plaque:
This is the most common form of gingivitis, it is clinically characterized by redness, edema
Bleeding gums, the gum is painful and sensitive.
Plaque control and removal of PB retention factors causes return to baseline
B- gingival diseases modified by systemic factors ( endocrine and hematological)
C- Gingival Diseases Modified by Drug Treatments (Cyclosporines – Hydontoinates – Niphedepine)
D- gingival diseases modified by malnutrition (see general diseases course)
2 – non-plaque induced gum disease
Viral origin/fungal origin/genetic origin/systemic origin/traumatic injuries/reaction to foreign bodies (see general illness course)
II-Chronic periodontitis:
It is the most common form of periodontitis with a slow to moderate rate of progression, it affects people of all ages.
The prevalence and extent of periodontal destruction increases with age and inadequate hygiene.
Chronic periodontitis can be associated with local contributing factors and cofactors, systemic and environmental
- The microbial flora is variable (Porphyromonas gingivalis, Eikenella corrodens, Campylobacter rectus) with the presence of subgingival tartar
The classification is based on the extent of the lesion.
- More than 30% of sites affected 🡺 generalized
- Less than 30% of sites reached 🡺 localized
On the other hand, on the severity of the disease
- Loss of attachment between 1 to 2mm🡺 beginner
- Loss of attachment between 3 to 4mm 🡺 moderate
- Loss of attachment ≥ 5mm 🡺 severe
III-Aggressive periodontitis: this is a specific entity in its own right compared to Chronic Periodontitis; there are two clinical forms
- Localized aggressive periodontitis:
It mainly affects the 1st M and the INC sector with a loss of proximal attachment on at least two permanent teeth including one 1st M, alveolysis cannot affect more than two teeth other than the 1st M and the INC
- Generalized aggressive periodontitis:
Interproximal lesions involving at least three permanent teeth other than the incisors and the first molars
- Common characteristics of PAL and PAG:
– attachment losses and alveolysis which are rapid
-the subject who is in good general health
-a family component (notion of heredity)
-The specific microbial flora
IV-periodontitis, systemic manifestations
- Periodontitis associated with hematological disorders
2- Periodontitis associated with genetic disorders
V-Necrotic periodontal disease GUN and PUN
VI-Periodontal abscesses:
-Gingival abscess ( involvement of the marginal gingiva and/or the papillary gingiva)
-Periodontal abscesses (damage to the dental ligament and alveolar bone)
-Pericoronal abscess located on a tooth in the process of erupting ,
In the mouth we observe a swelling of the gum, red and smooth, the mobile and painful tooth has pressure from the adenopathy and fever, presence of suppuration.
VII-Endo-periodontal lesions
According to HARRINGTON in 1979 a true endo-periodontal lesion is defined by three conditions:
- The affected tooth is necrotic (a loss of pulp vitality)
- There is a loss of attachment (bone lysis) and a bone defect that can extend to the apex of a tooth.
- Combined endodontic and periodontal therapies are necessary.
Classification and clinical forms of periodontal diseases
Classification and clinical forms of periodontal diseases
VIII-Acquired or congenital oral and dental anomalies related to periodontal diseases (see direct local factors promoting the accumulation of PB)
- Primary occlusal trauma: This is the result of traumatic occlusal forces on a healthy periodontium.
- Secondary occlusal trauma : This is the result of physiological or traumatic occlusal forces on a periodontium weakened by periodontal disease.
CONCLUSION :
- All the classifications described have advantages and disadvantages.
- The goal of each classification is to opt for a conventional system used by the maximum number of periodontologists so that they can speak the same language.
Classification and clinical forms of periodontal diseases
Cracked teeth can be healed with modern techniques.
Gum disease can be prevented with proper brushing.
Dental implants integrate with the bone for a long-lasting solution.
Yellowed teeth can be brightened with professional whitening.
Dental X-rays reveal problems that are invisible to the naked eye.
Sensitive teeth benefit from specific toothpastes.
A diet low in sugar protects against cavities.