Introduction to Periodontal Diseases PDF

Introduction to Periodontal Diseases Ronald George, D.D.S. Assistant Professor Midwestern University College of Dental Medicine Illinois © CDMI Objectives: 1. Identify the components of a healthy periodontium 2. Descr...

Introduction to Periodontal Diseases Ronald George, D.D.S. Assistant Professor Midwestern University College of Dental Medicine Illinois © CDMI Objectives: 1. Identify the components of a healthy periodontium 2. Describe and recognize the signs of gingivitis 3. Describe and recognize the signs of periodontitis 4. Recall the 2018 Classification of Periodontal and Peri-Implant Diseases and Conditions 5. Describe Peri-Implant Mucositis 6. Describe Peri-Implantitis This presentation may contain copyrighted material (“Material”), the use of which may not have been specifically authorized by the copyright owner. Midwestern University is making the Material available through this presentation solely and strictly for illustrative purposes, including criticism, comment, and teaching, with the objective of advancing dental education. This use of the Material constitutes a “fair use” of any such copyrighted Material as provided for in Section 107 of the United States Copy Right Law. In accordance with Title 17 U.S.C. § 107, the Material is distributed without profit to those who have research and/or educational interests. Reproduction or dissemination of the Material, including this presentation, in any format or medium is prohibited. All rights reserved. Outline I. Periodontics VI. Periodontitis 3. Periodontitis as a II. History A. Overview Manifestation of III. Periodontium 1. Clinical attachment loss Systemic Disease A. Tissues 2. Bone loss 4. Periodontal Abscesses and 1. Gingiva 3. ≥4mm Pocket depth Endodontic-Periodontal Lesions 2. Cementum B. Pocket C. Periodontal Manifestations of Systemic 3. PDL C. Systemic diseases Diseases and Developmental and Acquired D. Irreversible Conditions 4. Alveolar bone VII. Gingival Recession 1. Systemic Diseases or IV. Gingival health VIII. Histopathology Conditions Affecting the A. Characteristics IX. 2018 Classification Periodontal Supporting Tissues B. Anatomy A. Periodontal Health, Gingival Diseases and 2. Mucogingival Deformities 1. Gingival margin Conditions and Conditions 2. Free gingiva 1. Periodontal health and gingival 3. Traumatic occlusal forces 3. Gingival groove health 4. Tooth and Prothesis Related 4. Attached gingiva 2. Gingivitis: dental biofilm induced Factors 5. Mucogingival junction (plaque) D. Peri-Implant Diseases and Conditions 6. Alveolar mucosa 3. Gingival diseases: non-dental biofilm 1. Peri-implant Health C. Sulcus induced 2. Peri-implant Mucositis D. Radiographs B. Periodontitis 3. Peri-implantitis V. Gingivitis 1. Necrotizing Periodontal Diseases 4. Peri-implant Soft and Hard A. Overview 2. Periodontitis Tissue Deficiencies B. Characteristics a. Stage X. Implants C. Reversible b. Grade A. Peri-implant mucosistis D. Pericoronitis B. Peri-implantitis XI. Parting Words What tooth is this? Mesiolingual developmental groove #21 Mandibular Left 1st Premolar Periodontics “Periodontics is that specialty of dentistry which encompasses the prevention, diagnosis and treatment of diseases of the supporting and surrounding tissues of the teeth or their substitutes; the replacement of lost teeth and supporting structures by regeneration, tissue engineering, implantation of natural and/or synthetic devices and materials; and the maintenance of the health, function and esthetics of these tissues and structures.” AAP Connect, The Glossary of Periodontal Terms History  Historical Background of Periodontology “Gingival and periodontal diseases have afflicted humans since the dawn of history” Newman and Carranza’s Clinical Periodontology Periodontal disease was the most common of all diseases found in ancient Egyptians. Hippocrates (460-377BC) the father of modern medicine discussed the etiology of periodontal disease. He believed that inflammation of the gums could be caused by accumulations of calculus. Albucasis (936-1013) had a clear understanding of the major etiologic role of calculus deposits and described techniques of