Perio 4

(( ‫ﻋﻠﻴﻢ‬ َ ‫ﻋ ْﻠ ٍﻢ‬ ِ ‫ق ُآ ﱢﻞ ِذي‬ َ ‫ﺸﺎ ْء َو َﻓﻮ‬ َ ‫ﻦ َﻧ‬ ْ ‫ت َﻣ‬ ٍ ‫ﺟﺎ‬ َ ‫)) َﻧ ْﺮ َﻓ ُﻊ َد َر‬ Today's lecture is about classification of periodontal diseases , periodontal diseases are diseases which affect the periodontium & as all of u know that the periodontium composed of 4 supporting tissues which are the gingiva , PDL , alveolar bone and cementum , Regarding the gingiva we can divide it anatomically into 3 parts : 1- free gingiva >> it is extended from the gingival margin to the free gingival groove at the level of CEJ . 2- attached gingiva >> which is attached to the underlying bone , it is extended from the free gingival groove to the mucogingival junction , This junction separate the attached gingiva from the movable mucosa which we call it alveolar mucosa . * Attached gingiva from its name there should be bone underneath it to be attached to it , so if some one ask u a question and told u that u have a free gingiva of 2mm & a periodontal pocket of 9 mm & the Q. is what is the value of attached gingiva?? … here the attached gingiva is not present , becoz when there is a true periodontal pocket , that’s mean there is no bone ( alveolar bone has been resorbed ) , SO … when there is no bone underneath the gingiva , we cant call that part of the gingiva attached gingiva .

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3- interdental gingiva .

ATTACHED GINGIVA

FREE GINGVA

There are 7 clinical features for the healthy gingiva : 1- pink coral in color ( ‫)زي ﻟﻮن اﻟﻤﺮﺟﺎن‬ but remember that there are some individuals who have racial melanin pigmentation ( dark gingiva ) .

,

2- knife edge of the gingival margine & the interdental papillae ( no edema or swelling on the margins ). 3- firmly attached to the tooth surface , when we insert the probe inside the gingival sulcus , the tissue should be firm in texture , that’s mean can not be easily isolated from the tooth surface. 4- the depth of the gingival sulcus should be from (0-3 mm) . 5-no bleeding on probication . 6- stippling appearance which look like the orange cover from outside .

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* In histological section we can see invaginations from the epithelium into the connective tissue ,we call these invaginations rete ridges & these rete ridges are responsible for the normal stippling appearance in the gingiva. * this stippling appearance presents only in 30 – 60 % of indivisuals. 7- scalloped contour. 1 or 2 of these features we might not find them in all people .

◄ Now, any disease that affect the periodontium ( including the gingiva) , is called periodontal disease . We classify periodontal diseases according to the new classification system which has been done in 1999 by the international workshop for the classification of periodontal disease. The American academy of periodontology (AAP) & the international workshop divided periodontal diseases into : 1- gingival diseases . 2- periodontitis . 3- periodontitis as a manifestation of systemic diseases 4- abscesses of the periodontium . 5- periodontitis associated with endodontic lesions . 6- developmental or acquired deformities & conditions . We will explain all of these diseases briefly , but u will learn more about them in the next semester insha2 Allah .

* according to this classification gingival diseases are divided into : A – plaque induced gingival diseases ( inflammatory diseases ), That’s mean the initiating factor for inflammatory periodontal diseases is DENTAL PLAQUE . B- non-plaque induced gingival lesions .

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Characteristics common to all gingival diseases : * Signs & symptoms are confined to gingiva, there is no involvement of PDL or alveolar bone . * The presence of dental plaque to initiate & / or exacerbate the severity of the lesion.

