PERIODONTAL DISEASE CLASSIFICATION.pdf

We talked about the main disease that you will be coming across with a gingivitis, with inflammation of the gingiva, which does not cause attachment loss. And the diagnosis would be either, I mean, following the previous one, the dental plaque induced while with the current one the dental biofilm in...

We talked about the main disease that you will be coming across with a gingivitis, with inflammation of the gingiva, which does not cause attachment loss. And the diagnosis would be either, I mean, following the previous one, the dental plaque induced while with the current one the dental biofilm induced. Okay, nothing crazy as a change in terms of the extent. And this always comes as a as a confusion. When we're saying extent, we mean how many teeth have been affected with a disease. Okay. Not extend in terms of severity. That's a different thing. So localized less than 30% of sides or teeth, as we said, and 30% and more. It's generalized severity. We used to use that close classification to classify inflammation. If it's mild, moderate or severe with mild, you see usually you just have a a change in the color, but not no bleeding in the moderate inflammation. You start having more redness and edema and more bleeding showing up delayed or not. And the severe obviously if you see those cases, you touch them and they just start to bleed instantly. So we used to use that in the past to classify the severity of inflammation with the current classification. The periodontist discussed that yes, it's a classification, but it may be a little bit subjective in identifying some things. So we don't put the severity in the disease per se. But when we describe it, people may ask you like how severe is the inflammation. That's a way to classify that okay. And as a reminder, that's why I put this thing here with a new classification. We said everything more than 30% is considered generalized and less than 30% localized. Now they have added this thing with a bleeding on probing that's always about bleeding on probing. If you have the whole dentition less than 10%, they consider that clinically healthy. Now, we're not here to say if we agree or disagree with that. That's what they have put in the classification. The reason they have put this thing over here is because they've seen from epidemiologic studies that having bleeding on less than 10% of the sites, the chances of disease recurrence and everything is very, very low. Is it always accurate? If you want my opinion? No, because you can have a side bleeding and we learn about the lung side. It still has 30% of chances of this side breaking down and losing attachment. But that's what they have here. And this will be coming across. So if you're having a patient that say that has gingivitis, you treat them and then you do your reevaluation and you see that 5% of the sides may show some delayed bleeding technically in your diagnosis, according to the new one, you can say that it's considered clinically healthy. Okay. And also remember now I'm trying to connect with the dots with the four stages of the gingivitis with initially early the established. Remember in the initial you may not even see any changes or so. That's why they have the bleeding on probing that refers to bleeding on probing on you. Okay. Just keeping that in mind for periodontitis. We know that it's inflammation that progresses to the period to the tissues, the PDL, the attachment apparatus. So attachment loss we see attachment loss. We see bone loss we see pockets. In the past we used to say the chronic versus aggressive. Now we have the staging and the grading regarding extent exactly the same. Less than 30% of the teeth localized 30% and more is generalized. The severity. It basically starts with a clinical attachment loss 1 to 2mm, 3 to 4 five and above. We still have the same thing for the staging 1 to 3 and four. But we need to take into consideration the depth of the pockets, inflammation and bone loss, etcetera. And as something that you can see here again, with the bone loss, we say less than 15% of the root length, 15 to 30 and more than 30%. So that gives you a comparison. This hasn't changed significantly just for the staging that we will see later on. And regarding the aggressive, it's a little bit different with a localized and generalized in those in this disease we have this smaller incisor pattern that are being affected. If you have up to two other permanent teeth other than those molar first molars and incisors being affected, it's localized if you have more is generalized. And I have here again the characteristics of aggressive personalities. We talked about those last time as well. And so with the aggressive we said we have this molar incisor pattern that's with the nucleus ification. So we don't call that anymore. The extent localized generalized is still the same. And the severity we have the staging and the grading. As we discussed I'm just having it here for your reference. I'm not going to go over that again because at the end we can discuss it again with the cases. But it's exactly the same thing as we said with a stage one, two, three and four. These represent what we used to call mild. These what we used to call moderate. And those two are severe. What differentiates those two is the severity and complexity of the disease, and the number of teeth missing because of perio or planning to be extracted because of perio. Okay. And sometimes I mean, these are considered like hopeless, prudently hopeless teeth. Not because all we have also some period, but we also have a fracture and we have severe caries and root