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Introduction
Meisam Amiri
S.Vahid Dehnad
Hadi Kaseb
Hamid Noor Mohammadi
Javid Rasekhi
Hasan Tadbiri
Ali Tavakol
Group 1
Assistant Professor:
Dr.Azimi DDS
Gingivitis &
Periodontitis
Gingivitis &
Periodontitis
Gingivitis
Gingivitis Gingivitis is inflamatory changes of gingiva
by Microbial products.
Stages of gingivitis: Initial lesion Early lesion
Established lesion Advanced lesion
Initial lesion
Capillary dilation and increased blood flow (sub clinical gingivitis)
Margination , emigration and diapedesis of PMNs Presence of leukocytes in gingival sulcus and
increased GSF (Gingival Sulcus Fluid) If continued, macrophage and lymphoid cells
infiltration in junctional epithelium and connective tissue
Early Lesion
Appearance of Erythema due to capillary proliferation
Bleeding during probing Increased Destruction of collagen up to 70%) Entrance of PMNs into the periodontal pocket
and phagocytosis of microorganisms
Established lesion
Congestion and dilation of blood vessels Disorder in venous return and so local anoxia
gingiva Blue Discoloration of gingiva Majority of plasma cells
Advanced lesion
Extension of lesion to the alveolar bone Periodontal destruction phase
Generalized Marginal Gingivitis
Marginal supragingival plaque and gingivitis
Marginal supragingival plaque and gingivitis
Gingivitis: clinical features. Localized, diffuse, intensely red area facial of tooth and dark pink marginal changes in the
remaining anterior teeth
Localized diffuse gingivitis
Desquamative gingivitis
Characterized by intensive erythema desquamation and ulceration of the free end attached gingiva
It may be asymptomatic or a mild burning sensation to an intensive pain
Desquamative gingivitis is a part of clinical manifestations of the following mucocutaneous autoimmune conditions:
Bullous pemphigoid Pemphigus vulgaris Linear IGA Dermatitis herpetiformis Lupus Erythematosus Chronic ulcerative stomatitis
Differential Diagnosis
Chronic bacterial fungal and viral infections Reactions to medications mouth washes and
chewing gum Crohn’s disease Sarcoidosis Some leukemia
Chronic desquamative gingivitis
Necrotizing Ulcerative Gingivitis (NUG)
Acute disease Sudden occurrence
1. Punched out and crater like papillae2. Grey pseudomemberanous slough with a linear erythema 3. Spontaneous gingival hemorrhage or pronounced bleeding on
the slightest stimulation4. Sialorrhea5. Can occure in disease free-mouthes or can be superimposed on
chronic gingivitis or periodontal pockets6. constant radiating, gnawing pain 7. Intensified pain by eating spicing or hot food or chewing8. Metallic foul taste9. Pasty saliva
Clinical manifestations:
Systemic Manifestation ( in mild to moderate disease)
Minimum of systemic complication Local lymphadenopathy and slight elevation in
temperature
Systemic Manifestation ( in Severe disease)
High fever Increased heart rate Leukocytosis Loss of appetite General lassitude
Diagnosis
Based on:
1. Gingival pain
2. Ulceration and bleeding
Differential Diagnosis
Acute Herpetic Gingivostomatitis Chronic periodontitis Desquamative gingivitis Streptococcal gingivostomatitis Aphthous Stomatitis Gonococcal gingivostomatitis Candidiasis Agranulocytosis Dermatoses ( pemphigus, erythema multiform and
lichen planus)
Predisposing factors
Preexisting gingivitis Injury to the gingiva Smoking Deep periodontal pocket and periodontal flaps Gingiva traumatized by opposing teeth in
malocclusion Nutritional deficiency Debilitating disease Psychosomatic factors
Acute necrotizing ulcerative gingivitis
Acute necrotizing ulcerative gingivitis
Acute necrotizing ulcerative gingivitis: typical punched-out interdental papilla between the mandibular canine and
lateral incisor
Acute necrotizing ulcerative gingivitis: typical lesions with progressive tissue destruction
Acute necrotizing ulcerative gingivitis: typical lesions with spontaneous hemorrhage
Acute necrotizing ulcerative gingivitis: typical lesions have produced irregular gingival contour
Periodontitis
Periodontitis
Usually painless or areas of localized dull pain
Risk factors: Prior history of periodontitis Local factors Systemic factors ( NIDDM, IDDM) Environmental and behavioral ( smoking and
emotional stress) factors Genetic factors
Sign and Symptoms
Formation of periodontal pocket Gingival Recession Bone resorption Tooth mobility Pus
Taste of metal Halitosis Itchiness Abscess Tooth Migration Pain
Types of Periodontitis
1. Chronic
2. Aggressive
Chronic Periodontitis
After the third decade of life Correlation between local stimulant factors
and destruction rate Mild to moderate destruction Large spectrum of Microorganisms involved Most Common form
Microbial plaque ( supragingival & infragingival , often with calculus formation), periodontal inflammation, Attachment loss, alveolar bone loss ( both horizontal and vertical ), Pocket formation
Vertical bone loss is usually associated with angular bony defect and intra bony pocket formation
Horizontal bone loss is usually associated with supra bony pocket
Discoloration from pale red to purple Loss of stippling form of gingiva Changes in the surface topography: Blunted or
rolled gingival margin and flattened or cratered papilla
Gingival bleeding ( either spontaneous or in response to probing )
Stages of Chronic Periodontitis
Pocket Mobility Bone loss
Early 3-5 mm None1-30 %
Moderate 5-7 mm 1-2 mm30-50 %
Advanced >7 mm >2 mm >50 %
Aggressive periodontitis
Before third decade of life No correlation between local stimulant factors and
destruction rate Severe destruction Considerable presence actinobacillus
actinomycetemcomitans Role of genetic factors Dysfunction of phagocytosis Intensification of macrophage function
Localized Aggressive Periodontitis
1.Involvement of first molars or incisors ( less than 30% of the sites assessed in the mouth demonstrate attachment loss and bone loss)
2.Severe reaction of serum antibody against infectious agents.
