Methods of examination parodontal patients. Auxiliary and special.
The American Dental Association (ADA) and the
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
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.
- No attachment loss
- Bleeding may or may not be present
- Pseudopockets may be present
- Only the gingival tissues have been affected by the inflammatory process.
The following radiographic findings commonly describe Case Type I.
- No radiographic evidence of bone loss
- The crestal lamina dura is present
- The alveolar bone level is within 1 to
2 mm of the CEJ area
Early Periodontitis
The following clinical findings may be present in Case Type II.
- Bleeding upon probing may be present in the active phase
- Pocket depths or attachment loss of 3 to
4 mm - Localized areas of recession
- Possible Class I furcation invasion areas
Radiographic findings may include.
- Horizontal type of bone loss is most common
- Slight loss of the interdental septum
- Alveolar bone level is 3 to
4 mm from the CEJ area
Moderate Periodontitis
The following clinical findings may be present in Case Type III. This case illustrates a patient with Moderate Periodontitis.
- Pocket depths or attachment loss of 4 to
6 mm - Bleeding upon probing
- Grade I and/or Grade II furcation invasion areas
- Tooth Mobility of Class I
Radiographic Findings
- Horizontal or Vertical bone loss may be present
- Alveolar bone level is 4 to
6 mm from the CEJ area - Radiographic furcations of Grade I and/or Grade II
- Crown to root ratio is 1:1 (loss of 1/3 of supporting alveolar bone)
Advanced Periodontitis
This case illustrates common clinical findings in patients with Advanced Periodontitis, Case Type IV.
- Bleeding upon probing
- Pocket depths or attachment loss over
6 mm - Grade II, Grade III
- Mobility of Class II or Class III
Common radiographic findings include:
- Horizontal and vertical bone loss
- Alveolar bone level is
6 mm or more from the CEJ area - Radiographic furcations
- Crown to root ratio is 2:1 or more (loss of over 1/3 of the supporting alveolar bone)
The
Gingivitis Subdivisions are listed below:
- Plaque-Associated Gingivitis (illustrated)
- Chronic Gingivitis
- Acute Necrotizing Ulcerative Gingivitis
- Gingivitis Associated with Systemic Conditions or Medications
- Hormone-Induced Gingival Inflammation
- Drug-Influenced Gingivitis (illustrated)
- Linear Gingival Erythema (LGE)
- Gingival Manifestations of Systemic Diseases and Mucocutaneous Lesions
- Bacterial, Viral or Fungal
- Blood Dyscrasias (for example Acute Monocytic Leukemia)
- Mucocutaneous Diseases (Lichen Planus, Cicatricial Pemphigoid)
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:
- Adult Periodontitis – Plaque-Associated (illustrated)
- Early-Onset Periodontitis
- Prepubertal
- Juvenile Periodontitis
- Rapidly Progressive (illustrated)
- Periodontitis Associated with Systemic Diseases (illustrated)
- Necrotizing Ulcerative Periodontitis
- Refractory
- Peri-implantitis
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.