caries. That's a different discussion. Okay. Clear. Just bring it up here for your reference. And again with the oh and something to bring back again in order to identify. So the attachment loss and the bone loss is exactly the same. Remember like we used to call before. Now regarding the generalized we have adding the molar incisor pattern. And these are complexity factors that as you see the more complex the disease goes the more advanced stage with grading. Now it depends. It refers to the rate of progression if it progresses fast or slow. The majority of what we used to call chronic bronchitis cases fall usually under this great big category, okay. Because if you take the percentage of bone loss divided by age, you usually come up with a range over here. There are some cases that it progresses really, really slow. And you may see those. You may have a lot of plaque and calculus and deposits. But again you're saying, oh, this should be a super advanced case, but you don't see that that's a slow progression. And great. It's the rapid rate. Usually all the aggressive cases fall under this category that we used to call before. The risk modifiers, the modifiers, the risk factors of smoking and diabetes should be taken into consideration when present. But after you have identified that first okay. So when you're discussing about cases, you're not saying, oh, is he smoking? Is the patient smoking? Is the patient the diabetic. So that's the great no. This may change things to a worse category, of course, after you establish that, because somebody may have just a rapid rate of progression and may smoke five cigarets a day, that doesn't mean that it's going to go great. Be right. It's still going to stay great. See. Clear. Okay. We're going to see that in action with case. It's going to make way more sense. But just as a reminder. So let's finish those two last categories of the disease which are things that you will be seeing clinically. Those two categories are also associated with a lot of other. A dental thing. So you may see those being associated with other dental things as well. So for end up lesions I'm not going to expand a lot. Although this is one of my favorite topics like because nobody likes them. So I said I'm going to like it. So what are those combined endometrial lesions you have. And an identical lesion that starts epically in molars. You may even see that in vacations. And you have a periodontal lesion that starts on the crystal part. And those 2nd May be independent. They may merge together depending on the severity and everything like that. Again, this is a whole topic I'm not going to go into end up area. You will listen more about those on your period two classes and everything, but at least being able to identify and diagnose those lesions. So usually you will see areas having a resolution, maybe resolution, maybe in the vacation in molars. And you may also see some crystal bone loss as an angular defect or a horizontal defect. Usually those teeth with the end of area have like deep pockets. And you see, this technically is a separation between those two defects. Right. So this is the barrier part. And this is the end of part. And sometimes depending on the severity and when you check you may be able to probe through and go all the way down. I'm not going to say too much now, but keep in mind, the fact that you're able to go all the way down doesn't mean that your period disease is all the way down, right? So it's very, very critical to identify and diagnose that because your treatment will be as such. You will need to treat the end of first and then the period if you start in these two. Let's assume this probe goes all the way down 15mm for example. And you're saying, oh, I have a deep pocket. I'm going to do my scaling and route planning, which is the deep cleaning that we do for the patients. And you go all the way down to scale in a root plan there you will have a very bad outcome. Why? Because you are bothering and you're removing and you're destroying the fibers that may be disorganized or because of any component which is completely different. And then when you're expecting the healing, it's not going to happen. But if you do, let's say at the end of the treatment first, you will see that this will heal nicely, assuming you did a good job and there's no other factor, and then you will only have to deal with the trooper dental issue, which is on the top part. Okay, so so the way sometimes this looks like and that's why that's my own thing, I don't want to necessarily take credit, but you won't see that anywhere. It looks like a keyhole right. You have the bottom thing and the top part. So you can see like it looks like a keyhole that you can identify two separate lesions. Okay. So why do we have those end up lesions. Obviously we do have communication between the periodontal and the end part of the tooth through apical foramen lateral canals the dental tubules the drainage other anatomic entities. So as you can see here you can have accessory canal sometimes ranging up to like 60%. You can see on the mid third of the route you can have accessory canals. And obviously I'm sorry on the crystal part you can have exposed tubules at the CG about 80%. So there are different reasons why those 2nd May communicate and affect each other. And as we discussed before, clinical approach is very, very important to have to go from your differential diagnosis to your final diagnosis identified through combined and downtick periodontal lesions. Identify. As I told you, that's a very big chapter and discussion on that. There can be a periodontal lesion that just shows up