Deep pockets may remain stable and uninflamed, especially in cases where patients receive long term careful supportive periodontal care and are referred to as “healthy pockets”. RECENTLY, a committee representing both the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) met in November 2017 with the charge of updating the 1999 classification of periodontal disease and conditions. Differential diagnosis is based on the history and the specific signs and symptoms of necrotizing periodontitis and the presence or absence of an uncommon systemic disease that definitively modify the host immune response.6,24,27, Evidence supports necrotizing periodontitis as a separate disease entity based on (1) distinct pathophysiology characterized by prominent bacterial invasion and ulceration of epithelium; (2) rapid and full thickness destruction of the marginal soft tissue resulting in characteristic soft and hard tissue defects; (3) obvious symptoms; and (4) faster resolution in response to specific antimicrobial treatment.27 This painful and infectious condition should be diagnosed primarily basedon its typical clinical features, which includes necrosis and ulceration in the interdental papilla, gingival bleeding, pseudomembrane formation, and halitosis.18,24 In severe cases, bone sequestrum also may occur.58 Pain and halitosis are observed less often among children, while systemic conditions such as fever, adenopathy, and sialorrhea (hypersalivation) are observed more frequently.18,59 Necrotizing periodontal diseases are strongly associated with impairment of the host immune system. Other conditions affecting the periodontiumPeridontal abscesses and endodontic-periodontal lesionsBoth periodontal abscesses (PA) and endodontic-periodontal lesions (EPL) share similar characteristics that differentiate them from other periodontal conditions. These levels are: (1) pristine periodontal health, characterized by total absence of clinical inflammation, and physiological immune surveillance on a periodontium with normal support; (2) clinical periodontal health, characterized by an absence or minimal levels of clinical inflammation in a periodontium with normal support; (3) periodontal disease stability, characterized as a state in which the periodontitis has been successfully treated and clinical signs of the disease do not appear to worsen in extent or severity despite the presence of a reduced periodontium; and (4) periodontal disease remission/control, characterized as a period in the course of disease when symptoms become less severe but may not be fully resolved with a reduced periodontium (Table 2  see PDF).6,21 It should be noted that “pristine periodontal health” characterized by no attachment loss, no bleeding on probing (BoP), no sulcular probing >3 millimeters (mm) in the permanent dentition and no redness, clinical swelling/edema or pusis a rare entity, especially among adults.21 Therefore, minimal levels of clinical inflammation observed in “clinical periodontal health” is compatible with a patient classified as periodontally healthy. The definitions of mild, moderate, and severe gingivitis continue to be a matter of professional opinion. ICD: International Statistical Classification of Diseases and Related Health Problems. Accessed November 28, 2018. 66, No. The new classification was agreed at the joint meeting of the American Association of Periodontology and European Federation of Periodontology at the World Workshop in Periodontology, held in Chicago during November 2017. Pediatric Dentistry-Infancy through Adolescence, 6th ed. Eur J Dent 2007;1(2):111-4.47. J Am Dent Assoc 1982;104(5):653-60.42. J Periodontol 2018;89(Suppl 1):S223-S236.14. Other signs and symptoms may include radiographic evidence of bone loss in the apical or furcation region, spontaneous pain or pain on palpation and percussion, purulent exudate or suppuration, tooth mobility, sinus tract/fistula, and crown and/or gingival color alterations.18,24 Signs observed in EPL associated with traumatic and/or iatrogenic factors may include root perforation, fracture/cracking, or external root resorption, commonly associated with the presence of an abscess accompanied by pain. Periimplant health, peri-implant mucositis, and periimplantitis: Case definitions and diagnostic considerations. PPD or probing attachment levels alone should not be used as evidence of gingival health or disease; rather, they should be considered in conjunction with other important clinical parameters such as BoP, as well as modifying and predisposing factors. Accessed June 22, 2018. Available at: “ staging”. Berglundh T, Armitage G, Araujo MG, et al. The system developed by the American Dental Association classification. Drug-influenced gingival enlargements occur as a side effect in patients treated with anticonvulsant drugs (e.g., phenytoin, sodium valproate), certain calcium channel–blocking drugs (e.g., nifedipine, verapamil, diltiazem, amlodipine, felodipine), immune-regulating drugs (e.g., cyclosporine), and high-dose oral contraceptives.11,57 For drug-influenced gingival conditions to occur, the presence of plaque bacteria is needed. J Periodontol 2017;88(3):273-80.56. Accessed November 28, 2018. 1. J Clin Diagn Res 2016;10(10):ZC143-ZC146.50. 5. In: Nowak, AJ, Christensen JR, Mabry TR,Townsend JA, Wells MH, eds. The current classification of non-dental plaque-induced gingival conditions is based on the etiology of the lesions. The objective of the workshop was to update the previous disease classification established at the 1999 International Workshop for Classification of Periodontal Diseases and Conditions.5 One of the major highlights included the recategorization of three forms of periodontitis, the development of a multidimensional staging and grading system for periodontitis, and the new classification for peri-implant diseases and conditions.6, The intent of this best practices document is to present an abbreviated overview of the new classification of periodontal and peri-implant diseases and conditions, including gingivitis. 