AAP Classification of Periodontal Diseases and

Conditions (1999)
Gingival Diseases
Dental plaque-induced gingival diseases
Non-plaque induced gingival lesions
Chronic Periodontitis (Slight: 1-2mm CAL; moderate: 3-4mm
CAL; severe: >5mm CAL)
Localized
Generalized (>30% of sites are involved)
Aggressive Periodontitis (Slight: 1-2mm CAL; moderate: 3-
4mm CAL; severe: >5mm CAL)
Localized
Generalized (>30% of sites are involved)


AAP Classification of Periodontal Diseases and
Conditions (1999)
Periodontitis as a Manifestation of Systemic Diseases
Associated with hematological disorders
Associated with genetic disorders
Not otherwise specified
Necrotizing Periodontal Diseases
Necrotizing ulcerative gingivitis
Necrotizing ulcerative periodontitis
Abscesses of the Periodontium
Gingival abscess
Periodontal abscess
Pericoronal abscess
AAP Classification of Periodontal Diseases and
Conditions (1999)
Periodontitis Associated with Endodontic Lesions
Combined periodontic-endodontic lesions
Developmental or Acquired Deformities and Conditions
Localized tooth-related factors that modify or predispose
to plaque-induced gingival diseases periodontitis
Mucogingical deformities and conditions around teeth
Mucogingival deformities and conditions on edentulous
ridges
Occlusal trauma
The Periodontal Disease Classification System of the American Academy of Periodontology - An Update, Journal
of Canadian Dental Association, 2002; 66:549-7
Crystal S. Baik
What is Refractory Periodontal Disease
Refractory periodontal disease refers to destructive
periodontal diseases in patients who demonstrate
continued attachment loss in spite of adequate
treatment and proper oral hygiene.
Contributing factors include:type of therapy
provided, furcation involvement, microflora, and
smoking history.

Journal of Canadian Elizabeth Black
Dental Association, December 2000
Periodontal Disease and Diabetes
The diabetic state is associated with:
Decreased collagen synthesis
Increased collagenase activity
Altered neutrophil function
Elevated blood sugar levels suppress the
hosts immune response and results in:
Poor wound healing
Susceptibility to recurrent infections
Periodontal disease is often considered the
6
th
complication of diabetes and may place
the individual at risk for future diabetic
complications

*From The Amer Acad of Periodontology,
pamphlet "Diabetes and Periodontal
Disease", 2002 Prepared by
Kristina Fekete
Periodontal Disease & Diabetes
BRITTLE DIABETICS:
More susceptible to gingivitis,
gingival hyperplasias and
periodontitis
More harmful proteins (cytokines) in
their gingival tissues
Decreased beneficial proteins
(growth factors) interferes with the
healing response
Increased levels of serum
triglycerides may be related to
greater probing depths and
attachment loss

*From Fedi, The Periodontic Syllabus, 4th
ed., 2000 Prepared by Kristina
Fekete
Periodontal Disease and Diabetes
TREATMENT:
Closely monitor blood glucose levels
Maintenance of meticulous oral hygiene
and strict recall appointments
Short appointments in relaxed, non-
stressful environment
Have source of oral glucose available
Effective treatment of periodontal
infection and reduction of periodontal
inflammation are associated with a
reduction in the level of glycosylated
hemoglobin the marker of diabetic
control

*From Little & Falace, Dental Management
of the Medically Compromised Patient, 5th
ed., 1997 Prepared by
Kristina Fekete
Periodontal Treatment and Diabetes
-The diabetic patient requires special precautions prior to
periodontal treatment
-treatment in the uncontrolled diabetic is
contraindicated
-treatment in the brittle diabetic requires
prophylactic antibiotics, started 2 days
preoperatively (Penicillin VK) and continuing
through the immediate post-op period
-treatment of the well-controlled diabetic may
the same as an ordinary patient


Periodontal Treatment and Diabetes
Protocol for Treatment:
Clinician should make sure that prescribed insulin has been taken,
followed by a meal
Morning appointments are appropriate because of optimal insulin
levels
Monitor vitals, including blood glucose prior to treatment
Procedures performed may alter the patients ability to maintain
caloric intake, therefore post-op insulin doses should be altered
accordingly
Tissues should be handled as atraumatically and minimally as possible
(less than 2 hrs)
Epinephrine should not be used in concentration greater than
1:100,000 due to epinephrine effects on insulin
Diet recommendations should be made to maintain proper glucose
balance
Frequent recall and fastidious home oral care should be stressed

