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California Continuing Education Credits: 2 units

PIC HOMEPAGE

Periodontal Disease Recognition


Classifications and Categories of Periodontal Disease
Completion of Periodontal Exam

The American Dental Association (ADA) and the American Academy of Periodontology (AAP)
have developed systems for classifying periodontal diseases. Both the ADA and AAP
classifications systems will be described in detail and a few examples will be illustrated. Ideally,
each patient needs to be identified or categorized into an ADA and AAP periodontal
classification.

  
      

The system developed by the American Dental Association classification system is primarily
based on the severity of attachment loss. The clinician uses the clinical and radiographic data
gathered and classifies the patient into one of the four Case Types. These Case Types are
commonly required for insurance billing. In addition, the ADA provides treatment
recommendations for each Case Type which is not part of this tutorial.
Case Type I: Gingivitis
Case Type II: Early Periodontitis
Case Type III: Moderate Periodontitis
Case Type IV: Advanced Periodontitis

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The following clinical findings commonly describe Case Type I.


@m [o attachment loss
@m Bleeding may or may not be present
@m Pseudopockets may be present
@m Only the gingival tissues have been affected by the inflammatory process.

The following radiographic findings commonly describe Case Type I.

@m [o radiographic evidence of bone loss


@m The crestal lamina dura is present
@m The alveolar bone level is within 1 to 2 mm of the CEJ area

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The following clinical findings may be present in Case Type II.

@m Bleeding upon probing may be present in the active phase


@m Pocket depths or attachment loss of 3 to 4 mm
@m ·ocalized areas of recession
@m Possible Class I furcation invasion areas

Radiographic findings may include.

@m Horizontal type of bone loss is most common


@m ºlight loss of the interdental septum
@m Alveolar bone level is 3 to 4 mm from the CEJ area
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The following clinical findings may be present in Case Type III. This case illustrates a patient
with Moderate Periodontitis.

@m Pocket depths or attachment loss of 4 to 6 mm


@m Bleeding upon probing
@m Grade I and/or Grade II furcation invasion areas
@m Tooth Mobility of Class I

Radiographic Findings

@m Horizontal or Vertical bone loss may be present


@m Alveolar bone level is 4 to 6 mm from the CEJ area
@m Radiographic furcations of Grade I and/or Grade II
@m Crown to root ratio is 1:1 (loss of 1/3 of supporting alveolar bone)

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This case illustrates common clinical findings in patients with Advanced Periodontitis, Case
Type IV.

@m Bleeding upon probing


@m Pocket depths or attachment loss over 6 mm
@m Grade II, Grade III
@m Mobility of Class II or Class III
Common radiographic findings include:

@m Horizontal and vertical bone loss


@m Alveolar bone level is 6 mm or more from the CEJ area
@m Radiographic furcations
@m Crown to root ratio is 2:1 or more (loss of over 1/3 of the supporting alveolar bone)

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The American Academy of Periodontology classification system was established to identify


distinct types of periodontal diseases by taking into consideration factors such as age of onset,
clinical appearance, rate of disease progression, pathogenic microbial flora and systemic
influences. The two major categories are Gingivitis and Periodontitis. Within each category there
are specific types of diseases identified.

Gingivitis ºubdivisions are listed below:

@m Plaque-Associated Gingivitis (illustrated)


m Chronic Gingivitis
m Acute [ecrotizing Ulcerative Gingivitis
m Gingivitis Associated with ºystemic Conditions or Medications
§m Hormone-Induced Gingival Inflammation
§m Drug-Influenced Gingivitis (illustrated)
§m ·inear Gingival Erythema (·GE)
@m Gingival Manifestations of ºystemic Diseases and Mucocutaneous ·esions
m Bacterial, Viral or Fungal
m Blood Dyscrasias (for example Acute Monocytic ·eukemia)
m Mucocutaneous Diseases (·ichen Planus, Cicatricial Pemphigoid)

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This slide illustrates a patient who presents clinical findings representative of Plaque Associated
Gingivitis:
Gingival redness, edema, bleeding upon probing, enlargement and tenderness.
Radiographic evaluation shows no signs of bone loss.

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Patients diagnosed with Acute [ecrotizing Ulcerative Gingivitis may present with the following
clinical findings: Papillary necrosis, bleeding, pain and fetor oris (odor).

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Changes in the levels of circulating estrogen and progesterone can cause gingival hyperplasia,
this can occur at puberty or during pregnancy. Clinical findings of patients diagnosed with
Hormone-Induced Gingival Inflammation may include the following:
Gingival redness, bleeding upon probing, edema and gingival
enlargement associated with proliferation of blood vessels.

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Patients that take medications such as Dilantin, Cyclosporin or
Procardia often present with gingival overgrowth.
This case illustrates a patient who is taking the medication
Cyclosporin for treatment of a kidney transplant.
Clinical findings include: Fibrotic gingival response,
pseudopockets and bleeding upon probing.

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Patients that are HIV+ may exhibit this type of gingival response.

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Two examples of cases in this gingivitis category include patients with Acute Herpetic
Gingivostomatitis or Candida Albicans.


  
Patients with a history of blood disorders, such as Acute Monocytic ·eukemia, commonly leads
to a compromised or reduction of the host immune response. Clinical Findings often include;
spontaneous bleeding upon probing or by simply touching the gingival tissues.

   
 
Examples of gingival diseases in this category include; ·ichen Planus, Pemphigus Vulgaris and
Desquamative Gingivitis.

Periodontitis ºubdivisions are listed below:

@m Adult Periodontitis - Plaque-Associated (illustrated)


@m Early-Onset Periodontitis
m Prepubertal
m Juvenile Periodontitis
m Rapidly Progressive (illustrated)
@m Periodontitis Associated with ºystemic Diseases (illustrated)
@m [ecrotizing Ulcerative Periodontitis
@m Refractory
@m Peri-implantitis

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Adult Periodontitis is the most common chronic form of periodontitis. The presence of local
factors such as plaque is usually comparable with the disease progression. This slide illustrates a
patient with active periodontal disease associated with the presence of plaque and calculus.

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This case illustrates a patient diagnosed with ·ocalized Juvenile Periodontitis. In these patients,
local factors are minimal, there is rapid loss of attachment, bilateral symmetry is common,
destruction of bone is often localized to first permanent molars, permanent incisors but can be
generalized destruction, and mild to moderate inflammatory response.

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A rare periodontal disease, onset is often during or immediately following eruption of the
decidous dentition. Clinical findings include generalized severe and rapid destruction of bone.
Other medical conditions are usually present.
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This case is a young female diagnosed with Rapidly Progressive Periodontitis. In these type of
cases, clinical manifestations of inflammation may be present, local factors are minimal,
generalized severe and rapid bone destruction occurs.

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With certain systemic conditions the inflammatory response is altered in the presence of local
irritants thereby, accelerating the progression of periodontal disease. The patient in this case has
a history of Diabetes.

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[ecrotizing Ulcertative Periodontitis can be described similar to Acute [ecrotizing Ulcerative
Gingivitis. Findings may include erythema, ulceration and necrosis of the gingival margin, with
destruction of the supporting bone. The deep interdental osseous craters are distinctive when
compared to other types of bony defects found in periodontal diseases.

 
These type of cases normally do not respond to "well-executed" periodontal therapy.

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This is a new category established by the AAP. Patients in this category have implants that
exhibit a "periodontitis-like-process" similar to natural teeth.

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