Clinical signs of inflammation: Enlarged gingival contour : remember what I told u about the knife edge of healthy gingiva, but when there is inflammation , these gingival margins become edematous & swallowed ,,,, * gingival enlargement happens in 2 clinical forms >>> 1- edematous ( gingival tissue is filled with fluids ) , if we puncture it fluid will come out . 2- fibrous ( enlargement of the tissue itself , it looks like apiece of meet ). Red in color and / or bluish red . Bleeding upon stimulating . Increased gingival exudates , fluids will come out from the gingival sulcus when we press on it . Pathological increase in sulcular depth, The normal depth of gingival sulcus is o – 3 mm , but remember that there is some sort of individual variations, for instance , if u examine a pt. & u found that his gingival sulcus depth is 0 mm in normal healthy situation , after that this pt. came back to u with signs & symptoms of gingival inflammation & u examine him & found that his gingival sulcus depth is 3mm , then u say oh, 3mm is within the normal range so , this pt. has no inflammation .. this is wrong becoz for that pt. the normal value is 0 mm...

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SO … in periodontal examinations ,u need to do different visits for examination in order to calculate the real measurements . No radiographic evidence , This is v. important , becoz when u take an X-ray for a patient who has only gingivitis , the alveolar bone should be in its normal level without any distraction, becoz the inflammation involves only the soft tissue which is the gingiva . SO … if u have a radiographic evidence of PDL widening or alveolar bone resorbtion , then the condition is not gingivitis ,it is converted into periodontitis .

( ‫ﻚ و ﻋﻈﻴ ِﻢ ﺳﻠﻄﺎﻧﻚ‬ َ ‫ل وﺟﻬ‬ ِ ‫ﻚ اﻟﺤﻤﺪ آﻤﺎ ﻳﻨﺒﻐﻲ ﻟﺠﻼ‬ َ ‫بﻟ‬ ‫) ﻳﺎ ر ﱢ‬

END OF PART 1 …………. TO BE CONTINUED >>>

DONE BY : JAMILEH M. HASAN .

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(( ‫)) ﺑﺴﻢ اﷲ اﻟﺮﺣﻤﻦ اﻟﺮﺣﻴﻢ‬ Periodontology lecture 4Îpart two Dr haider al waely Dr was talking about signs of gingival inflammation, now one of the important signs is the REVERSIBILITY of the disease…. Gingivitis is reversible when the etiology of the disease –since its inflammatory gingival disease and cozed by dental plaque accumulation- is removed.. so when I remove plaque the condition –gingivitis- will return back to its normal physiological appearance..and not only that, but it will also return to normal by removal of factors that help plaque accumulation(which is the initiator).

Reversibility is not applicable in other categories of diseases such as periodontitis(which is inflammation of the periodontal ligament that leads to destruction in the alveolar bone) which is irreversible upon removal of dental plaque.. SO … reversibility is one of the signs of gingival diseases…

* Gingivitis can have a possible role as a precursor to attachment loss around the tooth between the alveolar bone and PDL Î that means that if your patient has gingivitis then it might be converted to periodontitis which is worse.. but if patient has periodontitis then it was –for sure- preceded by gingivitis ,,, not every gingivitis is converted to periodontitis but every periodontitis is preceded by gingivitis Î that is due to variations b\w individuals in the balance b\w host resistance and microbes present in him and this balance determines the PD condition whether inflamed or sound….so when these two

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factors are in balance then there is no disease but when disruption occurs then surely disease will develop..

* Disruption of balance might be due to an increase in the accumulation of specific pathogenic micro-organism- that propagate PD disease- in the gingiva, or due to suppression of immune response of the patient.. For example ,, when the patient is quitting tooth brush then he will have poor plaque control and increase in its accumulation and therefore balance will be disrupted due to increase in microorganisms(MO) in his mouth.. or when the patient is passing specific or certain physiological imbalance in his body –due to hormonal changes, puberty, malnutrition, and decrease in immune responses- then there will also be a disruption of the balance bcoz the hosts resistance is weaker now…but if the patient's body can resist these factors then there won't be a cause for a disease or conversion from one type to another (gingivitis to periodontitis)… Now we come to signs of periodontitis : PERIODONTITIS is inflammation of the supporting tissue of teeth cozed by specific MO which results in progressive destruction of alveolar bone and the periodontal ligament and gingival recession and pocket formation..

