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2017 Classification of Periodontal and

Periodontal Health,

Periimplant Diseases and Conditions

Gingivitis & Gingival
Conditions

Periodontitis

Other Conditions Affecting

the Periodontium

Peri-implant Disease &

Conditions

Periodontal Health, Gingivitis & Gingival Conditions

1. Periodontal 2. Gingivitis Biofilm 3. Gingival Diseases

Health & Gingival Induced Non-biofilm
Health Induced

Periodontal Health and Gingival Health:

Periodontal health can be defined as a condition when periodontium lack of
from free inflammatory periodontal disease that allows an individual to function
normally and avoid consequence (mental or physical) due to current or past disease.
Healthy periodontium determined by clinical absence of disease related with
gingivitis, periodontitis or other periodontal conditions. Periodontal health can also
achieve with patient that had diagnosed with gingivitis, periodontitis or other
periodontal conditions after proper treatment. Clinical gingival health on an intact
periodontium is characterized by the absence of bleeding on probing, erythema and
edema, patient symptoms, and attachment and bone loss.

We can classify gingival health into two:

• Clinical gingival health on an intact periodontium: Clinical gingival

health on an intact periodontium is characterized by the absence of
bleeding on probing (<10%), erythema and edema, patient symptoms, and

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 attachment and bone loss. Physiological bone levels range from 1.0 to
3.0 mm apical to the cemento-enamel junction. In addition, there is no
probing attachment loss.

• Clinical gingival health on a reduced periodontium: Clinical gingival

health on a reduced periodontium is characterized by an absence of
bleeding on probing, erythema, edema and patient symptoms in the
presence of reduced clinical attachment and bone levels. This can be
divide in two category:

➢ Clinical gingival health on a reduced with stable periodontitis patient:

-Bleeding on Probing <10%
-Pocket Probing depths ≤4mm
-Probing Attachment Loss – Yes
-Radiological Bone Loss – Yes
➢ Clinical gingival health on a reduced with non-periodontitis patients
(recession, crown lengthening….)
- Bleeding on Probing <10%
- Pocket Probing depths ≤3mm
- Probing Attachment Loss – Yes
- Radiological Bone Loss – Possible

Gingivitis:
Gingivitis is a non-destructive type of periodontal disease which is an often
painful inflammation of the gingiva. Gingivitis most commonly occurs due to bacterial
buildup on the teeth. The main symptom of gingivitis is red, puffy gingiva, bleeding
during brushes of teeth. This problem can be resolves with brushing, and regular
flossing as well as with antiseptic mouthwash may help. Gingivitis can progress to
periodontitis if a person does not treat it properly.

There are two main types of gingivitis:

1- Dental plaque-induced gingivitis: this type is the most common form of

gingival disease which is associated with retained dental plaque. This
disease may occur on an intact periodontium or a reduced
periodontium, regardless of cause, are patients with signs of gingival
inflammation as measured by bleeding on probing (BOP).

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 Diagnostic look-up table for gingival health or dental plaque-induced gingivitis in
clinical practice

There are three distinct categories of Biofilm-induced gingivitis:

I. Associated with biofilm alone

II. Drug-influenced gingival enlargement
III. Gingivitis Mediated by either Systemic Risk Factors or Local Risk Factors

2- Non-plaque-induced gingivitis: this type of gingivitis is less common

than plaque-induced gingivitis which caused by factors other than
plaque such as systemic condition. These conditions may be
manifestations of systemic conditions or they may be localized to the
oral cavity. Some conditions may be further exacerbated by local
factors such as plaque or oral dryness, however are not caused by
plaque biofilm and usually do not resolve following plaque removal.

Non- plaque-induced gingivitis can be due to:

▪ Genetic/developmental
▪ Infections
▪ conditions Inflammatory/immune
▪ Reactive processes
▪ Neoplasms
▪ Endocrine/metabolic diseases
▪ Traumatic lesions
▪ Gingival pigmentation

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 2017 classification of periodontitis, staging, and grading :

Periodontitis
Associated
with Systemic
Necrotizing Diseases
Periodontal Periodontitis
Diseases

periodontitis

1- Necrotizing Periodontal Diseases:

Patients in this condition have clinical features may include necrotic papillary and
marginal gingiva, bleeding, pain, and marginal gingiva that is covered by a
yellowish white slough or pseudomembrane. Alcohol misuse play important in the
predisposition of necrotizing periodontal diseases as well as affects immune
responses. Severe necrotizing gingivitis can lead to necrosis of the alveolar bone,
resulting in necrotizing stomatitis in the immunocompromised individuals. If left
untreated, necrotizing stomatitis results in extensive osteonecrosis and, in some
extreme cases, noma. Three forms of necrotizing periodontal diseases have been
described in 2017:

► Necrotizing gingivitis
► Necrotizing periodontitis
► Necrotizing stomatitis and noma (cancrum oris)

2- Periodontitis Associated with Systemic Diseases: periodontitis due to systemic

diseases mainly due to uncommon systemic diseases like leukocyte adhesion
deficiency, Papillon-Lefevre syndrome, etc. which cause alteration in host
response in the course of periodontal disease. The clinical manifestation of
many of these
disorders appear at an early age and may be confused with
aggressive forms of periodontitis with rapid attachment loss and the potential
for early tooth loss. In addition, the periodontitis that observed in the poorly
controlled diabetic patient are excluded from this category.

