[MUSIC] Let's review the classification of periodontal diseases. Generally speaking, periodontal diseases encompass two groups of diseases, the gingival and the periodontal. When the disease is confined to the gums only, it is then known as gingivitis. When the destruction and the inflammation spreads to lower structures, such as the bone, and the periodontal ligament the condition is known then as periodontitis. Let's start discussing gingival diseases first. We have the plaque-induced gingival diseases which are the diseases induced by bacteria and we have non-plaque-induced gingival diseases which are produced by contributing factors. The plaque-induced gingival diseases are gingivitis associated with dental plaque only. Gingival diseases modified by system factors. Gingival diseases modified by medications. And, gingival diseases modified by malnutritions. The local contributing factors are plaque, poorly performed dental work like crowding and otherwise any condition that prevents the patient from exercising good oral hygiene. There's a group of gingival diseases which is influenced by systemic factors. One such example is gingival diseases associated with endocrine system. An example would be puberty gingivitis, hormonally mediated gingivitis, or gingivitis during pregnancy, stimulated by the hormone progesterone. There's also gingivitis associate with blood dyscrasias, such as the various types of leukemias. Gingival diseases can also be modified by medications. We have drug induced gingival enlargements and drug induced gingivitis. There are three classes of drugs that cause such gingival enlargement. The first one is the Dilantin, which is used to control seizures. The second one is the Cyclosporine which is the anti-rejection drugs administered to patients who have organ transplants. The last group of medications are the calcium channel blocking drugs used to control hypertension. They all result in gingival enlargements. We also have the non-plaque induced gingival legions of specific bacterial origin. Gingival diseases specific of viral origin, such as herpetic gingivostomatitis. We could also have gingival diseases of fungal origin. Fungus may grow and cause gingivitis in situations where the patient has been taking antibiotics for a long time, or under appliances such as full or partial dentures. There are also gingival lesions of genetic origin, and an example of such a condition is hereditary idiopathic fibromatosis. Gingival condition could also be a manifestations of systemic conditions such as mucocutaneous disorders, allergic reactions, and other. Gingivitis can also be caused by traumatic lesions such as chemical injury, physical injury, and internal injury as well as by embedding of foreign body reactions. We will now go and start reviewing the various types of periodontal diseases. There are two types of periodontitis. The chronic periodontitis which can be localized to one area of the mouth, or generalized. And we also have a group of very aggressive periodontal disease which also can be localized and generalized. The difference between the chronic and the aggressive condition is that the progression is much more rapid in the aggressive type. And the onset is at much earlier age. This picture demonstrates a typical appearance of generalized chronic periodontitis. The gums are swollen, edematous. The color is bluish-red, and you can see that the teeth start spreading a little bit due to lack of bony support. In the aggressive periodontitis often start in late teenage years and they can affect either selected teeth, such as first molars and anteriors, or they could spread like wildfire and indeed effect the entire dentition. It is not uncommon in patients with aggressive form of periodontitis to have a very significant bone loss in their early adulthood. Periodontitis can also be a manifestation of systemic diseases. They can be associated with hematological disorders, such as leukemia. They can be associated with genetic disorders, such as idiopathic fibromitosis and other non-specified conditions. There is a whole host of diseases known as Necrotizing Periodontal Diseases. Those diseases are caused by actual infiltration of the gums Into the gingival tissues. The first areas affected, are actually the inter-dental pappili. The interesting thing about these conditions, is that they have been strongly correlated with stress and poor oral hygiene. In fact, the earlier term for this conditions were trench disease, trench mouth, because it was associated with soldiers in first World War I, who were fighting in the trenches and of course were subjected to a tremendous amount of stress. The necrotizing ulcerative gingivitis causes cratering in the gingival papilla and permanent scarring which then has to be corrected surgically. In this photograph, you can see the cratering of the gingiva which has destroyed the normal gingiva architecture, causing exposure of the root and increased interproximal spaces. During periodontal inflammation, there is increased secretion of gingival fluid, which becomes very similar to pus and is sometimes referred to as purulent exudate. Because this purulent exudate can be secreted freely from the gingival pockets, the patient usually does not feel any pain and therefore does not seek treatment for periodontitis in a timely manner. Once in a while, due to misplaced calculus or food, the orifice of a pocket becomes clogged and the purulent exudate has no place to escape. When this happens an abscess may form. Abscess, therefore, is a localized area of intense inflammation which results in swelling and possible fever and intense pain. Those abscesses can be confined to the gingiva only or they can spread to deeper structures and are then known as periodontal abscesses. Abscess which is not treated can destroy the entire bony support within a very short time resulting in the loss of the tooth. It can also lead to potentially dangerous and fatal conditions such as cellulitis, which can then result in patients' deaths. In this picture you can see an example of both a gingival and a periodontal abscess. The first way to treat this abscess is, of course, to establish a drainage and then perhaps use antibiotic treatment, and once the acute phase subsides then a treatment to eliminate the causes needs to be taken. Periodontitis can also be associated with palpal lesions. So if there is infection of a palp that destroys and infects the nerves, that infection can then spread to the adjacent areas. And escape through the periodontal ligament. When this happens, we have a combined endodontal-periodontal lesion, or periodontal and odontic lesion. In this slide, we demonstrate the escape route of the toxins and inflammatory fluid from the apex of the root through the periodontal ligament, resulting inflammation of a gingival pocket. There are some localized tooth related factors which modified or predisposed the patient to plaque induced diseases. This could be poor quality dental work, such as overhang fillings which prevent the patient from exercising good plaque control. It could also be a restoration which is overly bulky and does not permit the patient to either brush or floss effectively for plaque removal. Periodontal diseases also encompass bunch of conditions known as mucogingival conditions. These are deformities or diseases that affect soft tissue only, namely the keratinized gingiva and the uvular mucosa. The most common condition is the gingival recession, which could be due to inappropriate toothbrushing or due to other traumatic factors. It could also be through a frenal pull which attaches the muscles and is overly strong. Both of these conditions can be corrected surgically.