scaling teeth with instruments he developed. Serefeddin Sabuncuoglu (1385-1468) initiated drug and surgical treatment of the gums. Bartholomeus Eustachius (1520-1574) wrote a small book about dentistry, Libellus de Dentibus (“A Little Treatise on the Teeth”), which was the first original book about the teeth, and it included a description of the periodontal tissues as well as information about the diseases of the mouth, their treatment modalities, and the rationale for treatment. Girolamo Cardano (1501-1576) appears to have been the first to differentiate among the types of periodontal disease. Anton Van Leeuwenhoek (1632-1723) developed the microscope. Using material from his own mouth, Leeuwenhoek first described oral bacterial flora. He even performed antiplaque experiments involving the use of strong vinegar. Newman and Carranza’s Clinical Periodontology Historical Background of Periodontology Pierre Fauchard is regarded as the father of the dental profession as we know it. His book, The Surgeon Dentist, which was published in 1728, covered all aspects of dental practice, including restorative dentistry, prosthodontics, oral surgery, periodontics, and orthodontics. Fauchard described in detail his periodontal instruments and the scaling technique for using them. Newman and Carranza’s Clinical Periodontology Historical Background of Periodontology 19th Century Leonard Koecker (1785-1850) wrote a paper in 1821. He mentioned the careful removal of tartar and the need for oral hygiene by the patient, recommending that it be performed in the morning and after every meal with the use of an astringent powder and a toothbrush, with care taken to place “the bristles … into the spaces of the teeth.” Levi Spear Parmly (1790-1859) is considered the father of oral hygiene and the inventor of dental floss. During the mid-19th century, John W. Riggs (1811-1885) was the leading authority on periodontal disease and its treatment in the United States; in fact, at the time, periodontitis was known as “Riggs’ disease.” Riggs seems to have been the first individual to limit his practice to periodontics and can therefore be considered the first specialist in this field. During the second half of the 19th century an era that can be called modern medicine, anesthesia was discovered, germ theory of disease was established, asepsis in surgery, and the discovery of radiographs. Adolph Witzel (1847-1906) was the first to identify bacteria as the cause of periodontal disease. J. Leon Williams (1852-1932) described a gelatinous accumulation of bacteria adherent to the enamel surface in relation to caries In 1899 G.V. Black (1836-1915) coined the term “gelatinous microbic plaque” Newman and Carranza’s Clinical Periodontology Historical Background of Periodontology 20th Century During the first third of the century, Bernhard Gottlieb (1885-1950), Balint J. Orban (1899-1960), among others developed the basic histopathic concepts on which modern periodontics was built Also during this time, Oskar Weski (1879-1952) and Robert Neumann (1882-1958) refined the surgical approach to periodontal therapy Isadore Hirschfield (1882-1965) championed the nonsurgical approach Alfred Fones (1869-1938) opened the first school for dental hygienists in 1913 Per-Ingvar Branemark developed a technique in the 1950’s involving the use of titanium screw shaped intraosseous implants. It was gradually adopted by the dental profession after 1982. Jens Waerhaug (1907-1980) among others, research opened a new era in the understanding of the periodontium and management of periodontal problems Several workshops and international conferences have summarized the existing knowledge of periodontology – the latest in 2017 The American Academy of Periodontology was founded in 1914 by two female periodontists, Grace Rogers Spalding (1881-1953) and Gillette Hayden (1880-1929). The AAP has become the leader in organized periodontics. In 1995 the AAP mandated that all postgraduate periodontal programs increase to a 3-year curriculum because of increased knowledge in periodontics, implants and sedation Newman and Carranza’s Clinical Periodontology Periodontium Color Atlas of Dental Medicine - Periodontology Periodontium (peri = around, odontos = tooth) The periodontium is the supporting structures of the teeth necessary to maintain teeth in function The tissues that make up the Gingival margin periodontium include: Gingiva Gingival groove Cementum Cementum Periodontal ligament (PDL) Alveolar bone All components function as a single unit Alveolar Process Pathologic changes occurring in one component may have ramifications for the maintenance, repair, or regeneration of another component Woelfel’s  Periodontium NOTE: Gingiva includes gingival margin, Gingiva – Oral tissue free gingiva and attached gingiva (oral mucosa) that is covered by keratinized tissue Gingiva (epithelium). Keratinized tissue contains keratin a fibrous protein found in skin and hair that provides surface toughness. attaching Junction Alveolar mucosa – e Alveolar mucosa nonkeratinized mucous membrane apical to the NOTE: Alveolar mucosa is not found on the palate since the hard palate attached gingiva has attached keratinized tissue continuous with the palatal gingiva Periodontium Cementum – specialized mineralized tissue covering the root surfaces and attaches the principal periodontal ligament fibers to the root of the tooth Gingiva Periodontal Ligament (PDL) – Periodontal ligament vascular and cellular connective tissue which surrounds the roots Alveolar bone proper of the teeth connecting the cementum to the tooth socket Root cementum wall Alveolar bone (alveolar process Alveolar process & alveolar bone proper) - the portion of the maxilla and mandible that forms and NOTE: the compact layer of bone called the alveolar bone proper supports the tooth socket alveoli is all called bundle bone and radiographically the lamina dura Gingival Health Gingival Health - Characteristics Characteristics: NOTE: 3 Cs Color is coral pink or pink with melanin pigmentation Contour - papillae fill gingival embrasure and are knife edged Scallops are parabolic Consistency is firm and resilient Surface texture is stippled (orange peel) and matte (dull) NO bleeding NO mucogingival defect (adequate zone of attached gingiva)goodattatchedgingiva NO suppuration (purulent exudate or pus) Sulcus depths 1-3mm Gingival Health - Anatomy Free Gingiva That part of the gingiva that surrounds the tooth and is not directly attached to the tooth surface or alveolar bone Surrounds each tooth to form a collar of tissue with a space between it and the tooth called the gingival sulcus The depth of the sulcus can be measured with a periodontal probe (1-3mm) Gingival margin Free Gingiva NOTE: attached gingiva is bound to underlying tooth surface and bone  Gingival Health - Sulcus Gingival Sulcus NOTE: “Sulcus” The probing depth is the is a term used Gingival distance from the gingival in periodontal margin health as margin to the base of the opposed to sulcus “Pocket” which is used Junctional epithelium is the when there is tissue that forms the base of periodontal disease the sulcus by attaching to the enamel of the crown near the CEJ cementoenamel junction (CEJ) In health, the probing depth should be from 1 to 3mm in depth Gingival Health (With Intact Periodontium - No Bone Loss) What would we see radiographically? Interproximal (crestal) bone approximates the cementoenamel junction (1-2mm apical to the CEJ of adjacent teeth) NOTE: the compact layer of alveolar bone proper is called lamina dura radiographically Gingivitis Gingivitis - Overview Inflammation of the gingiva An inflammatory condition confined to and altering the gingival tissues Inflammation results from the response of the body to harmful metabolic products of bacterial colonies within dental plaque that are in close proximity to gingival tissues Increase in inflammatory cells and a breakdown of the connective tissue in the gingiva Increase in tissue fluids – edema/swelling Proliferation of small blood vessels – redness Loss of integrity of the epithelium - ulceration NOTE: Plaque induced gingivitis is the most common form of gingivitis  Gingivitis - Characteristics Characteristics: NOTE: (3 Cs) Redness (color) Rolled swollen margins (contour) Loss of (consistency)/resiliency Smooth and shiny surface texture Loss of