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 3- Periodontitis: inflammation of the supporting tissues of the teeth which
caused by specific or groups microorganism, that resulting in progressive
destruction of the periodontal ligament and alveolar bone with increased
probing depth formation, recession, or both. Clinically periodontitis can be
distinguished from gingivitis via detectable attachment loss, formation of
periodontal pocket, change in the density and height of the alveolar bone.
Changes in color, contour, and consistency, as well as bleeding with probing all
of them are clinical signs of periodontitis. In periodontitis, attachment loss
occurs either continuously or as in episodic burst of disease activity.

Periodontitis Staging & Grading:

stage 2 stage 3 stage 4

Stage 1
Clinical Clinical Clinical Clinical
attachment loss: attachment loss: attachment loss: attachment
1-2mm 3-4mm ≥ 5 mm loss: ≥ 5 mm
Radiographic Radiographic Radiographic Radiographic
bone loss: bone loss: bone loss: bone loss:
Coronal third of Coronal third of Middle or apical Middle or apical
the root the root third of the root third of the root
Tooth loss due to Tooth loss due to Tooth loss due Tooth loss due
periodontitis: No periodontitis: No to periodontitis: to periodontitis:
tooth loss tooth loss ≤4 teeth ≥5 teeth

o Stage I: located between gingivitis and periodontitis, shows the early attachment
loss. Persistence of gingival inflammation and biofilm dysbiosis lead to stage I
periodontitis. Clinical attachment loss at a relatively early age may have
heightened susceptibility to disease onset.
o Stage II: At this stage of the disease process that represents established
periodontitis in which a carefully performed clinical periodontal examination
identifies the characteristic damages that periodontitis has caused to tooth
support. management of stage II relatively simple for many cases as application
of standard treatment principles involving regular personal and professional
bacterial removal and monitoring is expected to arrest disease progression.

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o Stage III: significant damage to the attachment apparatus and, in the absence of
advanced treatment, tooth loss may occur. presence of deep periodontal lesions
that extend to the middle portion of the root and whose management is
complicated by the presence of deep intrabony defects, furcation involvement,
history of periodontal tooth loss/exfoliation, and presence of localized ridge
defects that complicate implant tooth replacement.
o Stage IV: considerable damage to the periodontal support and may cause
significant tooth loss, and this translates to loss of masticatory function. In this
stage, the dentition is at risk of being lost, In the absence of proper control of the
periodontitis and adequate rehabilitation. In stage IV, deep periodontal lesions
that extend to the apical portion of the root and/or history of multiple tooth loss
as well as this stage complicated by tooth hypermobility because of secondary
occlusal trauma and the sequelae of tooth loss.

Grading of periodontitis: categorized into three grades based on risk of rapid

progression (using direct measures such as radiographic bone loss or clinical
attachment loss, and indirect measures such as bone loss/age ratio).

► Primary criteria: Direct evidence:

o Grade A: Slow, no CAL or RBL over 5 years
o Grade B: Moderate, ≤2mm loss over 5 years
o Grade C: Rapid, ≥2mm loss over 5 years
► Indirect evidence:
o Grade A: <0.25% bone loss/age, heavy biofilm deposits with low levels
of destruction
o Grade B: 0.25-1.0% bone loss/age, destruction consistent with biofilm
deposits
o Grade C: >1.0% bone loss/age, destruction exceedss expectations,
suggests rapid progression.

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Reference:

✓ Steps for determining a diagnosis of periodontitis - the 2018 AAP/EFP

classification of Periodontal & Peri-implant diseases. Dentalcare. (n.d.).
Retrieved August 7, 2022, from https://www.dentalcare.com/en-us/ce-
courses/ce610/steps-determining-diagnosis-periodontitis
✓ Periodontal Health and Gingival Diseases and ... - Wiley Online Library.
(n.d.). Retrieved August 7, 2022, from
https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.17-0719
✓ Tkacz, K., Gill, J., & McLernon, M. (2021, August 27). Necrotising
periodontal diseases and alcohol misuse - A cause of osteonecrosis? Nature
News. Retrieved August 7, 2022, from
https://www.nature.com/articles/s41415-021-3272-
9#:~:text='Necrotising%20periodontal%20diseases'%20is%20an,untreated
%2C%20can%20result%20in%20osteonecrosis.
✓ DWARAKANATH, C. H. I. N. I. D. O. R. A. I. S. W. A. M. I. (2019).
Newman and Carranza's clinical periodontology: Third south asia edition.
ELSEVIER INDIA.
✓ Newman, M. G., Elangovan, S., Dragan, I. F., & Karan, A. K. (2022).
Newman and Carranza's essentials of clinical periodontology: An
integrated study companion. Elsevier.

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