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.