Transcribed by Jacqueline Heath

10/30/14

[Diagnosis of Oral Diseases] [60] [Classification of Periodontal Diseases] by [Dr. Loomer]

The slides are not posted on NYUClasses, so I typed out the names of the slides on the podcast.
However, it may not be perfect, especially if he posts a different version of the PPT later. However, the
titles should help I hope!
[1] Intro slide
This is a really easy lecture but a very important one because its important to have a classification to
diagnose your patient and use the classification to figure out what their diagnosis is. And the diagnosis
of course helps to dictate treatment, but mainly you do a diagnosis to communicate, to tell the patient
what they have, to tell other health care providers what they have so you can communicate. So its a
communication tool and well talk about that.
[2] The Periodontium
Okay, so just to review the parts of the periodontium. Its important to know because the diagnosis is
going to depend on the attachment, the level of attachment of the tooth, the periodontal ligament, the
tooth to the bone. So when you have loss of attachment your diagnosis changes. So remember the
parts of the periodontium, its the supporting apparatus of course, alveolar bone, periodontal ligament
[for the rest of the lecture, Im using periodontal ligament for periodontal ligament and periodontal for
periodontal], cementum, youve got the gingival tissue.
[3] Plaque/Bacteria
And remember when you have periodontal disease or gingivitis, its a bacteria in the pocket, your
periodontal pathogens, well talk about that in just a minute just as a brief overview. When they are
permitted to grow, and that could be because of lack of oral hygiene or that could be through decrease
in the host defense mechanisms or it could even be due to opportunistic pathogens. Some bacteria
somehow gets into the oral biofilm and starts to overgrow and now what it does is it elicits the host, the
patient to produce inflammation ad its the inflammation that causes the destruction. So we think of
periodontal disease as an inflammatory disease that has a microbial etiology. So you need the bacteria,
maybe viruses as well, to initiate the process of disease but its the inflammation that causes the
destruction. And the human produces the inflammation. So bacteria do produce products like
lipopolysaccharides, enzymes, and they can cause tissue destruction but they cause minimal amount in
comparison to the host. And the host, what the host is trying to do is trying to extract your teeth. If
your teeth fall out by losing the bone, then the bacteria dont have a place to live and the bacteria cant
penetrate into the blood stream to affect more vital organs like the heart. So were trying to extract our
teeth, of course we want to prevent that. We want to keep bacteria under control so we dont have
that.
[4] Major Categories
So the main categories in looking at the classification are these. There are obviously health, so diagnosis
would be health. You can diagnose someone with periodontal health for example. Gingivitis, well talk
about plaque induced and ones that are not related to plaque. Obviously the ones related to plaque are
the most common. And then periodontitis, there are a variety of types of periodontitis and youll have

lectures in more depth in how to treat these types of periodontal diseases. But well talk a little bit, not
too much about acute. Acute is periodontal abscess basically. Chronic, aggressive, or diseases
associated, or hormone drug associated.
[5] Health
So remember what health is? Its where you have basically no attachment loss, theres no tooth, no
bone or tissue loss around the tooth, the bone and tissue looks nice and pink, healthy, there is no
bleeding when you probe anywhere. Lack of bleeding on probing, correlates well to periodontal health
or stability. When you have bleeding on probing that means there is inflammation in the gingiva. So
you get some bleeding so lack of bleeding correlates well with health. And interproximally of course you
want to see the same thing, nice stippled gingiva, its not edematous, the tissues are where theyre
supposed to go.
[6] Health (2)
You can see this patient has had some recession. But now theyve been treated and theyre keeping
good oral hygiene so the tissues look nice and healthy.
[7] Gingivitis
So gingivitis, by definition, is inflammation of the gingiva. It basically occurs when you have, a diagnosis
of GINGIVITIS would occur when you have no loss of attachment around the tooth. So you have
inflammation of the gingiva, it bleeds when you probe as well as an indication that there is inflammation
there. But you havent lost any tissue attachment. So the most coronal part of the periodontal ligament
attaches to 1-2 mm below the CEJ. So a normal attachment, where the probe should be when you
probe, remember youre about 2 mm above the alveolar bone and the alveolar bone should be on a
radiograph, if youre looking at a bitewing, should not be more than 1-2 mm from the CEJ. So if youre
looking at an x-ray, trying to determine if there is any bone loss on this patient, and if there is bone loss,
that means there has been attachment loss. That means that your alveolar crest should be within 1-2
mm of the CEJ. Its never at the CEJ because you have soft tissue covering the bone. The soft tissue
attachment will be at the CEJ but thats of course, you cant see on a radiograph. So you can use your,
even though your x-rays arent used to make the diagnosis, its the clinical findings, they are a good
adjunct and they help you determine if there is any bone loss and it helps you with your diagnosis. A
few caveats with gingivitis, the typical case is where you dont have any attachment loss, but you can
also get it when you have Periodontitis, now when you have periodontal disease, Periodontitis, you have
attachment loss, well talk about it in just a minute, but obviously there is inflammation of the gingiva.
But when you come up with a diagnosis, you dont write the patient has gingivitis and periodontitis
because the periodontitis implies that they have inflammation and the periodontitis includes gingivitis.
and the research has shown that in order to get periodontal disease, you have had to had gingivitis, but
not everyone who has gingivitis, even if its not treated, will go on to develop periodontitis. So there is a
lot of different factors, host factors, genetics, local factors, that will determine if the patient goes on
from gingivitis to periodontitis. But remember if you have periodontitis, it means that at some point you
had gingivitis.
[8] Gingivitis associated with dental plaque

