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Introduction Meisam Amiri S.Vahid Dehnad Hadi Kaseb Hamid Noor Mohammadi Javid Rasekhi Hasan Tadbiri Ali Tavakol Group 1 Assistant Professor: Dr.Azimi.

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Presentation on theme: "Introduction Meisam Amiri S.Vahid Dehnad Hadi Kaseb Hamid Noor Mohammadi Javid Rasekhi Hasan Tadbiri Ali Tavakol Group 1 Assistant Professor: Dr.Azimi."— Presentation transcript:

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2 Introduction Meisam Amiri S.Vahid Dehnad Hadi Kaseb Hamid Noor Mohammadi Javid Rasekhi Hasan Tadbiri Ali Tavakol Group 1 Assistant Professor: Dr.Azimi DDS

3 Gingivitis & Periodontitis

4 Gingivitis

5 Gingivitis Gingivitis is inflamatory changes of gingiva by Microbial products.

6 Stages of gingivitis: Initial lesion Early lesion Established lesion Advanced lesion

7 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

8 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

9 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

10 Advanced lesion Extension of lesion to the alveolar bone Periodontal destruction phase

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12 Generalized Marginal Gingivitis

13 Marginal supragingival plaque and gingivitis

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15 Gingivitis: clinical features. Localized, diffuse, intensely red area facial of tooth and dark pink marginal changes in the remaining anterior teeth

16 Localized diffuse gingivitis

17 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

18 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

19 Differential Diagnosis Chronic bacterial fungal and viral infections Reactions to medications mouth washes and chewing gum Crohns disease Sarcoidosis Some leukemia

20 Chronic desquamative gingivitis

21 Necrotizing Ulcerative Gingivitis (NUG) Acute disease Sudden occurrence

22 1. P unched out and crater like papillae 2. G rey pseudomemberanous slough with a linear erythema 3. S pontaneous gingival hemorrhage or pronounced bleeding on the slightest stimulation 4. S ialorrhea 5. C an occure in disease free-mouthes or can be superimposed on chronic gingivitis or periodontal pockets 6. c onstant radiating, gnawing pain 7. I ntensified pain by eating spicing or hot food or chewing 8. M etallic foul taste 9. P asty saliva Clinical manifestations:

23 Systemic Manifestation ( in mild to moderate disease) Minimum of systemic complication Local lymphadenopathy and slight elevation in temperature

24 Systemic Manifestation ( in Severe disease) High fever Increased heart rate Leukocytosis Loss of appetite General lassitude

25 Diagnosis Based on: 1. G ingival pain 2. U lceration and bleeding

26 Differential Diagnosis Acute Herpetic Gingivostomatitis Chronic periodontitis Desquamative gingivitis Streptococcal gingivostomatitis Aphthous Stomatitis Gonococcal gingivostomatitis Candidiasis Agranulocytosis Dermatoses ( pemphigus, erythema multiform and lichen planus)

27 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

28 Acute necrotizing ulcerative gingivitis

29 Acute necrotizing ulcerative gingivitis

30 Acute necrotizing ulcerative gingivitis: typical punched-out interdental papilla between the mandibular canine and lateral incisor

31 Acute necrotizing ulcerative gingivitis: typical lesions with progressive tissue destruction Acute necrotizing ulcerative gingivitis: typical lesions with progressive tissue destruction

32 Acute necrotizing ulcerative gingivitis: typical lesions with spontaneous hemorrhage

33 Acute necrotizing ulcerative gingivitis: typical lesions have produced irregular gingival contour

34 Periodontitis

35 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

36 Sign and Symptoms Formation of periodontal pocket Gingival Recession Bone resorption Tooth mobility Pus Taste of metal Halitosis Itchiness Abscess Tooth Migration Pain

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42 Types of Periodontitis 1. C hronic 2. A ggressive

43 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

44 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

45 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 )

46 Stages of Chronic Periodontitis PocketMobility Bone loss Early 3-5 mm None 1-30 % Moderate 5-7 mm 1-2 mm % Advanced >7 mm >2 mm >50 %

47 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

48 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

49 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

50 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

51 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

52 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

53 Note Some patients may have systemic manifestations such as weight loss, mental depression, and general malaise

54 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

55 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)

56 Diagnosis is based on: 1. A ge of onset 2. R apid rate of disease progression 3. N ature and composition of hosts immune response 4. F amilial aggregation of diseased individuals

57 Radiograph showing moderate semilunar bone defect on mesial of first molar in a patient with localized juvenile periodontitis

58 Rapidly progressive adult periodontitis in a 28-year-old female, clinical view

59 Maxillary radiograph showing generalized severe Periodontitis

60 Necrotizing Ulcerative Periodontitis Extension of NUG into the periodontal structures leading to attachment and bone loss

61 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

62 Systemic Manifestation High fever Malaise Lymphadenopathy

63 Risk Factors Stress Heavy smoking Poor nutrition

64 Types of NUP Non AIDS type NUP AIDS associated NUP

65 Non AIDS Type NUP Occurring after repeated long term episodes of NUG Other notes has been described before

66 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

67 Necrotizing ulcerative periodontitis in a 45-year-old white male, HIV-negative

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69 Necrotizing ulcerative periodontitis (NUP) in a 28-year-old woman with a CD4 count of 48. NUP of mandibular anterior region

70 Necrotizing ulcerative periodontitis (NUP) in a 28-year-old woman with a CD4 count of 48. Necrotizing stomatitis in mandibular left molar area

71 Necrotizing ulcerative periodontitis (NUP) in a 28-year-old woman with a CD4 count of 48. Radiograph of sequestra in mandibular left molar area

72 Necrotizing ulcerative periodontitis (NUP) in a 28-year-old woman with a CD4 count of 48. Sequestrae removed in conjunction with extraction of teeth

73 Necrotizing ulcerative periodontitis (NUP) in a 28-year-old woman with a CD4 count of 48. Mandibular anterior area one week post-treatment

74 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

75 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

76 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

77 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.

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