stippling Bleeding upon probing Spontaneous bleeding Suppuration NOTE: Bleeding upon probing is a hallmark of gingivitis Gingivitis - Characteristics Newman and Carranza’s Essentials of Clinical Periodontology  Gingivitis Reversible – removal of plaque Home care No loss of attachment No bone loss Professional cleanings Oral hygiene instructions (OHI) Plaque disclosing solution or tablets Recalls  Pericoronitis NOTE: Inflammatory involvement of the pericoronal flap (operculum) and adjacent structures partiallyeruptedwisdomteeth Newman and Carranza’s Essentials of Clinical Periodontology Periodontitis biking Imoreloss NOTE: Bone loss  Periodontitis - Overview Gingivitis if untreated may progress to periodontitis calculus amylase Plaque and dental calculus contribute to disease development and progression Inflammation of the periodontal tissues resulting in NOTE: Plaque can calcify to form a hard NOTE: complex mineral layer called dental calculus clinical attachment loss, alveolar bone loss, and “Periodontal that is firmly attached to the tooth Pocket” is periodontal pocketing (≥ 4mm pocket depth) used when Inflammatory breakdown extends from the gingiva to there is the periodontal ligament and bone when the junctional periodontal epithelium migrates apically onto the root because the disease connective tissue attachment has broken down Progression of the disease causes breakdown of bone and adjacent periodontal ligament Smoking and diabetes increase the odds of periodontal disease progression Periodontal disease may be a risk factor for several NOTE: calculus can form both systemic diseases including cardiovascular disease supragingival (coronal to the gingival margin) and subgingival (apical to the gingival margin) Periodontitis - Pocket NOTE: Loss of attachment Lorette restorebone Newman and Carranza’s Essentials of Clinical Periodontology Periodontitis – Systemic Diseases Newman and Carranza’s Essentials of Clinical Periodontology Periodontitis inflammationaroundtooth Irreversible – Bone Loss Treatment Nonsurgical – Scaling & Root Planing Surgical Maintenance Gracey Curets Periodontitis “A patient with gingivitis can revert to a state of health, but a periodontitis patient remains a periodontitis patient for life, even following successful therapy, and requires life-long supportive care to prevent recurrence of disease.” 2017 World Workshop  Gingival Recession Gingival Recession Loss of gingival tissue usually with underlying bone loss Gingival margin apical to the CEJ with exposure of the root surface Papillae may be blunted or rounded Papillae may no longer fill the interproximal space Possible causes: Periodontitis blacktriangle Lack of attached gingiva Poorly aligned teeth with abnormal tooth and root prominence Lack of underlying bone Thin periodontal tissues Aggressive tooth brushing Poor restorations  noal thedgingivamucogingivaldeed When plaque is left undisturbed Histopathology of Periodontal Disease no plaque Newman and Carranza’s Essentials of Clinical Periodontology  2018 Classification Periodontal Health, Gingival Diseases and Conditions 1. Periodontal health and gingival health Clinical gingival health on an intact periodontium Clinical gingival health on a reduced periodontium Stable periodontitis patient Non-periodontitis patient (Ex. Crown lengthening) 2. Gingivitis: dental biofilm induced (plaque) Associated with dental biofilm alone Mediated by systemic or local risk factors Drug-influenced gingival enlargement 3. Gingival diseases: non-dental biofilm induced Genetic/developmental disorders Specific infections Inflammatory and immune conditions Reactive processes Neoplasms Endocrine, nutritional & metabolic diseases Traumatic lesions/foreign body Gingival pigmentation Periodontal Health, Gingival Diseases and Conditions 1. Periodontal health and gingival health Clinical gingival health on an intact periodontium nolossofattachmentorboneloss Clinical gingival health on a reduced periodontium Stable periodontitis patient Non-periodontitis patient (Ex. Crown lengthening) Periodontal Health, Gingival Diseases and Conditions 2. Gingivitis: dental biofilm induced (plaque induced) Associated with dental biofilm alone