Classification of Periodontal Disease

Question 1

What is gingival health?

Answer 1

Intact periodontium is characterised by the absence of BOP, erythema, oedema, patient symptoms and attachment and one loss.

Bone levels should be 1-3mm apical to the CEJ.

less than 10% bleeding sites with probing depths less than or equal to 3mm.

Question 2

What is plaque-induced gingivitis with an intact periodontium?

Answer 2

BOP- less than 30% is localised, greater than 30% is generalised.

No radiological bone loss
No interdental recession.

Question 3

What is plaque induced gingivitis with modifying factors?

Answer 3

Factors that potentially modify plaque-induced gingivitis (other than plaque).

Sex steroid hormones- pregnancy, menstruation, puberty, oral contraceptives.

Hyperglycaemia
Leukaemia
Smoking
Malnutrition
Overhangs, poor margins on restorations

Drug-influences gingival enlargements

These factors make it worse but don’t cause it- plaque is still the causative factor.

Question 4

What are non-plaque induced gingival diseases?

Answer 4

Hereditary gingival fibromatosis- overgrown fibrotic gingivae

Herpetic gingivostomatitis

Lichen Planus

Pemphigoid

Vitamin C deficiency

Question 5

What diseases come under the heading “necrotising periodontal diseases”?

Answer 5

Necrotising Gingivitis and Necrotising periodontitis

Question 6

What is Necrotising Gingivitis?

Answer 6

Necrosis and ulceration in the interdental papilla- characteristic punched out appearance.
Gingival bleeding
Pain
Pseudomembrane formation (sloughing).
Halitotis
Lesions develop quickly.
Regional lymphadenopathy (usually submandibular), fever.

Question 7

What is Necrotising Periodontitis?

Answer 7

Same signs and symptoms as NG but additionally-
- Periodontal attachment and bone destruction- associated with deep pocket formation.
- Ulcers with central necrosis develop into craters.
- Frequent extra-oral signs

Question 8

What is necrotising stomatitis?

Answer 8

Bone denudation extended through the alveolar mucosa, large areas of osteitis and bone sequestrum.

Question 9

What factors might cause someone to have NG or NP?

Answer 9

In patients who are already severely immunocompromised
- HIV/AIDS
- Other conditions which would make them immunocompromised- CD4+ load is less than 200.

In children- severe malnourishment, extreme living conditions, severe viral infection.

In patients who are temporarily and/or moderately compromised patients
- stress, nutrition, smoking, habits, previous NPD, residual craters, tooth malposition.

Question 10

What diseases come under the banner of “periodontitis as a manifestation of systemic disease?

Answer 10

Mainly diseases that affect the course of periodontitis resulting in the early presentation of severe periodontitis.

Papillon Lefevre syndrome- mutation of cathepsin C gene.
LAD syndrome
Down’s syndrome
Hypophosphatasia

Question 11

What diseases come under the category of “Systemic diseases or conditions affecting the periodontal tissues”?

Answer 11

Rare conditions affecting the periodontal supporting tissues independently of dental plaque biofilm-induced inflammation.

Squamous cell carcinoma
Langerhans cell histiocytosis

Question 12

What is the difference between a gingival abscess and a periodontal abscess?

Answer 12

Gingival abscess- localised purulent infection that involves the marginal gingiva or internal papilla.

Periodontal abscess- A localised accumulation of pus within the gingiva wall of a periodontal pocket resulting in the destruction of the collagen fibre attachment and the loss of alveolar bone.

Question 13

How do gingival abscesses and periodontal abscesses present?

Answer 13

Gingival abscess-
- rapidly expanding localised area if swelling that may be shiny, smooth or pointed.
- Suppuration may be present.
Usually painful for the patient and TTP.

Periodontal abscess-
- Ovoid elevation in the gingiva along the lateral part of the root
- TTP in lateral direction
Usually associated with a deep periodontal pocket with bleeding and tenderness on probing.
- Suppuration may occur through a fistula or through the perio pocket.
- Bleeding
- Increased mobility and TTP.
- tooth may feel high in the occlusion.
- Bone loss radiographically.
- Responds to sensibility tests.

Can be acute or chronic.

Question 14

What is the aetiology of gingival and periodontal abscesses?

Answer 14

Gingival abscess- foreign object stuck within the gingivae- bristles of toothbrush, nails in a nail biter, calculus, bits of food.

Periodontal abscess- Acute exacerbation of periodontitis, following debridement if calculus deposits pushed into perio tissues, after surgical therapy due to sutures, systemic antimicrobials without surgical debridement.

Question 15

What is the emergency management of a gingival and periodontal abscess?

Answer 15

Gingival abscess- incise and drain the abscess, irrigate with saline, mechanical debridement. Prescribe 0.2% chlorhexidine.