3.Lack of clinical inflammation.
4.Minimal amount of plaque
5.distolabial migration of the maxillary incisors with concomitant diastema formation
6.Incresing mobility of first molars
7.Sensitivity of denuded root surfaces to thermal and tactile stimuli
8.Deep dull radiating pain during mastication probably because of irritation of the surrounding structures by mobile teeth and impacted food
9.periodontal abscess
10.Regional lymph node enlargement
Radiographic finding: Vertical loss of alveolar bone around the first
molars and incisors Arched shape loss of alveolar bone extending
from distal surface of second premolar to mesial surface of second molar
Generalized Aggressive Periodontitis
Involvement of at least three other teeth in addition to first molars and incisors ( more than 30% of the sites assessed in the mouth demonstrate attachment
loss and bone loss) Mild reaction of serum antibody against infectious
agents Usually under the age of 30 Destruction occurres episodically of variable length Small amounts of bacterial plaque
Two gingival tissue responses can be found:
1.A severe acutely inflamed tissue often proliferating ulcerated and fiery red, bleeding may occurre spontaneously, suppuration may be an important feature; This response occurres in destructive stage
2.The gingival tissues may appear pink free of inflammation and occasionally with some degree of stippling; Deep pockets can be demonstrated by probing
Note
Some patients may have systemic manifestations such as weight loss, mental depression, and general malaise
Radiographic Findings
Can range from severe bone loss associated with the minimal number of teeth to advanced bone loss affecting the majority of teeth. A comparison of radiographs taken at different times illustrates the aggressive nature of this disease
Risk factors for aggressive periodontitis
Microbiologic factor Immunologic factor (HLA typing such as HLA
A1 and B15, functional defects of PMN, monocytes or both)
Genetic factors Environmental factors (Smoking)
Diagnosis is based on:
1. Age of onset
2. Rapid rate of disease progression
3. Nature and composition of hosts immune response
4. Familial aggregation of diseased individuals
Radiograph showing moderate semilunar bone defect on mesial of first molar in a patient with localized juvenile
periodontitis
Rapidly progressive adult periodontitis in a 28-year-old female, clinical view
Maxillary radiograph showing generalized severe Periodontitis
Necrotizing Ulcerative Periodontitis
Extension of NUG into the periodontal structures leading to attachment and bone loss
Possible Sing and Symptoms
Necrosis and ulceration of the coronal portion of the interdental papilla and / or gingival margin
Painful bright red marginal gingiva Bleeding on even slight manipulation Halitosis
Systemic Manifestation
High fever Malaise
Lymphadenopathy
Risk Factors
Stress Heavy smoking Poor nutrition
Types of NUP
Non AIDS type NUP AIDS associated NUP
Non AIDS Type NUP
Occurring after repeated long term episodes of NUG
Other notes has been described before
AIDS associated NUP
Prevalence is up to 5% Large areas of soft tissue necrosis Exposure of bone Sequestration of bone fragments which may
extend to vestibular area or palate Bone loss which may be extremely rapid Greater numbers of opportunistic infections
Necrotizing ulcerative periodontitis in a 45-year-old white male, HIV-negative
Necrotizing ulcerative periodontitis in a 45-year-old white male, HIV-negative
Necrotizing ulcerative periodontitis (NUP) in a 28-year-old woman with a CD4 count of 48. NUP of mandibular anterior
region
Necrotizing ulcerative periodontitis (NUP) in a 28-year-old woman with a CD4 count of 48. Necrotizing stomatitis in
mandibular left molar area
Necrotizing ulcerative periodontitis (NUP) in a 28-year-old woman with a CD4 count of 48. Radiograph of sequestra in
mandibular left molar area
Necrotizing ulcerative periodontitis (NUP) in a 28-year-old woman with a CD4 count of 48. Sequestrae removed in
conjunction with extraction of teeth
Necrotizing ulcerative periodontitis (NUP) in a 28-year-old woman with a CD4 count of 48. Mandibular anterior area
one week post-treatment
Necrotizing ulcerative periodontitis (NUP) in a 28-year-old woman with a CD4 count of 48. Mandibular left molar region
2 months postoperatively. Note uneventful healing
Refractory Periodontitis
Those patients who are un-responsive to any treatment provided, whatever the thoroughness or frequency
Must be exactly distinguished from recurrent disease or incomplete retreated cases
Results from different bacterial agent – specific alteration of the host response or a combination of these
Failure to eliminate plaque retentive factors Smoking
Notes
Pretreatment clinical findings and severity are not diagnostic of refractory periodontitis
Impaired PMN phagocytosis and reduction of PMN chemotaxis can be a reason of refractory periodontitis
Periodontitis as a manifestation of systemic diseases
Severe periodontitis has been observed in patients with primary neutrophil disorders such agranulocytosis, neutropenia, Chediak-Higashi syndrome, lazy leukocyte syndrome, Dawn syndrome, Papillon-Lefevre syndrome and inflammatory bowel disease.