Most common form of gingivitis Mediated by systemic or local risk factors Systemic factors Sex steroid hormones Puberty, menstrual cycle, pregnancy, oral contraceptives Hyperglycemia, leukemia, smoking, malnutrition Local risk factors Prominent subgingival restoration margins Hyposalivation Drug-influenced gingival enlargement (ex. Phenytoin) Phenytoin Periodontal Health, Gingival Diseases and Conditions 3. Gingival diseases: non-dental biofilm induced Genetic/developmental disorders Hereditary gingival fibromatosis Specific infections Bacterial origin, Viral origin, Fungal Inflammatory and immune conditions Hypersensitivity reactions, Autoimmune diseases, Hereditary Gingival Granulomatous inflammatory conditions Fibromatosis Reactive processes Epulides (ex. Pyogenic granuloma) Neoplasms Premalignant Malignant Endocrine, nutritional & metabolic diseases Pyogenic Granuloma Vitamin deficiencies (ex. Vitamin C) Traumatic lesions/foreign body Physical/mechanical insults, Chemical (toxic) insults, Thermal insults Gingival pigmentation Melanoplakia, Smoker’s melanosis, Drug induced pigmentation, Amalgam tattoo Periodontitis 1. Necrotizing Periodontal Diseases NOTE: Necrotizing = causing or undergoing necrosis Necrotizing Gingivitis Necrotizing Periodontitis Necrotizing Stomatitis (soft tissues of the oral cavity) 2. Periodontitis (Staging & Grading) Stages: Based on Severity, Complexity of Management and Extent Stage I: Initial Periodontitis Stage II: Moderate Periodontitis Stage III: Severe Periodontitis with potential for additional tooth loss Stage IV: Severe Periodontitis with potential for loss of the dentition Extent and distribution: localized (30% teeth), molar incisor distribution Grades: Evidence or risk of rapid progression, anticipated treatment response Grade A: Slow rate of progression Grade B: Moderate rate of progression Grade C: Rapid rate of progression 3. Periodontitis as a Manifestation of Systemic Disease 4. Periodontal Abscesses and Endodontic-Periodontal Lesions  NOTE: May represent different stages of the Periodontitis same disease 1. Necrotizing Periodontal Diseases NOTE: Necrotizing = causing or undergoing necrosis Necrotizing Gingivitis (NG) Bacterial cause NG Necrosis and sloughing of gingival tissues Characteristic lesions are (punched-out), craterlike depressions at the crest of the interdental papillae Bleeding, fetid odor and pain Predisposing factors include psychologic stress, smoking, malnutrition and immunosuppression NP Necrotizing Periodontitis (NP) Loss of clinical attachment and alveolar bone Rapid destruction of bone Spontaneous bleeding Gingival recession NP Severe pain Necrotizing Stomatitis (NS) (soft tissues of the oral cavity)  Periodontitis 2. Periodontitis (SEE Staging & Grading) Stages: Based on Severity, Complexity of Management and Extent Stage I: Initial Periodontitis Stage II: Moderate Periodontitis Stage III: Severe Periodontitis with potential for additional tooth loss Stage IV: Severe Periodontitis with potential for loss of the dentition Extent and distribution: localized (30% teeth), molar incisor distribution Grades: Evidence or risk of rapid progression, anticipated treatment response Grade A: Slow rate of progression Grade B: Moderate rate of progression Grade C: Rapid rate of progression Periodontitis: Staging & Grading sulcus marginofgingiva tobaseof NOTE: CAL is the measurement from the CEJ to the base of the sulcus importantfor recession  NOTE for Severity: Mild – Stage 1 Moderate – Stage 2 Severe – Stage 3 & 4 Periodontitis: Staging NOTE: Referral for Stage III & IV (Perio surgery/regeneration) NOTE: Indicates current disease status a radiographic NOTE: Molar/Incisor pattern Periodontitis: Grading NOTE: Indicates future disease status NP NOTE: Indirect evidence used with new patients, when history is not known  1 Assess ftp.ip.Ygngjegeth probedepths 2 33 Staging and Grading geteethloss is Establish.iq ÉÉ É 314 toothloss 3 Establis at fafpggpssigelA c Periodontitis 3. Periodontitis as a Manifestation of Systemic Diseases Papillon Lefevre Syndrome (early presentation of periodontitis) 4. Periodontal Abscesses and Endodontic-Periodontal Lesions Periodontal Abscess