Of course, some pictures, some EM pictures of plaque from the pocket. And there are other localized
contributing factors, well talk about it in just a minute as well, but the most common type of gingivitis is
the gingivitis associated with dental plaque. And youre going to see that 95% of the patients that have
gingivitis that you treat in your practice will just be due to plaque. And getting the patient to remove the
plaque once youve dont your debridement and cleaning, now that youve removed all the dental
plaque and calculus, in order to prevent the gingivitis from reoccurring, they need to do good oral
hygiene.
[9] Diagram of bacteria complexes
I think youre going to get this in a future lecture, but just very simple, you dont have to remember it for
the purposes of this lecture but just for illustration, some researchers in Boston, Supranski mostly and
his crew, the looked at patients that had periodontal disease and they cultured their plaque and they
did, not a huge amount, they did 15-20 different species that you can grow that are found in patients
with periodontal disease. And as you may or may not know, certain ones are more pathogenic. So the
red complex is considered the most pathogenic microorganisms. And if you have a lot of the red
complex or orange complex, which are the next most pathogenic, you know, thats indicative of a
disease pocket. If you have the green type of bacteria in your pocket, or the yellow, youre less likely to
have diseases. So certain bacteria are more prevalent in a disease site than other types. And of course
its the gram negative anaerobic bacteria that are the most common in a pocket. But having said that,
do remember that there are a lot of bacteria that you cant grow that we can isolate using PCR, DNA
procedures, but we cant grow they up and some of them could be important but we just dont know
how to do research on them because we cant grow them. So, this is sort of some of the current
research but in the future I think it is going to change.
[10] Gingivitis picture
And here is some pictures of gingivitis and you can see the plaque around the margin. Typically patients
may brush their teeth but they might not get right down to the margin. So when youre giving OHI to
them youve got to instruct them to get the bristles right at the margin or slightly below, directed into
the pockets so you get some of those bristles subgingival, and you can see the red inflammation around,
the erythema, around some of the areas and if you probe that area, actually I do have a pointer, if you
probe that area, actually I dont have a pointer. [Student: use the mouse] Use the mouse, thats a good
suggestion. You can see this area would definitely bleed if there was, if you were probing that area.
[11] Chronic Marginal Gingivitis?
Another picture, sort of the same thing, you can see a lot of plaque, heavy accumulation, and it doesnt
look so bad here, so probably theyre brushing but maybe not getting down to the gingival margin. And
this would be a more moderate case, we dont really classify gingivitis according to the severity, we just
say gingivitis. And some people will call it marginal, because it occurs at the margin. If you only have it
in the interdental papilla, you could call it papillary, but I think either, it doesnt really matter as long as
you write gingivitis. And the key feature here is that there is no attachment loss.
[12] Chronic marginal gingivitis (2)
And this could be a more severe kind of gingivitis. It could appear more red. So its going to depend on
the thickness of the gingiva, the biotype is it very thick gingiva, is it highly keratinized or is it thinner, if