6. Tobacco use by adolescents: The role of the oral health professional in evidence-based cessation program. The proceedings were published in the Journal of Clinical Periodontology … Monitoring gingival health or inflammation is best documented by the parameter of BoP since it is considered the primary parameter to set thresholds for gingivitis and the most reliable for monitoring patients longitudinally in clinical practice.6,21 Clinicians are encouraged to start probing regularly when the first permanent molars are fully erupted and the child is able to cooperate for this procedure in order to establish a baseline, detect early signs of periodontal disease, and prevent its progression. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. MMWR Morb Mortal Wkly Rep 2017;66(23):597-736. Oral contraceptives and the periodontium. Peri-implantitis is preceded by peri-implant mucositis.6,25. The American Dental Hygienists’ Association (ADHA) congratulates the American Academy of Periodontology (AAP) on the release of the proceedings from the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions and the new periodontal disease and peri-implant disease classification system. In 1989, a classification system was proposed that included five types of periodontitis: adult periodontitis, early onset periodontitis, periodontitis associated with systemic disease, necrotizing ulcerative periodontitis, and refractory periodontitis. This paper was developed under the direction of the Task Force to Update the Classification of Periodontal Diseases and Conditions and approved by the Board of Trustees of the American Academy of Periodontology in April 2015. Hyposalivation interferes with plaque removal, thereby increasing the risk of caries, halitosis, and gingival inflammation among other oral conditions. The 2020 American Academy of Periodontology Virtual Annual Meeting will be held Nov. 6-15, 2020. Dental plaque biofilm-induced gingivitisDuring the 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions, revisions of the 1999 classification system5 for dental plaque-induced gingival diseases included four components: (1) description of the extent and severity of the gingival inflammation; (2) description of the extent and severity of gingival enlargements; (3) a reduction in gingival disease taxonomy; and (4) discussion of whether mild localized gingivitis should be considered a disease or variant of health.22 These four components are addressed in this review. However, there is evidence to suggest that removable dental prostheses can serve as plaque retentive factors and be associated with gingivitis/periodontitis, increased mobility and gingival recession in patients with poor compliance.20 Moreover, there is evidence to suggest that design, fabrication, delivery, and materials used for fixed dental prostheses procedures can be associated with plaque retention, gingival recession, and loss of supporting periodontal tissues.13,20, Lastly, it is important to point out that dental materials, including commonly used appliances (e.g., stainless steel crowns, space maintainers, orthodontic appliances) may be associated with hypersensitivity reactions observed clinically as localized inflammation. Katuri KK, Alluri JK, Chintagunta C, et al. nutrition. Sex steroid hormones and cell dynamics in the periodontium. Assessment of periodontal health status in smokers and smokeless tobacco users: A cross-sectional study. In the absence of baseline radiographs, radiographic bone level ≥3 mm in combination with BoP and probing depths ≥6 mm is indicative of peri-implantitis. The clinician uses the clinical and radiographic data gathered and classifies the patient into one of the four Case Types. Conversely, patients with thin periodontal phenotypes, with inadequate oral hygiene, and requiring cervical restorative and/or orthodontic treatment are at an increased risk for gingival recession.12,20 Monitoring specific gingival recession sites is considered a proper approach in the absence of any pathosis. Med Princ Pract 2011;20(4):374-6.59. Mariotti A, Mawhinney MG. Endocrinology of sex steroid hormones and cell dynamics in the periodontium. classification system for periodontal diseases For a comprehensive review on this topic, the reader is encouraged to review the position paper on non-dental plaque-induced gingival diseases by Holmstrup et al.19 and the workshop consensus report by Chapple et al.11. Classification of periodontal diseasesThe new classification of periodontal disease proposed in the 2017 workshop defines three distinct forms: (1) periodontitis (single category grouping the two forms of the disease formerly recognized as aggressive or chronic); (2) necrotizing periodontitis; and (3) periodontitis as a manifestation of systemic conditions. CHICAGO — Dentists treating patients with chronic periodontitis, a severe form of gum disease that can lead to tooth loss, are advised to use scaling and root planing (SRP), deep cleaning of the teeth, as initial treatment, according to new guidelines from the American Dental Association (ADA). WHO: World Health Organization. Needleman I, Garcia R, Gkranias N, et al. In addition, the ADA provides treatment recommendations for each Case Type which is not part of this presentation. Available at: “”. J Periodontol 