Localized accumulation of pus located within the gingival wall of the periodontal pocket Common dental emergency Rapid destruction of periodontal tissue May have systemic consequences Endodontic-Periodontal Lesions Involve both the pulp and periodontal tissues Acute and chronic forms Deep periodontal pockets Negative or altered response to pulp vitality tests endolesion Possible bone resorption in the apical or furcation region Other possibilities include pain, exudate, tooth mobility, sinus tract and gingival color alterations Periodontal Manifestations of Systemic Diseases and Developmental and Acquired Conditions 1. Systemic Diseases or Conditions Affecting the Periodontal Supporting Tissues 2. Mucogingival Deformities and Conditions Gingival phenotype Gingival/soft tissue recession Lack of gingiva Decreased vestibular depth Aberrant frenum/muscle position Gingival excess Abnormal color Condition of the exposed root surface 3. Traumatic occlusal forces Primary occlusal trauma Secondary occlusal trauma Orthodontic forces 4. Tooth and Prothesis Related Factors Localized tooth related factors Localized dental prostheses related factors Periodontal Manifestations of Systemic Diseases and Developmental and Acquired Conditions 1. Systemic Diseases or Conditions Affecting the Periodontal Supporting Tissues Systemic disorders that have a major impact on the loss of periodontal tissue by influencing periodontal inflammation Genetic disorders Diseases associated with immunologic disorders Diseases affecting the oral mucosa and gingival tissues Diseases affecting connective tissue Metabolic and endocrine disorders (ex. Diabetes mellitus) Acquired immunodeficiency diseases Inflammatory diseases Other systemic disorders that influence the pathogenesis of periodontal disease (ex. Smoking) Systemic disorders that can result in loss of periodontal tissue independent of periodontitis Neoplasms Other disorders that may affect periodontal tissue Periodontal Manifestations of Systemic Diseases and Developmental and Acquired Conditions 2. Mucogingival Deformities and Conditions Gingival phenotype (gingival thickness, keratinized tissue width, bone morphotype and tooth dimension) Gingival/soft tissue recession Facial or lingual surfaces Interproximal Lack of gingiva Recession Decreased vestibular depth Aberrant frenum/muscle position Gingival excess Pseudo-pocket Inconsistent gingiva margin Excessive gingival display Gingival enlargement Abnormal color Condition of the exposed root surface Frenum pull  Periodontal Manifestations of Systemic Diseases and Developmental and Acquired Conditions 3. Traumatic occlusal forces Primary occlusal trauma 1° Injury resulting in tissue changes from excessive occlusal forces applied to a tooth or teeth with normal support Normal bone Secondary occlusal trauma height Injury resulting in tissue changes from normal or excessive occlusal forces applied to a tooth or teeth with reduced support Orthodontic forces 2° Widened PDL Indicators of occlusal trauma: Mobility Thermal sensitivity Fremitusmovingtoothw bite Discomfort/pain on chewing Reduced bone Occlusal discrepancies Widened PDL space height Wear facets Root resorption reducedperidontum Tooth migration Cemental tear Fractured teeth Periodontal Manifestations of Systemic Diseases and Developmental and Acquired Conditions Enamel Pearl 4. Tooth and Prothesis Related Factors Localized tooth related factors Cervical enamel projections and enamel pearls Developmental grooves Tooth and root fractures Palato Radicular Groove Root resorption Tooth position Open Contact Root proximity Open contacts Caries Localized dental prostheses related factors Violation of Biologic Width Violation of the biologic width restorationinto (supracrestal tissue attachment) Fixed dental restorations and protheses Dental materials Removable dental prostheses Overhang Orthodontics Peri-Implant Diseases and Conditions 1. Peri-implant Health (Absence of visual signs of inflammation and bleeding on probing) 2. Peri-implant Mucositis (Bleeding on probing and visual signs of inflammation) 3. Peri-implantitis (Inflammation and progressive loss of bone) 4. Peri-implant Soft and Hard Tissue