its thinner gingiva then the layer of keratin is less and youre probably going to see a more red
appearance. If its thicker it might not look as erythematous.
[13] Gingivitis associated with dental plaque
So a couple of common factors that can contribute to it.
[14] Overhangs
Overhangs are one of the most common. So iatrogenic we call it, or dentistry related. And you can see
the overhangs here is going to cause some, the plaque is going to be able to collect around that. And
thats going to cause some localized inflammation and of course, if left unchecked, that will probably
lead to periodontitis. If you have a little crack in the tooth, the bacteria, because theyre microscopic of
course, they can get into that crack that can cause localized bone loss, so sometimes youre going to see
a patient with a crack and a lot of inflammation around that. Okay.
[15] Gingivitis associated with the endocrine system
And there are a few types of gingivitis that are associated with different factors. Usually plaque is part
of the story but there may be other things that are contributing as well. And specifically endocrine
system, hormonal related.
[16] Puberty
And very common is puberty associated GINGIVITIS and it tends to be a little more, uh, it doesnt tend to
be localized, it tends to be pretty much throughout the mouth, but sometimes its only in the anteriors.
But it occurs obviously in someone going through puberty. Typically their oral hygiene isnt good its
kind of an exaggerated response to plaque accumulation. Sometimes youll see gingivitis in a patient
who is not puberty aged but its just in the anterior part of the mouth. Say from canine to canine, you
dont see it in the posterior. Often occurs in a class II malocclusion where theyre very over-closed, and
that tends to be called mouth breathing gingivitis. Where patients lips are not closed together.
Normally when theyre not because of their occlusion their lips are always open and therefore they
breathe through their mouth because their mouth is open and it dries out the gingiva and that leads to
inflammation. So if you see gingivitis just in the anterior, just observe the patient in the chair and
observe if their mouth is closed or their mouth is open. If their mouth is open at rest, usually that
means that theyre a mouth breather and that if they keep good oral hygiene that may mean they
keep the gingivitis but its not detrimental, it wont progress onto anything.
[17] Pregnancy: pyogenic granuloma
Pregnancy gingivitis is common. It usually occurs in a localized area Yes? [Student: you said puberty
exacerbates the gingivitis, but it doesnt cause it, right? It just makes it worse.] Makes it worse.
[Student: But there is another condition that causes...] You would need the bacteria, so if you have the
increase in hormone without any bacteria, you shouldnt see the GINGIVITIS, but you get a more
exaggerated response to the same amount of plaque. So somebody that might be older, wouldnt
have... With the same amount of plaque, would see less of a gingivitis response. So youse more of an
exaggerated. And the thing to know about hormones, as Im sure you can imagine, is there is a variation
depending upon the individual. Not every patient with the same amount of plaque is going to respond
the same because the host is different. But if you do see it in someone that age, usually the hormonal

levels are playing a role. And its the same thing in pregnancy. Because of your higher level of estrogen,
etc. Sometimes you see an exaggerated response to plaque. Sometimes people will, be a little more
granulomatous, this is a little more fibrous. But it tends to occur often at the interdental papilla and
sometimes expand from there. This is sort of a classic appearance. Often in the anteriors, Im not sure
why more in the anteriors, but it often overgrows, and it could be diagnosed as, if you took a biopsy, you
would diagnose it as a pyogenic granuloma. So just a lot of granulomatous tissue. If its treatment
depends on what trimester the patient is in. And if its causing them problems or not. But typically if
you dont do anything, in most cases, as long as its not really fibrous, if you dont do anything, once the
patient delivers and is back to normal down the road, it tends to regress back to its original shape. But
often they want you to remove it because its either unsightly, or hard to keep clean or it bleeds when
you try to brush it, so usually patients want some kind of treatment. [Student: question] Yes. [Do the
patients have pain with that?] Um, it varies, most wont but some will. Its usually when theyre
brushing the area or flossing the area. Not just pain. Because, dont forget, its more of an abscess, its
more of an outgrowth. So its a localized area. But its often unsightly because its often in the anterior
and it bleeds easily. And you can see how vascular it is. I keep forgetting to use the pointer, you can see
how vascular it is, so it can profusely bleed. It will readily bleed when you touch it.
[18] Gingivitis associated with other drugs
You can also get gingival enlargement associated with a variety of drugs. The most common ones that
youll see are immunosuppressant type drugs, calcium channel blockers like Nyphetapine????????, for
example, or antiseizure like Nypetulin??????????? And I have a few slides of that. And Phenytoin, its
given for epilepsy to control seizures. It varies the effect in patients. Ive seen very mild and Ive seen
very severe so there is definitely a genetic component to whether youre susceptible to gingival
overgrowth or not. But it often is... You know it could be very subtle, like on the bottom here, there is a
little bit but its kind of subtle and you may not even diagnose it as that if you didnt know the patient
was on it. Cuz once you see it in the medical history youre looking for it, right? But you can see its
much more severe in the anteriors, the maxillary anteriors. So, and it looks more fibrous, it doesnt look
as much erythematous but again its going to depend on the individual and the amount of plaque.
[19] Mouth Breathing
Oh, I do have a slide of the mouth breathing. This is a more severe one, where it looks a little more
edematous, a little bit edematous but its also a little bit erythemous, sometimes youll see a line of
erythema. And typically you can see it sort of stops where the angle of the mouth is. Where the tissues
in the back are getting saliva and theyre not drying out so theyre not getting the same reaction. Any
questions about gingivitis? Its pretty straight forward, look for inflammation, youre number one clinical
diagnostic sign that there is gingivitis is bleeding on probing. And there isnt attachment loss remember.
But you can get gingivis you can have somebody, occasionally youll have somebody, and its a little bit
controversial, theyve had periodontal disease, youve treated them scaling and root planning, surgery,
their pockets are reduced, now theyre healthy, but now they start to slack off and they start to develop
gingivitis. So its a patient with a history of periodontitis who now develops gingivitis. And how do you
diagnose that? Do you call it periodontitis or do you call it gingivitis? So its a little bit controversial. If
youve treated the patient and you know theyre stable and now its a recurrence of gingival
inflammation, I would call that gingivitis, but if youve never seen the patient before, you dont know
their history. So their pockets are shallow but they have attachment loss, I would call it periodontitis.