Periodontal Treatment and Diabetes
Recent Studies:
-Effective treatment of periodontal infection and reduction of periodontal
inflammation are associated with a reduction in the level of glycated
hemoglobin
-Increased serum triglyceride levels in uncontrolled diabetics have been
shown to be related to greater attachment loss and probing depths

-ThereforeControl of periodontal disease should be an important part of
the overall management of the diabetic patient

Sources:
Carranza and Newman, Clinical Periodontology, 8
th
ed.
Grossi, et al. Treatment of Periodontal Disease in Diabetics Reduces Glycated
Hemoglobin. Journal of Periodontology, Vol. 68, No. 8

Chris VanDeven

Smoking and Periodontal Disease
Smoking is a major cause of
periodontal disease.
Smokers are 4x as likely to develop
periodontitis as non-smokers.
Smoking may be responsible for
more than half of the periodontal
disease among adults in the U.S.
Up to 90% of refractory periodontitis
patients are smokers.
References:
1) Tomar, S., Asma, S. ; J Periodontol 2000;71:743-751
2) Johnson GK. Slach NA. Impact of tobacco use on periodontal
status. [Review] Journal of Dental Education. 65(4):313-21, 2001 Apr.
Graham Smith
Smoking and Periodontal Disease
Smoking may increase levels of
certain periodontal pathogens.
Smoking has a negative effect on
host response, such as neutrophil
function and antibody production.
Smoking has been shown to have a
cytotoxic effect on gingival fibroblasts
and could slow down wound healing.
References:
3) Rota MT.; Tobacco smoke in the development and therapy of periodontal disease: progress and
questions. [Review] Bulletin du Groupement International Pour la Recherche Scientifique en
Stomatologie et Odontologie. 41(4):116-22, 1999 Oct-Dec.
2) Johnson GK. Slach NA. Impact of tobacco use on periodontal status. [Review] Journal of Dental
Education. 65(4):313-21, 2001 Apr.
Graham Smith
Smoking and Periodontal Disease
Smoking may be one parameter to
use in deciding to treat refractory
periodontitis in smokers with a
systemic antibiotic therapy directed
against smoking-associated
periodontal bacteria.
Smoking cessation seems to have a
beneficial effect on periodontal
health.
References:
4) Lie MA. [Smoking as a risk factor for periodontitis]. [Review] [Dutch] Nederlands Tijdschrift voor
Tandheelkunde. 106(11):419-23, 1999 Nov.
5) van Winkelhoff AJ. Bosch-Tijhof CJ. Winkel EG. van der Reijden WA. Smoking affects the subgingival
microflora in periodontitis. Journal of Periodontology. 72(5):666-71, 2001 May.
Graham Smith
What is Periostat?
Doxycycline Hyclate- inhibits collagenase activity and
reduces the collagenase activity in gingival crevicular
fluid of patients with adult periodontitis
Indicated for use as an adjunct to scaling and root
planing to promote attachment level gain and to reduce
pocket depths
Periostat is available as a tablet(20mg) to be taken orally
two times a day (about an hour before, or two hours after
meals). Should be taken with plenty of fluids.
Typical treatments range from 3months to 12months.
www.Periostat.com R.Macnowski


What is Periostat?
Clinical studies have shown that the use of Periostat,
along with SC/RP is more effective at regaining
attachment level, than treatment with SC/RP alone
Periostat is the first and only therapeutic agent designed
to modulate the host response and helps to slow the
progression of periodontal disease.
Periostat should be used when traditional SC/RP
treatments alone are ineffective, but before surgery is
indicated.
www.Periostat.com R. Macnowski


What is Periostat?
Periostat is not an antibiotic- the low dosages of
periostat have no detectable effect on bacteria.
Periostat should not be used with children, expecting
mothers, nursing mothers, or anyone with a tetracycline
hypersensitivity.
Periostat may cause hypersensitivity to sunlight
No reports of tooth staining
May reduce the effect of BCPs
www.periostat.com R.Macnowski