Periodontal Disease Recognition:
A Review course for Dental Hygienists

Ara Aguiar, RDH, MBA

California Continuing Education Credits: 2 units

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Periodontal Disease Recognition
Classifications and Categories of Periodontal Disease
Completion of Periodontal Exam

The American Dental Association (ADA) and the American Academy of Periodontology (AAP) have developed systems for classifying periodontal diseases. Both the ADA and AAP classifications systems will be described in detail and a few examples will be illustrated. Ideally, each patient needs to be identified or categorized into an ADA and AAP periodontal classification.

American Dental Association Classifications

The system developed by the American Dental Association classification system is primarily based on the severity of attachment loss. The clinician uses the clinical and radiographic data gathered and classifies the patient into one of the four Case Types. These Case Types are commonly required for insurance billing. In addition, the ADA provides treatment recommendations for each Case Type which is not part of this tutorial.

Case Type I: Gingivitis
Case Type II: Early Periodontitis
Case Type III: Moderate Periodontitis
Case Type IV: Advanced Periodontitis

American Dental Association: Risk Management Series, Diagnosing and Managing the Periodontal Patient, 1986

Gingivitis

The following clinical findings commonly describe Case Type I.


The following radiographic findings commonly describe Case Type I.

Early Periodontitis

The following clinical findings may be present in Case Type II.

Radiographic findings may include.

Moderate Periodontitis

The following clinical findings may be present in Case Type III. This case illustrates a patient with Moderate Periodontitis.

Radiographic Findings

Advanced Periodontitis

This case illustrates common clinical findings in patients with Advanced Periodontitis, Case Type IV.

Common radiographic findings include:

American Academy of Periodontology


The American Academy of Periodontology classification system was established to identify distinct types of periodontal diseases by taking into consideration factors such as age of onset, clinical appearance, rate of disease progression, pathogenic microbial flora and systemic influences. The two major categories are Gingivitis and Periodontitis. Within each category there are specific types of diseases identified.

Gingivitis Subdivisions are listed below:



American Academy of Periodontology: Current Procedural Terminology for Periodontics and Insurance Reporting Manual, 7th Edition

Plaque-Associated Gingivitis:
This slide illustrates a patient who presents clinical findings representative of Plaque Associated Gingivitis:
Gingival redness, edema, bleeding upon probing, enlargement and tenderness.
Radiographic evaluation shows no signs of bone loss.

Acute Necrotizing Ulcerative Gingivitis
Patients diagnosed with Acute Necrotizing Ulcerative Gingivitis may present with the following clinical findings: Papillary necrosis, bleeding, pain and fetor oris (odor).

Hormone-Induced Gingival Inflammation
Changes in the levels of circulating estrogen and progesterone can cause gingival hyperplasia, this can occur at puberty or during pregnancy. Clinical findings of patients diagnosed with Hormone-Induced Gingival Inflammation may include the following:
Gingival redness, bleeding upon probing, edema and gingival enlargement associated with proliferation of blood vessels.

Drug-Influenced Gingivitis
Patients that take medications such as Dilantin, Cyclosporin or Procardia often present with gingival overgrowth.
This case illustrates a patient who is taking the medication Cyclosporin for treatment of a kidney transplant.
Clinical findings include: Fibrotic gingival response, pseudopockets and bleeding upon probing.

Linear Gingival Erythema (LGE)
Patients that are HIV+ may exhibit this type of gingival response.

Bacterial, Viral or Fungal
Two examples of cases in this gingivitis category include patients with Acute Herpetic Gingivostomatitis or Candida Albicans.

Blood Dyscrasias
Patients with a history of blood disorders, such as Acute Monocytic Leukemia, commonly leads to a compromised or reduction of the host immune response. Clinical Findings often include; spontaneous bleeding upon probing or by simply touching the gingival tissues.

Mucocutaneous Diseases
Examples of gingival diseases in this category include; Lichen Planus, Pemphigus Vulgaris and Desquamative Gingivitis.

Periodontitis Subdivisions are listed below:


American Academy of Periodontology: Current Procedural Terminology for Periodontics and Insurance Reporting Manual, 7th Edition


Adult Periodontitis (Plaque-Associated)

Adult Periodontitis is the most common chronic form of periodontitis. The presence of local factors such as plaque is usually comparable with the disease progression. This slide illustrates a patient with active periodontal disease associated with the presence of plaque and calculus.

Early-Onset Periodontitis

Localized Juvenile Periodontitis
This case illustrates a patient diagnosed with Localized Juvenile Periodontitis. In these patients, local factors are minimal, there is rapid loss of attachment, bilateral symmetry is common, destruction of bone is often localized to first permanent molars, permanent incisors but can be generalized destruction, and mild to moderate inflammatory response.

Prepubertal Periodontitis
A rare periodontal disease, onset is often during or immediately following eruption of the decidous dentition. Clinical findings include generalized severe and rapid destruction of bone. Other medical conditions are usually present.

Rapidly Progressive

This case is a young female diagnosed with Rapidly Progressive Periodontitis. In these type of cases, clinical manifestations of inflammation may be present, local factors are minimal, generalized severe and rapid bone destruction occurs.

Periodontitis Associated with Systemic Diseases
With certain systemic conditions the inflammatory response is altered in the presence of local irritants thereby, accelerating the progression of periodontal disease. The patient in this case has a history of Diabetes.

Necrotizing Ulcerative Periodontitis
Necrotizing Ulcertative Periodontitis can be described similar to Acute Necrotizing Ulcerative Gingivitis. Findings may include erythema, ulceration and necrosis of the gingival margin, with destruction of the supporting bone. The deep interdental osseous craters are distinctive when compared to other types of bony defects found in periodontal diseases.

Refractory
These type of cases normally do not respond to "well-executed" periodontal therapy.

Peri-implantitis
This is a new category established by the AAP. Patients in this category have implants that exhibit a "periodontitis-like-process" similar to natural teeth.

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