Deficiencies (Healing after tooth loss leads to diminished alveolar ridge) Peri-implant Mucositis Peri-implantitis Peri-implantitis  TOOTH IMPLANT Implants Newman and Carranza’s Clinical Periodontology  Dental Implants  Endosseous dental implant Implant body Implant abutment Prosthesis or superstructure  Implant body is usually titanium Fundamentals of Periodontal Instrumentation Newman and Carranza’s Clinical Periodontology  Implant abutment and prosthesis are exposed to the oral cavity NOTE: OSSEOINTEGRATION - A direct contact/connection between living bone tissue and an implant Newman and Carranza’s Clinical Periodontology Newman and Carranza’s Clinical Periodontology Peri-implant Mucositis and Peri-implantitis Implants are susceptible to peri-implant biofilm induced inflammatory tissue changes  Peri-implant mucositis – presence of inflammation confined to the mucosa surrounding a dental implant with no signs of loss of supporting bone  Similar to gingivitis  Reversible - soft tissue only  Reported to affect up to 80% of patients with implants  Peri-implantitis – an inflammatory process around an implant which includes both soft tissue inflammation and loss of supporting bone  Similar to periodontitis  Irreversible - radiographic bone loss  Diagnosis = 1-1.5mm bone loss from baseline  Pain NOT a typical feature  Can progress quicker than periodontitis around natural teeth  Prevalence of peri-implantitis among patients is 11.2%-53%  Peri-implantitis At placement 2 year follow-up Surgical exposure Cement removed Excess cement Boney defect Andrea Hsu, Jung-Wan Martin Kim 2014 Parting Words: Gingivitis is inflammation confined to the gingival tissues without loss of attachment/bone loss. It is reversible. Not all untreated gingivitis will progress to periodontitis, however all chronic periodontitis patients must have experienced gingivitis. Periodontitis is inflammation of the periodontium with attachment/bone loss. Bone loss is irreversible. Periodontal diseases are multifactorial – medical/dental history, excellent radiographic technique and clinical examination are a must for accurate assessment and treatment! Dr. Geaman, Dr. Williams and Dr. Fan Thank you for sharing some time! References: 1. Newman and Carranza’s Clinical Periodontology, Newman, Takei, Klokkevold, Carranza, 13th Edition, Elsevier 2019 2. Hall’s Critical Decisions in Periodontology and Dental Implantology, Harpenau, Kao, Lundergan and Sanz, 5th Edition, People’s Medical Publishing House 2013 3. Clinical Cases in Periodontics, Nadeem Karimbux, 1st Edition, Wiley-Blackwell, 2012 4. Periodontology at a Glance, Clerehugh, Tugnait, Genco, 1st Edition, Wiley Blackwell 2009 5. American Academy of Periodontology, AAP Connect, The Glossary of Periodontal Terms 6. Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workshop 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018:89 (Suppl 1):S237-S248 7. Clinical Periodontology and Implant Dentistry, Jan Linde, Niklaus P. Lang, 6th Edition, Wiley Blackwell 2015 8. 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions, The American Academy of Periodontology, perio.org/2017wwdc 9. A New Classification Scheme For Periodontal and Peri-Implant Diseases and Conditions, Jingyuan Fan, DDS, PhD, Diplomate, American Board of Periodontology, CDMI, 2020 10. Fundamentals of Periodontal Instrumentation and Advanced Root Instrumentation by Jill S. Gehrig, Rebecca Sroda and Darlene Saccuzzo, 8th Edition, Wolters Kluwer, 2019 11. Essentials of Dental Radiography, Evelyn M. Thomson, Orlen N. Johnson, 9th Edition, Pearson 2012 12. Practical Periodontics, Kenneth Eaton, Philip Ower, Elsevier 2015 13. Color Atlas of Dental Medicine Periodontology, Wolf, Rateitschak, Hassell, 3rd Edition, Thieme, 2005 14. The Periodontic Syllabus, Vernino, Gray, Hughes, 5th Edition, Wolters Kluwer, 2008 15. Woelfel’s Dental Anatomy, Rickne C. Scheid, Gabriela Weiss, Ninth edition, Wolters Kluwer, 2017 16. How to Manage a Patient with Peri-implantitis, Andrea Hsu, Jung-Wan Martin Kim, J Can Dent Assoc 2014;79:e24 17. Newman and Carranza’s Essentials of Clinical Periodontology, Michael Newman, Satheesh Elangovan, Irina Dragan, Archana Karan, Elsevier 2022