Periodontal abscess- Must achieve drainage- either through the pocket or via external incision.
- Debride the pocket thoroughly but ensure you are shy of the base of the pocket.
- Occlusal adjustment may be required.
- Prescribe 0.2% chlorhexidine mouthwash.
- Recommend analgesia

No not prescribe metronidazole unless there are signs of systemic disease.

Question 16

What is a perio-endo lesion?

Answer 16

Combined periodontal/endodontic lesions are localised, circumscribed areas of infection originating in the periodontal and/or pulpal tissues.

Results in a communication between the periodontal pocket and the pulp.

Question 17

What is the typical presentation of a perio-endo lesion?

Answer 17

Abscess associated with a deep pocket surrounding a non-vital tooth- usually 10-12mm pockets.

Negative response to vitality tests.

Bone resorption in the apical or furcation region.

Spontaneous pain.

Pocket may circumscribe a large part of the tooth or be localised narrow deep lesion.

Smooth, shin swelling of the gingiva or mucosa.

Swelling ay be purulent exudate or fistula.

TTP

Mobile

Crown and gingival colour alterations.

Question 18

What is the aetiology of a perio-endo lesion?

Answer 18

May have arisen primarily from pulpal inflammatory disease expressed through the PDL or the alveolar bone into the oral cavity.

May have arisen from a perio pocket communicating to the pulp apically or through accessory canals.

Question 19

What is the emergency management of a perio-endo lesion?

Answer 19

Establish drainage by debriding the pocket and/or extirpating the pulp.
- SDCEP states start with pulp therapy and then do instrumentation.
- Likely will need surgical debridement and guided tissue regeneration.

May be incised if it is fluctuant and pointing.

Antibiotics if systemic effects- metronidazole- 200mg tablets, 9 tablets, 1 tablet 3 times a day.

Prescribe 0.2% chlorhexidine mouthwash.

Question 20

What is a peri-coronal abscess?

Answer 20

Associated with partially erupted tooth, most commonly 8’s.

Pericoronitis.

Question 21

What are the possible routes of communication with a perio-endo lesion?

Answer 21

Exposed dentinal tubules

Lateral and accessory canals- majority in the apical 1/3 of the tooth.

Frugal canals- may have a direct pathway of communication between the pulp and the periodontium.

Apical foramen- microbial and inflammatory by-products may exit the apical foramen causing periradicular pathology.
May also be a portal of entry for inflammatory by-products from deep pockets to affect the pulp.

Perforation- communication between the root-canal system and either peri-radicular tissues, periodontal ligament or the oral cavity.

Developmental groove.

Question 22

How do you classify perio-endo lesions?

Answer 22

Perio-endo lesions with root damage
- Root fracture or cracking
- Root canal or pulp chamber perforation
- external root resorption

Perio-endo lesions without root damage
- in periodontitis patients or in non-periodontitis patients- grade 1, 2 or 3.

Question 23

What is the difference between a grade 1, 2 or 3 perio-endo lesion?

Answer 23

Grade 1- Narrow deep periodontal pocket in 1 tooth surface

Grade 2- wide deep periodontal pocket in 1 tooth surface

Grade 3- deep periodontal pocket in more than 1 tooth surface.

Question 24

What is the pseudomembrane made of in NG and NP?

Answer 24

Fibrin, necrotic tissue, leucocytes, erythrocytes and bacteria.

Question 25

What types of bacteria may be present in NG and NP?

Answer 25

Spirochetes and Fusobacterias.

Prevotella Intermedia, Fusobacterium sp.

Question 26

What are the differential diagnoses with regards to NG and NP?

Answer 26

Herpetic gingivostomatitis
Desquamative gingivitis
Oral mucositis

Question 27

What is the treatment of NG and NP?

Answer 27

Supragingival PMPR to remove soft and mineralised deposits, then moving to sub gingival removal of deposits- pt might not tolerate this.
- do this for as many days as the acute phase lasts.

Mechanical oral hygiene should be limited
- prescribe chlorhexidine 0.2% twice daily.
- May also prescribe 0.3% hydrogen peroxisde diluted in 1:1 water.

If systemic features present- 200mg metronidazole, 1 tablet 3 times a day for 3 days.

Follow up patient daily if possible.
- as the symptoms subside- strict OH measures should be followed.

Commence treatment of the choleric periodontitis after acute phase.

Question 28

Patients with NP will have gingival craters at the end of treatment, what could you suggest they do for this?

Answer 28

Periodontal flap surgery
Regenerative surgery

Question 29

What does it mean if someone has gingivitis with a reduced periodontium?

Answer 29

There is probing attachment loss present but this is not due to periodontitis.
- i.e. crown lengthening surgery.

Pocket depths will still be less than 3mm.

BOP is greater than or equal to 10%.