2018;89(Suppl 1):S28-S45.20. Nevertheless, clinicians must understand their crucial role in ongoing management of gingivitis for their patients of all ages with and/or without a history of periodontal disease. However, it appears that adequate periodontal assessment and treatment, appropriate instructions, and motivation in self-performed plaque control and compliance to periodic maintenance protocols are the most important factors to limit or avoid the potential negative effects on the periodontium caused by fixed and removable prostheses whenhypersensitivity reactions are not suspected.13. Helv Odontol Acta 1981;25(1):25-42.38. FDA: Food and Drug Administration. J Periodontol 2003;74(11):1696-704.5. Dental plaque–induced gingival conditions. With regards to orthodontic forces, observational studies suggest that orthodontic treatment has minimal adverse effects to the periodontal supporting apparatus, especially in patients with good plaque control and healthy periodontium.14,20 However, non-controlled orthodontic forces can have adverse effects such as pulpal disorders as well as root and alveolar bone resorptions. Diabetologia 2012;55(1):21-31.45. Jepsen S, Caton JG, Albandar JM, et al. Novotna M, Podzimek S, Broukal Z, Lencova E, Duskova J. Periodontal diseases and dental caries in children with type 1 diabetes mellitus. Periodontal health. Fine DH, Patil AG, Loos BG. Tobacco addiction: Diagnosis and treatment. This paper was developed under the direction of the Task Force to Update the Classification of Periodontal Diseases and Conditions and approved by the Board of Trustees of the American Academy of Periodontology in April 2015. For a more comprehensive review of classifications, case definitions and diagnostic considerations, the reader is encouraged to read the positional paper and consensus report by Albandar et al.7 and Jepsen et al.,20 respectively. These disorders or conditions are grouped as periodontitis as a manifestation of systemic disease, and classification should be based on and follow the classification of the primary systemic disease according to the respective ICD codes.6 Moreover, they can be grouped into broad categories such as genetic disorders that affect the host immune response (e.g., Down syndrome, Papillon-Lefèvre,histiocytosis) or affect the connective tissues (e.g., Ehlers-Danlos syndrome, systemic lupus erythematosus); metabolic and endocrine disorders (e.g., hypophosphatasia, hypophosphatemic rickets); inflammatory conditions (e.g., epidermolysis bullosa acquisita, inflammatory bowel disease); as well as other systemic disorders (e.g., obesity, emotional stress and depression, diabetes mellitus, Langerhans cell histiocytosis, neoplasms). This document presents an abbreviated overview of the new classification of periodontal and peri-implant diseases and conditions.6-28 In addition to reviewing the proceeding papers from the 2017 World Workshop, an electronic search was conducted using PubMed®/MEDLINE using the terms: periodontal health AND children, periodontal health AND adolescents, gingival disease AND children, gingival disease AND adolescents, periodontal disease AND children, periodontal disease AND adolescents, gingivitis AND prevalence, periodontitis AND prevalence, gingival disease AND prevalence, periodontal disease AND prevalence, dental plaque AND children, dental plaque AND adolescents; fields: all; limits: within the last 10 years, humans, English, and clinical trials. The American Academy of Periodontology classification system was established to identify distinct types of periodontal diseases by taking into consideration factors such as age of onset, clinical appearance, rate of disease progression, pathogenic microbial flora and systemic influences. Hyperglycemia, hematologic malignancies (e.g., leukemia), and nutritional deficiencies also are significant systemic conditions that can negatively affect the gingival tissues. System is primarily based on the severity of attachment loss. Holmstrup P, Plemons J, Meyle J. Non-plaque-induced gingival diseases. An emphasis will be given for the classic as well as the latest techniques for diagnosing and treating periodontal disease, and also to training in performing cosmetic periodontal procedures. systemic modifying factorsi. 7. J Periodontol 2018;89(Suppl 1):S267-S290.27. American Academy of Periodontology. supragingival plaque; andb. American Academy of Periodontology. J Periodontol 2018;89(Suppl 1):S9-S16.22. J Periodontol 2018;89(Suppl 1):S249-S256.9. Mariotti A. Van der Velden U, Kuzmanova D, Chapple ILC. J Periodontol 2018;89(Suppl 1):S214-S222.15. Within each category there are specific types of diseases identified, Gingivitis Associated with Systemic Conditions or Medications, Gingival Manifestations of Systemic Diseases and Mucocutaneous Lesions, Blood Dyscrasias (for example Acute Monocytic Leukemia), Mucocutaneous Diseases (Lichen Planus, Cicatricial Pemphigoid), Periodontitis Associated with Systemic Diseases, Addition of a section on “Gingival Diseases”, Replacement of “Adult Periodontitis” with “Chronic Periodontitis“, Replacement of “Early-Onset Periodontitis” with “Aggressive Periodontitis”, Elimination of a separate disease category for “Refractory Periodontitis”, Replacement of “Necrotizing Ulcerative Periodontitis” with “Necrotizing Periodontal Diseases”, Addition of a category on “Periodontal Abscess”, Addition of a category on “Periodontic-Endodontic Lesions”, Addition of a category on “Developmental or Acquired Deformities & Conditions”, Gingival diseases of specific bacterial origin, Gingival manifestations of systemic conditions. 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