1. In the Name of God
the Most Merciful,
the Most Beneficient

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

12. Generalized Marginal Gingivitis

13. Marginal supragingival plaque and gingivitis

14. Marginal supragingival plaque and gingivitis

15. Gingivitis: clinical features
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
Crohn’s disease
Sarcoidosis
Some leukemia

20. Chronic desquamative gingivitis

21. Necrotizing Ulcerative Gingivitis (NUG)
Acute disease
Sudden occurrence

22. Clinical manifestations:
Punched out and crater like papillae
Grey pseudomemberanous slough with a linear erythema
Spontaneous gingival hemorrhage or pronounced bleeding on the slightest stimulation
Sialorrhea
Can occure in disease free-mouthes or can be superimposed on chronic gingivitis or periodontal pockets
constant radiating, gnawing pain
Intensified pain by eating spicing or hot food or chewing
Metallic foul taste
Pasty saliva

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:
Gingival pain
Ulceration 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

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

42. Types of Periodontitis
Chronic
Aggressive

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
Pocket
Mobility
Bone loss
Early
3-5 mm
None
1-30 %
Moderate
5-7 mm
1-2 mm
30-50 %
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:
Age of onset
Rapid rate of disease progression
Nature and composition of hosts immune response
Familial 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

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

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.

78. The End