And either way it doesnt really matter because youre going to treat it the same way, which is probably
just needs a cleaning and scaling and root planning. So dont worry too much. Know this... Once you get
in the clinic, you learn this as you see patients. Its kind of hard to conceptualize before youre really in
the clinic. So just remember the classifications. Some of the nuances youre faculty are there to teach
you on the floor. You have remember with these lectures, they are really an accompaniment to the
clinical teaching so you get a little taste of it here, but you apply it in the clinic and thats when you really
start to appreciate it.
[20] Next: Periodontitis
Okay, so next is periodontitis.
[22] Periodontitis
A definition of periodontitis is inflammation involving the gingiva. So its the gingival unit which means
the gingiva and the alveolar mucosa and extending to the periodontal ligament, alveolar bone and
cementum. Remember gingivitis was only the gingival unit, now weve extended it beyond that. And it
always involves the loss of attachment and radiographic evidence of bone loss. So if you have clinical
attachment loss and radiographic evidence of bone loss and depending on how you take your x-ray, if
its very early clinical attachment loss, it may not be obvious on an x-ray if its angled funny. But if you
have clinical attachment loss and inflammation, you have periodontitis. There is a caveat. There is one
situation where that doesnt occur and well talk about that in a little bit.

[23] Clinical Attachment Loss: distance from the CEJ

So what does it meant to have clinical attachment loss? Its normal when your probe goes to the CEJ.
This is your CEJ right here. Your bone would be a little bit below that. Remember 1-2 mm if we drew the
bone in, it would be 1-2 mm from the crest of the bone to the CEJ. Because you have your long
junctional epithelial attachment and then youre connective tissue attachment over the bone. So the
bottom of the probe when youre hitting the bottom of the pocket, youre hitting the long junctional
epithelium. Youre not probing to the bone youre probing to the long junctional epithelia. So here
youve got some attachment loss because youre probing beyond the CEJ. So from here, to here, to the
bottom of the probe, thats your attachment loss. But you have no recession here. And in this third
slide, its showing you have recession, so youre probing, your probe will measure from the gingival crest
to the bottom of the pocket. So lets say thats 3 mm and say this probe is a 3-6-9-12. So thats 3 mm.
But you also have 3 mm, well round up, you always round up in perio 3 mm recession so 3+3 you have
6 mm attachment loss here. So if were going to round up, how many mm of attachment loss do you
have in this little picture? Do I hear a 3? 3 is right, so remember when you dont have 1 mm markings,
you always round up, so youre... Or, actually, uh. Yeah you would round up. Actually here, actually, to
be really, youd probe four, but youve got approximately 3 mm of attachment loss. Okay, so in this one,
how many mm of attachment loss would you have? Zero, we have no attachment loss, right. Because
youre probing to the CEJ. Okay.
[24] Radiographic Evidence

