Different Types of Periodontal Diseases: The Classifications

Intorduction

A chronic multifactorial inflammatory illness known as periodontitis, which is distinguished by dysbiotic plaque biofilms and the gradual degeneration of the tooth-supporting framework, is characterized by inflammation. Inflammation that causes the periodontal attachment to disappear is the defining feature of periodontitis.

What Is the Need for Classifying Periodontal Disease Lesions?

Periodontal disease is a multifaceted disease that affects the periodontium also known as the supporting structures of the tooth. The disease is characterized by loss of attached gingiva and alveolar bone. The natural consequences of periodontal diseases when left untreated are definitely tooth mobility and eventual bone loss. However periodontal diseases are a group of disease that involves a wide spectrum of causative factors.

The clinical diagnosis of periodontal disease by the dentist always is indicative of the fact that the individual also has compromised systemic (affecting the entire body) health. The link between periodontal health and general systemic health is well established by research and clinical case evidence through the years. The following pathophysiological changes are seen in periodontal disease:

• Normal gingival contour.

• The presence of bleeding on probing.

• The presence of deep periodontal pockets (clinical attachment loss / CAL).

• The eventual reduction or loss of microbial changes in the gingival crevicular fluid (GCF) (fluid present in the crevices of gum and tooth junction).

• Loss of attached gingiva.

All this is indicative clinically of periodontal disease on dental examination.

Dentists and dental researchers, clinicians over several decades have aimed to classify the disease progress and the types of periodontal disease based on their features and causative factors. This also allows the dentist an easier way to diagnose based on age, gender, prevalence, etiology, detrimental risk factors, and systemic health status of the individual. The commonly accepted system of periodontal disease classification is given by the AAP (American Academy of Periodontology) in 1986. However, there were further amendments in 1999 when periodontal clinical concerns are also taken into consideration that is to be addressed by dentists and the revision of this classification was by the introduction of the gingival diseases category (that eventually progresses and is a major local cause in the oral cavity for Periodontal disease).

What Are the Classification and Types of Periodontal Disease?

The 1999 revision of the classification of periodontal disease by the AAP was proposed at the international workshop for the classification of periodontal diseases and conditions. The classification is based on the following causative factors of periodontal disease:

1. Gingival Conditions: The conditions involving the gingiva would be either plaque or non plaque-induced gingival diseases.

Plaque-induced diseases are caused commonly by:

• Systemic disease factors.

• Malnutrition.

• Drug-induced or systemic or local medications.

Non-plaque induced factors for gingival diseases may be caused by:

Specific infections impacting the oral cavity and especially the gingival health like

• Bacterial.

• Fungal.

• Viral infections.

• Dermatologic conditions.

• Allergic reactions or trauma to the gingiva or the periodontium.

2. Chronic or Adult Periodontitis: It is the most common form of periodontitis seen in both adolescents and adults. This is not an age-dependent periodontal disease and is characterized by subgingival calculus, bleeding on probing, and localized destruction of the gingival and periodontal tissue (that depends on systemic, drug, and local factors of the individual). As the disease progresses with age or severity, there would be eventual clinical attachment loss, mobility, and migration of teeth that are either individualized or segmental. The bone loss would be either horizontal or vertical.

3. Aggressive Periodontitis: This is a rapidly progressing periodontal disease condition only limited to young patients under the age of 30. Patients may have a localized and specific pattern of periodontal disease pattern called juvenile pubertal onset periodontitis which becomes more generalized with time and aging. This also has a familial link (familial aggregation patterns) with rapid clinical attachment loss of the periodontium, microbial deposits, and hyperresponsive macrophage phenotypes alongside interproximal attachment loss of the teeth, most commonly the incisors and the first molars.

4. Periodontitis as Systemic Disease Manifestation: Periodontal diseases as a result of systemic disease would be manifested in these enlisted conditions commonly:

• Hematologic disorders.

• Downs syndrome.

• Histiocytosis.

• Papillon lefevre syndrome.

• Leukocyte adhesion deficiency syndrome.

• Chediak higashi syndrome.

• Hypophosphatasia.

• Diabetes.

• HIV infections.

5. Necrotising Periodontal Disease: This is a distinguishable disease entity in periodontal disease that is well characterized specifically by little to no loss of clinical attachment level alongside the destruction of the papillary soft tissues. This has a recurrent onset pattern with aggressive soft tissue destruction and appears as marked edematous lesions, punched-out crater-like lesions, and ulcerations on the gingiva with an obvious bleeding tendency. HIV infections or other systemic diseases are also known as predisposing factors for such conditions.

6. Periodontal Abscess: This is a separately added category according to the 1999 AAP classification because of the clinical importance of these lesions. They present as acute exacerbations of pre-existing periodontal pockets and would occur due to various local reasons impacting the periodontium like trauma, foreign body reaction or impaction, root fractures (horizontal or vertical), cemental tears, or occlusal tooth trauma.

7.Periodontal Conditions Due to Developmental Deformities or Anomalies: This is a common cause of periodontal disease in predisposed individuals because of local deformities present in the gingiva or the periodontium for example mucogingival issues that are persistent from childhood or excess gingival display due to severe gingival recession or ridge-based deformities.

8. Perio- Endo Lesions: These are combined lesions wherein an endodontic lesion (because of involvement of the dental pulp pathology) may drain through a pre-existent periodontal pocket making the disease process two-way.

What Are the Recent Amendments to the Classification of Periodontal Disease?

In the year 2017 American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) co-presented the classification where they made certain changes. They proposed a classification framework with comprehensive treatment planning that allows a personalized approach to periodontal disease management. Highlights from the updated classification include a recategorization of various forms of periodontitis and the introduction of classification for peri-implant diseases and conditions. The classification was divided as follows:

1. Periodontal Health Gingival Disease and Conditions:

• Periodontal health and gingival health.

• Gingivitis: Dental biofilm induced.

• Gingival Disease: Non-dental biofilm induced.

2. Periodontitis:

• Necrotizing periodontal disease.

• Periodontitis.

• Periodontitis as a manifestation of systematic disease.

3. Other Conditions Affecting the Periodontium:

• Systemic diseases or conditions affecting the periodontal supporting tissues.

• Periodontal abscesses and endodontic-periodontal lesions.

• Mucogingival deformities and conditions.

• Traumatic occlusion forces.

• Tooth and prosthesis related factors.

4. Peri-Implant Disease and Conditions:

• Peri-implant health.

• Peri-implant mucositis.

• Peri-Implant implantitis.

• Peri-implant soft and hard tissue deficiencies.

Conclusion:

The diagnosis of the wide range of periodontal diseases would require an in-depth clinical examination by the dentist, and as periodontal health is also a known indicator of an individual's systemic health status. It is essential to understand and be aware of the importance of oral health, hygiene, and regular dental checkups. The diagnosis would be made by the dentist through several modalities like clinical features, radiographic examination, and in periodontitis clinical attachment loss, bone loss, tooth mobility, subgingival deposits, furcation involvement, gingival changes, tooth migration, and oral discomfort. All the signs and symptoms should be evaluated based on the patient's dental, medical and family history. Timely management of these groups of periodontal diseases by the dentist would be beneficial to oro-systemic health.