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Stages of Periodontal Disease

Gingival disease

Plaque-related gingivitis and marginal and papillary inflammation, with 1- to 4-mm probing depths and generalized zero clinical attachment loss, B, Radiographic images of the patient. Crestal bone intact.
 Soft tissue changes are not visible in the radiograph

A 12-year-old girl with a primary medical diagnosis of leukemia who exhibits swollen and spongy gingiva

Clinical images of a 9-year-old boy with severe gingival overgrowth as a result of a heart transplant and cyclosporine therapy.

Clinical images of gingival overgrowth after the use a of calcium channel blocker to control hypertension.

A generalized severe allergic response of the gingiva in response to an additive in chewing gum.


Self-inflicted gingival dehiscence/ recession induced via the patient's fingernail.

Periodontitis (Periodontal disease)

Early Bone loss

Radiograph showing horizontal bone loss slow progression; radiograph showing vertical bone loss  & combined bone loss

Clinical image of plaque-related slight early chronic periodontitis with 1 to 2 mm of clinical attachment loss in a 40-year-old woman. B, Radiographic images of the patient.

All Images are obtained from: Carranza's Clinical Periodontology, 12th Edition. W.B. Saunders Company, 072014.

Clinical Image of plaque-related moderate chronic periodontitis with 3 to 4 mm of clinical attachment loss in a 53-year-old man who smokes. B, Radiographic images of the patient.

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Clinical image of plaque-related severe advanced chronic periodontitis with >5 mm of clinical attachment loss in a 47-year-old woman. B, Radiographic images of the patient.

Clinical image of plaque-related aggressive moderate periodontitis with 1 to 7 mm of PD and 3 to 4 mm of clinical attachment loss in a 31-year-old man. B, Radiographic images of the patient.

 At present, periodontitis as a manifestation of systemic disease is the diagnosis to be used when the systemic condition is the major predisposing factor and when local factors (e.g., large quantities of plaque and calculus) are not clearly evident. In the case in which periodontal destruction is clearly the result of local factors but has been exacerbated by the onset of such conditions

Clinical image of plaque-related aggressive severe periodontitis with 3 to 13 mm of PD and 7 to 15 mm of clinical attachment loss in a 32-year-old man. B, Radiographic images of the patient.

Clinical image of plaque-related severe aggressive periodontitis in a 53-year-old man who smokes and who has diabetes and a hemoglobin A1c level of 10.7. B, Radiographic images of the patient. (Fig 2  followed

From Above the same 53-year-old diabetic patient on Selective probing depths shows severe periodontitis.

Periodontal abscess 24 Acute disease progression

Stage IV, Grade C:  Advanced Periodontitis marked by the radiographic appearance of bone loss Extending to middle third of root and beyond third of root and beyond (>33%), Rapid rate (
Evidences

Stage IV, Generalized; Molar/incisor pattern
Vertical bone loss to combined bone loss 
Secondary occlusal trauma  (tooth mobility degree ≥2)
Furcation involvement Class III/1V
Masticatory dysfunction/ rehabilitation required
Severe ridge defects
Bite collapse, drifting, flaring

Grade C Rapid Rate
% bone loss / age  >1.0%

Destruction exceeds given biofilm deposits; specific clinical patterns suggestive of periods
of rapid progression and/or early onset disease

Correlation with systemic impact: Diabetes

Contrast with appearance

Periodontitis (radiographic appearance).  A 42-year-old man with type 2 diabetes and generalised severe periodontitis. There is extensive alveolar bone loss (generally 50–75% of the root length) affecting the entire dentition, with an irregular (uneven) pattern of bone loss. Some of the teeth have lost nearly all their supporting alveolar bone as a result of periodontitis progression, e.g. the upper molars (both right and left), and the four lower incisors, all of which are grossly mobile and which are retained in the oral cavity only by the soft tissue attachment (having lost 100% of their bone support).  A 21-year-old man with no periodontitis. Alveolar bone levels are normal, with the crest of the alveolar bone being in close proximity to the cemento-enamel junction (the boundary between the enamel crown and the root).

Schematic representation of the proposed two-way relationship between diabetes and periodontitis. Exacerbated and dysregulated inflammatory responses are at the heart of the proposed two-way interaction between diabetes and periodontitis (purple box), and the hyperglycaemic state results in various proinflammatory effects that impact on multiple body systems, including the periodontal tissues. Adipokines produced by adipose tissue include proinflammatory mediators such as TNF-α, IL-6 and leptin. The hyperglycaemic state results in deposition of AGEs in the periodontal tissues (as well as elsewhere in the body), and binding of the receptor for AGE (RAGE) results in local cytokine release and altered inflammatory responses. Neutrophil function is also altered in the diabetic state, resulting in enhancement of the respiratory burst and delayed apoptosis (leading to increased periodontal tissue destruction). Local production of cytokines in the periodontal tissues may, in turn, affect glycaemic control through systemic exposure and an impact on insulin signalling (dotted arrow). All of these factors combine to contribute to dysregulated inflammatory responses that develop in the periodontal tissues in response to the chronic challenge by bacteria in the subgingival biofilm, and which are further exacerbated by smoking

Periodontitis (clinical appearance) in a 22-year-old man with poorly controlled type 1 diabetes and severe periodontitis. Note the generalised inflammation, abnormal gingival anatomy owing to tissue destruction, gingival recession, swelling and inflammation, spontaneous bleeding and abundant plaque deposits. The periodontal tissues around the lower incisors are particularly severely affected



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