Periodontitis appears clinically as *CLINICAL ATTACHMENT LOSS which means that the junctional epithelium is not at CEJ- which is its normal position- and ** APICAL MIGRATION OF THE GINGIVA toward the root apex.. *** ALVEOLAR BONE LOSS.. and **** POCKET FORMATION…

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When we say pocket we don’t mean the ordinary gingival sulcus but we mean a pathological manifestation that show that patient doesn’t have a healthy gingiva and he is suffering from periodontitis,, So HEALTHY PERIDONTIUM means a sulcus but IN PERIODONTITIS (Pathology) there is a pocket.. ;) Following the clinical picture of periodontitis… there is gingival inflammation (bcoz periodontitis is preceded by gingivitis) and as a result there will be : Increase in tooth mobility… drifting.. exfoliation of the tooth, and if the patient is not treated there might be tooth loss or inflammation will PROGRESS AS CHRONIC INFLAMMATION OR BURST OF ACTIVITY…what does this mean??

Keeping in mind that the balance in this patient may be disrupted.. some times certain disease in PD pass into remission state (silent. .non active.. balance is preserved)..and when the balance changes there will be activation of the disease and destruction will happen.. for EX. if a patient comes to you and he has periodontal disease but for some reason there is no bleeding on probing. .no pocket Î (remission phase)… and he comes to you a year later with deep pocket.. bleeding on probing.. bone loss Î this is the (reactivity phase)…

As we said gingivitis is not associated with MO and its only related to plaque (as initiator).. but periodontitis (which is preceded by gingivitis) is related to certain pathogenic species of MO's such as: 1- P.gingivalis 2- p.intermedia 3- AA which stands for actino bacillus actinomycetumcmitans 4- T.denticola

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And more … When these periodontal pathologic species are present in plaque of a person who has gingivitis then conversion to periodontitis is definite… Look at this This picture shows us at the left side: the attached gingiva is at CEJ..normal ginginal sulcus..

But in the middle it’s the start of periodontitis where the junctional epithelium starts to migrate apically (toward root apex) and loses its attachment to CEJ.. and the gingival sulcus will disappear.. and at the right side you can see that there is a true pathological perio. Pocket formed.. and alveolar bone loss is noticed too.

This radigraph shows bone loss b\w the premolar and the molar.. bone is not at its normal level.. and if you open the tissue you will see bone loss as a hole as in the radiograph below..at right side

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Two types of pockets are identified : 1-true (which we previously talked about_ 2-False which is due to gingival overgrowth or enlargement ** These radiographic evidences cant be seen in gingivitis .. CLASSIFICATION SYSTEM of gingivitis Î gingivitis associated with plaque could be >>> 1-associated with local contributing factors 2-not associated with factors.. Certain local factors in the patient mouth help plaque accumulation such as: malocclusion.. crowding of the teeth..etc Îgingival disease associated with modifying systemic factors Certain systemic changes exaggerate gingival tissue response to dental plaque such as: endocrine system changes or hormonal changes such as puberty .. menstrual cycle.. pregnancy .. Diabetes . Dr said that there will be a question in the exam about this in the midterm and the final as : If I (Dr) ask you about the initiating factor of gingivitis in diabetic patient? In puberty? In pregnancy? What will your answer be? Answer: plaque and hormonal changes are only exaggerating factors that increases gingival response to plaque…

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Puberty associated gingivitis

END OF PART 2 …. TO BE CONTINUED >>> THANK YOU

Your colleague : Razan M. Al shehab.