Radiographic evidence, uh can be very severe. You can see clearly here that there is a lot of bone loss.
So the normal, you can see the neighboring tooth, it looks pretty normal, youre within 1-2 mm of the
CEJ but here youve got extensive bone loss. So the radiographs do help you sometimes because
sometimes its difficult when youre probing to figure out where the CEJ is, to feel the CEJ. Sometimes
there is a break at the CEJ with your probe, but often youre subgingival so the radiographs are a good
adjunct but you really want to use, maybe I should change this slide, bitewings. Bitewings are the only
thing thats accurate for diagnosing, or for assessing bone level. PAs, panoramic radiographs are
completely non-diagnostic for periodontal disease and caries, but bitewings are very good. For caries as
well.
[25] photo of gingival flap
And here is a picture of it. When you lift the flap, you can see how extensive the bone loss is here. And
the trick is, when you use a radiograph because a radiograph is a two dimensional image of a 3
dimensional object, because there is bone on the lingual, on the palatal behind this, you may think that
there is bone here, you know, the whole way but really youre missing the bone on the buccal. So when
you probe, youll be getting deep probing depths on the buccal but the radiographic image may not look
as severe because its giving you the bone behind the tooth as well as the bone in front of the tooth.
And this patient is only missing the bone in front of the tooth. So radiographs, if your clinical findings
dont match you radiographs, dont worry about it. They dont always. But if you see a lot of bone loss
on a radiograph and youre only probing 2 mm, double check your probing because maybe youre
missing something. Maybe it is that way but maybe youre angulation was a little bit off. Its easy to
miss a deep pocket. [Question: Im a little confused with where the bone height is, like on the molar and
premolar?] So this is good, you can see there is one line here, and there is one that goes here. So one is
the buccal and one is the lingual. You dont know which is which unless you raise the flap, but this
patient probably has, its probably the buccal because usually thats more common to have bone loss on
the buccal more severe than on the lingual. And they have a furcation involvement and its extended of
course, almost interproximal bone [?] But it hasnt gone through and through. Yeah. And here, of
course theres not. And sometimes you can see if you have a severe bone loss on a tooth and on an
adjacent tooth theres no problem, that usually means that that patient has, that there are local factors
around that tooth that are contributing to the bone loss. Because it wouldnt you know usually
periodontitis disease is going to be kind of more or less even throughout the mouth or most of the
mouth. If its very sever on a localized area you want to look for that localized factor that is causing the
localized bone loss. Could be that theres a crack in the tooth or something related to that. Okay
Any other questions?
[26] Clinical Signs of periodontitis
Okay. So some clinical signs, so, remember we said that your clinical signs and symptoms are going to
give you your diagnosis but the part of your classification, things to look for are loss of attachment, we
talked about that.
Of course with loss of attachment youre going to get deepening pocket. If the pockets dont deepen,
the alternative is recession. The gums shrink as the pockets, as the bone loss occurs, the inflammation
occurs. You will see inflammation, so you do have gingivitis but we dont put it in the diagnosis because
your periodontitis implies you have gingivitis as well.

There could be swelling or edema, bleeding, of course bleeding on probing.

Now if you have a deep pocket and there could be bleeding from the bottom of the pocket, but the
margin of the gingiva could be healthy so when you probe, if theres inflammation at the gingival margin
and you probe and you get immediate bleeding but the problem... Inflammation is only at the bottom,
so say your patient is brushing okay but theyre not flossing to get down to the bottom of the pocket,
then itll take a few seconds for the blood from the bottom of the pocket to reach the supragingival for
your to visualize. So when I check for bleeding on probing, I check back five seconds later to see if there
is any bleeding. You may not see it immediately, it may take a few seconds for it to visually appear
around the patients tooth.
Exudate, thats pus, dead cells that are coming out of the pocket if theres an abscess, but even if theres
not an abscess, sometimes youll see it on patients. Its very common.
Migration, usually means teeth have shifted position because usually as they lose bone, and patients are
still biting, it forces the teeth to be pushed outwards, so youll see people with splayed teeth where the
teeth sort of stick out, and thats usually because theyve lost bone and the teeth are migrating to the
position of the least resistance.
Mobility, they become looser.
And of course abscess, where its swollen and bleeding, and that often has pain. Now the abscess we
diagnose as acute periodontitis. So its acute is a periodontal abscess.
[27] Periodontitis
So with periodontitis there are different types, and well go through the types. Theyre classified by the
nature of the disease. Thats the current classification so, things like, is it chronic or acute or aggressive
or is it associated with another disease for example.
[28] Periodontitis: classification overview
So there are two ways to classify it. So lets talk about chronic periodontitis first. Well these are all of
the categories first of all. Well go through each one individually. But chronic is going to be the one
youre going to see in 95% of the patients.
[29] Chronic Periodontitis
So by default, patient has chronic periodontitis and in certain subpopulations, youre going to change it
to something else. So youre looking for chronic periodontitis in most people. Its a slowly progressive
disease, so it doesnt occur rapidly, hence the word chronic. Right? And, but it tends not to be linear. So
there you may have periods when there is disease activity and you get bone loss, attachment loss and it
goes into a remission phase where there is nothing, and then it goes into an activity phase, etc. The new
NHANES study that came out a couple of years ago that looks at a big population, a big cohort of
patients in the CUS and they did full periodontal examinations on all these patients, or on a subset of
these patients I should say. And there is some chronic periodontitis in the majority of people in the US
and over 60% have subgingival calculus. So its a very common disease. Its considered the most
common inflammatory disease.
[30] To make a diagnosis we need:

So remember to make a diagnosis, there are three things you need. You need the distribution, so well
go through that. The severity of the disease and the name of the disease. So lets talk about
distribution.
[31] Distribution of the Disease
So we have two ways to classify it in periodontitis, either is generalized or localized and in a consensus
meeting that the American Academy of Periodontology had a number of years ago, they decided that
generalized means greater than 30%. I know that doesnt sound generalized. You think its more than
50, so its a, use that as a you know, a general rule, but it doesnt always apply, because 30% makes
sense if its 30% evenly distributed throughout the mouth, but if its only in 2 quadrants, thats probably
not generalized its probably more localized to those two quads, so think about it logically where the
teeth are diseased. Or it can be localized.
[32] Severity of disease
So the severity, we use three terms, mild, early or slight, actually there should be another one in here,
so you could call it mild, early or slight, if you have 1-2 mm of clinical attachment loss. If you have 3-4
thats considered moderate and if you have more than 5 its called severe, you can also call it advanced.
So if you had someone with 2 mm of attachment loss, you may call it, lets say its localized to one tooth,
you call it localized slight chronic periodontitis. Thats an example. Well go through this in just a minute
as well.
[33] Remember
But one thing to remember when youre looking at diagnosis or classification, its not the attachment
attachment loss is important but its not the probing depths. So you do the probing depth so n your
patients, and once the axiom is up and running, youll be doing the clinical attachment levels as well.
There isnt a line in your current charts for that, but theyre a little different.
[34] PD=4.
Remember as I explained before, in this, Ill just go over this case here, this scenario here. In this first
patient, they have a probing depth, in the first diagram, they have a probing depth of 4 mm, right
because heres your three line and youre about a mm over. And your clinical attachment level, you
probed right down to the base of the pocket so thats zero. Right? You have no clincial. In the second
patient, the second diagram, youve got a 4 mm probing depth but youve got 2 mm of attachment loss
and in the third one, youve got a probing depth of four, and you have some recession so youve got 4
mm probing depth, 2 mm recession, youve got a CA loss of 6. So in the middle one, your gingiva is
above the CEJ so you do 4-2=2. The first one is 4-4=0. So you can see you have 4 mm probing depths for
each of these scenarios but each 3 would have a different diagnosis. So in the first one, how would you
diagnose that tooth? Healthy. Good. And the second one? Early exactly, because its only 2, and the
last one? Severe. Right. So when you do a diagnosis, you go tooth by tooth and then come up with an
overall based on distribution.
[35] Distribution +
So remember, distribution, severity and the name of the diseases equals the diagnosis.

[36] Examples:
And I just stress these points because I sometimes see it done incorrectly in the clinic. Cuz chronic, you
have to remember chronic periodontitis chronic is the first name periodontitis is the last name. But
chronic is a noun in this case, but it can also be used as an adjective so people move the word chronic
around to different place, but think about it as a name here, not an adjective. So generalized, moderate
chronic periodontitis would be correct. Localized mild chronic periodontitis. Usually when its localized
its good to write down where its localized to. Generalized mild chronic periodontitis with localized
severe chronic periodontitis, so everywhere its mild, and then one area its severe. And as I said, mild
you can also call it slight or early, and youll also get faculty who are very passionate that you call it one
versus the other, so just you know, do whatever they want. Right? Because theyre all acceptable. Same
thing with advanced and severe, either one is acceptable.
[37] Incorrect Diagnosis
Incorrect diagnosis. So chronic generalized moderate periodontitis, that would be a wrong diagnosis
because chronic has to go over here. Mild generalized localized chronic periodontitis, again distribution
first then severity. So you get the idea right? And its important because youll have a lot of these
diagnosis questions on the boards as well.
[38] Other types of Periodontitis
Okay. So thats really the two main diseases, gingivitis, usually plaque induced but there are a few
exceptions, like hormonal related or drug related. Chronic periodontitis, is the garden variety of
periodontitis, 95% of the people or more maybe.
[39] Severity of Disease
Mild moderate, severe, which is 1-2, 3-4, 5+ remember when youre looking at the classification, just
sort of the severity, to emphasize one other point, there is no overlap, so its not 1-3 and then 3-4 and
4+. You dont want to have any overlaps so its 1-2 and then because we do it cuz were rounding up.
Okay. And then of course the name chronic periodontitis, but I do just want to review just very briefly
the other types of periodontitis, theyre much rarer, some of them you may see, and some of them very
infrequently.
[40] Periodontitis associated with Endodontic lesions
Periodontitis associated with an endo lesion, so you can have a tooth that has periodontal disease but
theyre separate. But you can also have an endo lesion thats expanded so now its involved, so now its
met the periodontal disease lesion. I can show you a diagram of that. So this first one, so over here
example, you have a lesion here and there is periodontal disease here but theyre separated. If this
lesion is allowed to expand and this one is also allowed to expand, then they can be a combined perioendo lesion. So when there are two lesions that are separate, we dont really think of it as a perio-endo
lesion, that is really two, the patient, the tooth really has two problems, really probably has three
problems cuz it probably has decay, right? And they are related but theyre treated independently. If
theyre combined, they can be treated together but typically once you have a combined lesion where
the bone loss is extended from the perio lesion to the bottom or from the endo lesion up to the perio. If
its combined like that typically the tooth is hopeless. And other thing to note and youll see this

