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Healthy periodontium Gingivitis Periodontitis

● Absence or up to two sites of clinically detectable ● Inflammation ● Loss of periodontal support due to
inflammation ● Erythema, edema, bleeding on probing microbial-associated, host-mediated
● Minimal or no bleeding on probing ● Normal (≤3 mm) probing depths inflammation
● Normal (≤3 mm) probing depths ● Stable periodontium with no current ● Deeper (≥4 mm) probing depths
● Can be on an intact (no attachment or bone loss) or progressive attachment or bone loss ● Presence of interproximal attachment
reduced (previous attachment or bone loss) periodontium loss from current disease state; not
including attachment loss from a history of
disease in currently stable patients

Periodontal Staging

Stage Stage I Stage II Stage III Stage IV

Greatest interdental 1-2 mm 3-4 mm ≥5 mm

clinical attachment loss

Percent bone loss ≤15% 15%-33% ≥33%

Severity
Teeth lost to periodontitis No tooth loss ≤4 teeth ≥5 teeth

Max. probing depth ≤4 Probing depths ≤5 mm Probing depths ≥6 mm In addition to Stage III:
mm Mostly horizontal bone Vertical bone loss ≥3 mm Need for rehabilitation
Complexity Mostly horizontal bone loss Furcation involvement Masticatory dysfunction
loss Class II or III Tooth mobility ≥ Class II
<20 remaining teeth

● Localized (<30% of teeth involved)

Extent ● Generalized (>30% of teeth involved)
● Molar/incisor pattern

Periodontal Grading

Grade Grade A: Slow rate Grade B: Moderate Grade C: Rapid rate

rate

Radiographic bone No loss over 5 years <2 mm over 5 years ≥2 mm over 5 years
Direct evidence
loss or CAL

Primary criteria Percent bone loss/age <0.25 0.25 to 1.0 >1.0

Indirect evidence Case phenotype Heavy deposits with Destruction Destruction

little destruction correlates disproportionate to
with deposits deposits

Smoking Non-smoker <10 cigarettes/day ≥10 cigarettes/day

Grade modifiers Risk factors
Diabetes No diabetes diagnosis HbA1c <7.0% in HbA1c ≥7% in
diabetic patient diabetic patient
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Peri-implant Diseases and Conditions

Healthy Peri-implant Periodontium Peri-implant Mucositis Peri-implantitis

● No visual signs of inflammation or bleeding on probing ● Signs of inflammation and bleeding on ● Signs of inflammation, bleeding on
● Health around implants with normal or reduced bone probing probing, and progressive bone loss
support ● Absence of progressive bone loss ● Increased probing depths compared to
● Isolated timepoint probing depths are not used since baseline
normal probing depths are not defined for implants

Tooth Mobility: Miller Classification

Class I Class II Class III

Mobility greater than physiologic Buccolingual mobility <1 mm Buccolingual mobility >1 mm or tooth depressable

Furcation Involvement

Hamp Classification

Class I Class II Class III

Horizontal furcation involvement <3 mm Horizontal furcation involvement >3 mm Through-and-through furcation involvement

Glickman Classification

Class I Class II Class III Class IV

Pocket formation into flute Pocket formation into furca Through-and-through furcation Through-and-through furcation
involvement involvement, can visualize
clinically

Recession: Miller Classification

Class I Class II Class III Class IV

● Recession does not extend to ● Recession extends to or beyond ● Recession extends to or ● Recession extends to or
mucogingival junction (MGJ) MGJ beyond MGJ beyond MGJ
● No loss of interdental bone or soft tissue ● No loss of interdental bone or soft ● Mild/moderate interproximal ● Severe interdental bone or
● 100% root coverage expected after tissue bone or soft tissue loss present soft tissue loss
connective tissue graft ● 100% root coverage expected ● Partial root coverage expected ● No root coverage expected
after connective tissue graft after connective tissue graft after connective tissue graft
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Bone Loss

Horizontal Vertical

● Bone loss is perpendicular to the long axis of the tooth along the whole alveolar crest ● Angular/oblique orientation of bone loss

Infrabony Defects

1 Wall 2 Wall 3 Wall 4 Wall

Hemiseptal defect Crater defect Trough defect Circumferential defect

Most common type of defect Most predictable regeneration

Example: extraction socket

Bacteria Involved in Periodontal Disease

Red Complex Orange Complex

P. gingivalis Associated with chronic periodontitis P. intermedia Associated with pregnancy gingivitis

T. denticola Associated with acute necrotizing F. nucleatum Bridging microorganism that binds
ulcerative periodontitis (ANUG) early and late colonizers

T. forsythia C. rectus

● A. actinomycetemcomitans - associated with aggressive periodontitis

● Pseudomonas sp. - associated with failing implants
●
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Treatment Planning for Periodontal Disease

Phase Treatment Goals

0. Preliminary Phase ● Emergency treatment

● Extraction of all hopeless teeth

1. Non-surgical Phase ● Plaque control, scaling and root planing, correction of local factors
● Patient education
● Local and systemic antibiotics
● Re-evaluation 4-8 weeks after initial therapy

2. Surgical Phase ● Reduce/eliminate pockets and correction of defects to soft or hard tissue
● If necessary, endodontics and/or implant placement

3. Restorative Phase ● Any definitive restorative or prosthodontic treatment

4. Maintenance Phase ● Periodic ongoing re-evaluation every 3 months for the first year
● Periodontal maintenance for life

Prognosis of Periodontally Involved Teeth

Bone Level Clinical Factors Local Factors

Excellent No bone loss None Gingival health

Good Adequate alveolar support None Potential to maintain

Fair Inadequate alveolar support Mobility and class I furcation Potential to maintain

Poor Moderate bone loss Mobility and class I or II furcation Difficult areas to maintain

Questionable Advanced bone loss Mobility and class II or III furcation Inaccessible areas

Hopeless Advanced bone loss Extraction indicated Unable to maintain