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What is the initiating factor    of this condition ?   _ hormonal changes    _ plaque accumulation 

This is edematous gingival enlargement  in pregnant woman , some time this  gingival enlargement in pregnant  woman taking some sort of pathological  changes and it has a cretin name we call  it either pyogenic granuloma or  pregnancy tumor. when you hear  pregnancy tumor it is not malignant its  only gingival enlargement in pregnant  woman due to accumulation of dental  black which has been exaggerated due    to hormonal changes . it look like a second tongue in here  mouth , we remove it by gingivectomy  we should cut that tissue but we always  prefer to perform that procedure after  delivery , if the women is not comfort  with this condition we can remove it    even during pregnancy. Its only treated by gingivectomy but you  should tell the woman to maintain good    oral hygiene …or it will return back . 

This picture for what happen in diabetic  patient its very edematous and flyable  (the tissue is easily retracted from the    tooth surface ) .

‫اﻟﺤﻤﺪ ﷲ اﻟﺬي ﻋﺎﻓﺎﻧﺎ ﻣﻤﺎ اﺑﺘﻠﻰ ﺑﻪ آﺜﻴﺮا ﻣﻦ‬ ‫ﺧﻠﻘﻪ‬ There is a condition associated with Blood  dyscrasias , this enlargement is fibrotic  while the others are edematous it is  associated with leukemic patient ( blood  cancer ) , this enlargement is also initiated    with dental plaque.  

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  * In certain blood diseases such as leukemia there is some gingival enlargement  which is not associated with accumulation of dental plaque but it is due to systemic    condition. * Other condition which associated with gingival enlargement without the presence  of dental plaque is caused by certain drugs ( anticonvulsant , immune suppressant ,  antihypertensive)  , its  a fibrotic enlargement and its not associated with dental    plaque  . *we have also Gingival diseases which is  modified by malnutrition , Ex. Ascorbic acid  deficiency gingivitis and here the initiating factor is dental plaque which has been    exaggerated by this nutritional deficiency .

 

Non‐Plaque‐Induced Gingival Lesions :   1_ Bacterial , viral , fungal origin  

 

  What does it mean bacterial ? it means that its caused by non periodontal pathogenic  bacteria which we talk about in the previous slide . 

 

 2_ Gingival lesions of genetic origin which called Hereditary gingival fibromatosis . 

 

3_ Gingival manifesta ons of systemic conditions  

 

Ex. Lichen planus , Pemphigoid , Pemphigus vulgaris 

 

4_ Allergic reac ons

 

5_ trauma c lesions 

 

6_ foreign body reaction 

     

ITS YOUR RESPONSIPILTY from now until you  graduate to keep your knowledge current …  knowing pharmacology ( analgesic ,  antibiotic ) , histology , pathology  … 

   

Some time the doctor keep a book in his disk  to see if there is anything missing . 

  DOCTOR ADVICE 

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  Hereditary Gingival Fibromatosis >>   There is gingival enlargement science child hood , the patient doesn't has any  medication the cause is hereditary Gingival Fibromatosis .     

Q in the exam … this patient has gingival enlargement science child hood  , she doesn’t have any medication … what is your differential diagnosis ? 

   

Hereditary Gingival Fibromatosis

      _  _  _  _                  _  _  _  _                     _  _  _   _              _  _  _  _    Periodontal Diseases  World Workshop in Clinical PeriodonƟcs (1989) divide periodontitis in to >>  9 9 9 9

Adult Periodontitis   Early onset Periodontitis   Periodontitis associated with systemic diseases  Necrotizing Ulcerative Periodontitis   The disadvantages of this classification are    1_overlap in the diseases because it depend only on the age of the  patient ,  2_ there is absence of gingival diseases ,   3_ inappropriate classifica on criteria . 