occasionally, if you see bone loss in the furcation, but no bone loss interproximally, thats an endo
lesion, thats not a perio lesion. Because perio always starts pretty much interproximally, you know 95%
of the cases, and eventually itll extend to the furcation with time but if its only in the furcation, not
interproximally, there is an endo lesion for it.
Student: You mentioned the combined perio-endo lesion. The prognosis is hopeless?
Loomer: If this has extended up the tooth and this has extended down and its now one radiolucency,
its a hopeless prognosis. They are very difficult to treat. Because your whole root has become infected
all the way down to the apex.
Student: So basically, so just based on that picture, where two lesions have combined. I learned in endo
that you do perio treatment and the prognosis depends on the perio treatment
Loomer: Right. So if you cant treat the per. Usually the endo can be treated, unless there is a fracture
or something where the root is calcified so its difficult to do a proper.. If you can do a proper endo, its
whether you can treat the perio disease. Thats true. Its good too, if you have a combined lesion, to
have a consult on both before you do either treatment because, say the perio condition looks like its
really treatable, you have a 5 mm pocket, you know you still have lots of bone, but lets say the canal is
really calcified and you cant get in there, even though the perio is treatable, now the endo isnt
treatable, so you do want a combined consult before you start. Yeah. But if its extended so much now
that youve lost bone all the way down to the apex where the endo lesion is, thats really hopeless.
Thats not predictably treated. You might see people who say, Ive done that and it worked but thats
infrequent. You cant do that on a predictable basis.
This slide is just showing you that sometimes you can have a, you know, the bacteria can travel from a
lateral canal, so sometimes that s why youll see the pulp will become necrotic and the bacteria can
travel via an accessory canal into the furcation, and thats why you may have bone loss in the furcation
first.
[41] Periodontitis with Endodontic lesions radiograph
Okay. And this is just an illustration, one of those hopeless areas where there is an endo lesion when
you probe down to the apex, the tooth is non-vital, and youve got a lot of bone less. In this case it
probably was, it could be periodontal disease that first occurred and then it became and endo, or it
could be that there was even a crack in that tooth. That tooth does have, it had partial endo. Maybe it
had a calcified canal that they couldnt treat or maybe it was done after, anyways. Hopeless... They
probably should have removed it originally. And you can see these lesions if the teeth are very close
together, now youve got bone loss on the adjacent teeth as well. So if its allowed to progress
untreated, you can affect the neighboring teeth as well.
Any questions on perio-endo? They can be a little tricky to diagnose, which came first, and a lot of times
theyre tricky to manage. But the most important thing to do if you have a tooth with multiple
problems, the most important thing is can you put a new filling or a new restoration or a new crown on
it. Thats your most important questions because maybe you can treat the endo or perio but if you cant
restore the tooth back to a functional state, then there is no point in doing any of the other work. So
you always want to decide can I restore this tooth and sometimes you need surgical procedures to
restore it but if you cant restore it, then you cant really figure that out, and usually you have to remove