              

‫ ﻓﻲ آﻞ‬... ‫ أﻏﻮاهﺎ اﻟﺸﻴﻄﺎن ﻣﻠﻴﺎ‬.. ‫ ﺗﺎﺋﻬﺔ ﺗﻠﺘﻤﺲ اﻟﻤﺄوى‬... ‫ﺳﻔﻴﻨﺔ ﻧﻔﺴﻚ ﺷﺎردة ﻓﻲ ﺑﺤﺮ اﻟﺪﻧﻴﺎ‬ ‫ ﺗﺒﺬر ﻓﻲ اﻟﻘﻠﺐ‬... ‫ ﻓﺘﻬﺐ رﻳﺢ ﻗﺪﺳﻴﺔ‬.. ‫ أهﺪاك ﻃﺮﻳﻖ هﺪاﻳﺘﻪ‬... ‫ﻏﺪاة وﻋﺸﻴﺔ ﻟﻜﻦ اﷲ ﺑﺮﺣﻤﺘﻪ‬ ‫ وﺷﺮاع اﻟﺨﻴﺮ ﺳﺘﻨﺸﺮﻩ ﻟﺘﻌﻮد إﻟﻰ ﺑﺮ‬... ‫اﻹﻳﻤﺎن وﺗﺰﻳﻞ اﻟﻐﻔﻠﺔ ﺗﻄﻮﻳﻬﺎ ﺗﻬﺰم أﺟﻨﺎد اﻟﺸﻴﻄﺎن‬ ‫وهﻨﺎك ﺳﻴﺤﻠﻮ ﻣﺮﺳﺎﻧﺎ ﻓﻲ أﻃﻴﺐ ﻋﻴﺶ وﺟﻨﺎن‬... ‫اﻷﻣﺎن‬ ‫ﻟﻠﺪآﺘﻮر ﺧﺎﻟﺪ اﺑﻮ ﺷﺎدي‬

 

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   Now its classified into :           Chronic    ,   Aggressive   ,  Periodontitis as a manifestations of systemic diseases               Chronic >> •

The most prevalent form in adults : its occur  usually in adult patient , but this  doesn’t mean that it may not happen in other patient .  

•

Amount of destruction consistent with local factors : what you can see in  patient mouth ( bad oral hygiene , plaque accumulation ) you can consist it  with the amount of destruction in the patient mouth . 

•

Associated with a variable microbial pattern 

•

Subgingival calculus frequently found

•

Slow to moderate rate of progression : slaw rate of periodontal and alveolar  bone distraction ,Ex. Patient came to you his age is 20 y , and has 5 mm of  alveolar bone loss , other pa ent came to you with 50 y having  5 mm  alveolar bone loss …  _ in the 20 y pa ent its >> aggressive periodon _ in the 50 y pa ent its >> chronic periodon

•

s  ( very fast ) 

s ( it take long time )

Possibly modified by or associated with the following: 

            Systemic diseases,  Local factors predisposing factors , Environmental factors    The aggressive and chronic are divided in :         Localized form:  you have true periodontal socket which is <30% of sites involved         Generalized form: >30% of sites involved          Slight: 1‐2 mm of clinical a achment loss         Moderate: 3‐4 mm of clinical a achment loss        Severe: ≥5 mm of clinical a achment loss   Note :  

Q  a patient came to your clinic  his age  is 53 y having a achment loss between  3_4 mm  and its affect less than 30 % of  the site or the teeth what's your  diagnosis would be ?  You should write 3 words >>  Localized , chronic , moderate  periodontitis  

at the end the doctor said the other slides are very important read them , and enjoy  your exam …. ‫ أﺧﺘﻜﻢ ﻧﺴﺮﻳﻦ اﻟﺸﻠﺒﻲ‬.... ‫اﻟﺤﻤﺪ ﷲ اﻟﺬي ﺑﻨﻌﻤﺘﻪ ﺗﺘﻢ اﻟﺼﺎﻟﺤﺎت ﻣﻊ اﻟﺘﻮﻓﻴﻖ ﻟﻠﺠﻤﻴﻊ ﺑﺎﻻﻣﺘﺤﺎن‬

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