the decay in many cases and in those questionable teeth where you arent sure whether you can restore
it or not. So the restoration is sort of the key question and then you can see can the other things now
be treated? If you can never restore the tooth, dont do the other stuff as well.
[42] Necrotizing Periodontal Diseases
Okay. Necrotizing periodontal diseases. There are two types. Necrotizing ulcerative gingivitis, and
necrotizing ulcerative periodontitis, these are not very common. This is sort of the classic appearance.
The difference is its necrotizing ulcerative periodontitis if you have a attachment loss if its strictly in the
gingiva, its called gingivitis. Youll see necrosis of the gingiva where the gingiva kind of just sloughs off.
Youll see this sort of yellow dead tissue. The patient has terrible halitosis, bad breath, typically you can
smell them coming into the clinic, they could be on the other side of the clinic, you know there is a
patient coming in with NUG we call it, or NUP. Theyre in a lot of pain. Pain is not a feature of normal
gingivitis, they dont have any pain. Thats why it progressed to periodontitis often because no one has
pain. With NUP or NUG they have a lot of pain because the tissue is being necrosed. And then exposed
the epithelium sloughs off, exposing the connective tissue. So its very painful.
[43] Necrotizing Periodontal Diseases photo 2
Another picture of it. Very striking. You know when you have it. When a patient has it. It used to occur
more commonly many years ago, I guess oral hygiene has improved in general in the population. You
might see it in an undiagnosed immunocompromised patient. Um, like in HIV where they dont know
and theyre not taking any medication and thats an early sign that there is something wrong. So the
first signs of HIV are intraoral, actually, either Kaposis, or NUP, which doesnt mean you have it, but its
a sign when you do have it. And its very painful. Its really responds well to treatment.
[44] Necrotizing Periodontal Diseases
Treatment would usually be, if its systemic, associated symptoms, like fever, you might want to give
antibiotics for that. But basically scaling and root planning, obviously under local because its painful.
Give them local anesthetic. They respond very well if theyre under a lot of stress. Sometimes youll see
these patients, it develops under stressful situations, so they commonly more see it in soldiers who are
in battle, they used to say medical students who are taking exams, you might see it more often, maybe
dental students, no, dental students have good oral hygiene. So sometimes you will see it in young
people as well. But once it resolves theyll remain with these areas of black triangles where theyve lose
the interdental papilla or the tissue, so they may need some treatment to work on that. So the tissue
doesnt regenerate necessarily. Easy to diagnose, not that common anymore.
[45] Next week:
Now you can talk about, I think, I think its not next week, but its coming up on a lecture on it. But Ill
just talk about in the last few minutes because youre going to have more of it down the road.
Periodontal diseases as manifestation of systemic diseases, so there are certain periodontitis that are
associated with other diseases. Or other areas.
[46] Aggressive Periodontitis
So aggressive periodontitis, and youre going to have a lecture in terms of treatment and a review. So
this is just an overview, but its different than chronic, which is very slow. This is very rapid. It used to

be, they used to call it early onset or juvenile periodontitis, and you just see a lot of rapid tissue loss in a
short period of time. So youve checked the patient and then 6 months later you have2,3,4 mm of
attachment loss. Normally periodontitis, you see maybe a mm, maybe mm. It doesnt really progress
very rapidly. It tends to occur in younger people, so it tends to be 35 and under. In a juvenile
population, which is under 16, tends to occur on the incisors or the molars first, because those teeth
hare in the mouth the longest, so if you only see bone loss, severe bone loss on the molars or the
incisors in that population, and theyll talk about specific treatment down the road. But typically chronic
periodontitis starts over the age of 35, and usually there is lots of plaque. These patients its often
under 35 and its not much plaque. So its not a neglect issue, its immune, its often theyre heavy
smokers, those kinds of factors play a role. So if its a young person with periodontal disease without a
lot of etiology, meaning plaque and calculus, think of aggressive. And aggressive, the main difference is
we treat it a little more aggressively with antibiotics and maybe host modulation therapy like anticollagenase drugs. Which youll learn about.
[47] Abscesses in the Periodontium
Abscesses, we talked about that, thats acute periodontitis. Thats another name for it. And it can be a
gingival abscess, just in the gingiva. It can be periodontal or peri-coronal if its a partially impacted
wisdom tooth. Youll get more on the treatment of that.
[48] Developmental or Acquired Deformities and Conditions
So acquired deformities So in part of the classification is acquired or developmental deformities. So,
the ones that are most relevant, there are tooth related ones like a tooth fracture, so if you see
someone with a crack in the tooth and they have localized periodontal disease, you wouldnt diagnose it
as severe, chronic periodontitis, thats an acquired deformity that would be diagnosed as a root
fracture. So these are kind of obvious things.
Im just going through a few of these. Thats why I say the classification is huge but these ones are more
minor. Mucogingival deformities, thats basically recession, gingival recession. So if a patient has really
good oral hygiene, there is no interproximal bone loss but they are heavy brushers, so you see the wear
along the tooth, the notching along the tooth if youve ever seen that in anybody. So there is loss of
attachment because the gingiva is receded, but thats not considered periodontal disease, thats a
mucogingival deformity. Recession due to dramatic tooth brushing. So you wouldnt diagnose that as
chronic periodontitis even though there is attachment loss. Because really things are healthy. Again.
Abnormal color, lack of keratinized gingiva, these would occur with the recession, not the... Abnormal
color could be due to amalgam tattoo for example.
Okay. Frenum or muscle pull relates to the frenums that can pull on the margin of the tissue and cause
recession. Um, thats about it. So just to... Ill have the ppt up for you so you can review it but those are
the other ones that you want to look for. Periodontal exam, I think youve gone through that with Julie
or Dr. Yip. Are there any questions on the classification. Its pretty straightforward, like I said, 98% are
going to be chronic periodontitis, if there is no attachment loss its gingivitis. But just remember
distribution, severity, name of disease. If you have any questions, feel free to contact me.
Peter.Loomer@nyu.edu. Or my office is on the third floor. Or Im in the clinic on Thursdays. Thank you!