because of an endo daunting component. And the only component that shows up because of a periodontal lesion. So you can have different ways over there, but usually when the cause is under the tooth is not vital. So you need to do an end of treatment. Obviously when there is a periodontal issue, the truth is vital. And you do periodontal treatment. And when you do have those two combined and lesions, you need to do both treatments, but you need to do and don't seek treatment first. Otherwise the prognosis of the tooth may be detrimental because you will be just affecting tissues that are not affected with barrier. Okay, just for your reference, that's how they have classified within your classification with subcategories with deeper pockets, etcetera. Nothing to worry about that. Now I'm not going to ask you about those things, just having it here as a reference. The important thing is to identify and recognize when something presents as an end up lesion and what kind of treatment you do first. You first assess and you treat the underlying part, let it heal and then you go with a periodontal treatment. Clear. All right. And now let's go to this last category which is amazingly long. It seems short but it's not. So this is a very very big category which we have developmental or acquired deformities and conditions. And they have four main categories. And then all these categories have a million subcategories. But we're going to start one by one. First of all this is coming up very very common as localized tooth related factors that modify or predispose to gingival inflammation periodontal disease. So what does this fancy thing mean is that you're having a tooth. Just a local factor tooth related factor which can be anatomic. It can be a dental restoration or something that makes the actual clinical representation look possibly worse. You can't compare it for sure, but definitely it's there and contributes to that. And what do we mean with that? For example, you can have anatomic issues like a palatal groove okay. So if you're having this clinically you're having a little groove no matter how much plaque you may have on the neighboring teeth. You see that here? You have such a big distraction on the bone over there because you have a thin line, you know, bacteria can come there. And if it happens that this area breaks down, obviously the distraction may be more severe. Does it mean that every two that has that may have this thing. No, but. They're more prone to develop that. And if you see that clinically before anything develops, you need to write it down and alert the patient and know that whenever you're seeing them, you're investigating that area before ending up with a severe lesion like that. Okay. You can have cavities in the vacation. That's another huge topic. With fractions. You will see that a lot of things are associated with for teeth and how they are. Because over here this is so narrow. Some vacation entrances is like 0.6 or 0.4 millimeters. The curate cannot even get in to clean those areas. So obviously accumulation can happen very nicely with all the breakdown that we know with plaque accumulation, calculus formation. ET cetera. You can have the CP, the cement enamel projections. I think we talked about those in our anatomy class briefly, which can cause some issues with the friction. You can have the enamel pearls. We talked about those as well. Route proximity. So what's the issue with the route proximity. There is sometimes barely any bone on that side. Or if and if there is present, it's so, so thin, so in presence of inflammation induced by plaque or anything like that, you just more prone of losing these bone, losing attachment around those teeth. And on the other hand, you can have open contacts. That's our job not to do that. Because what's wrong with the open context? Usually they're associated with more food impaction. And a lot of research has shown that food impaction is associated with greater attachment loss, bone loss, inflammation and pocketing in those areas. Okay. So it's very common that you may see that everything is fine. And whenever a contact is not being done properly, that you have more bone loss on that side with more inflammation and deeper pockets occlusion. Obviously, apart from having the crowding or misalignment of the teeth with route, proximity and everything like that, you can have traumatic injuries on the soft tissue, the teeth and the soft tissue process. So it's something to. To appreciate diagnose because in those patients you will have different treatment approach. You may consider orthodontic treatment. You may consider extraction. If the teeth are hopeless you may consider different things to fix whatever is happening on that side. So these are mainly like tooth anatomic factors that can play a role in dental restorations. We talked about those already. With the open contact a very common one can be an overhanging restoration where the patient here had a lot of inflammation in the upper pocket. And you will see here that it's not only these super nice cute overhang that can cause this thing. We also have an open contact. So it's a combination that can cause the inflammatory process here. And the thing is, sure, if you're getting like a five, six, seven millimeter pocket and you go and you do the perfect SRP in the world, unless you address that, you will not see the outcome you want. Okay. So you need to remove this assess obviously if the tooth is restored or not, and place a better restoration with a better contact and everything that you need to do a similar thing over here. When this patient presented and it had almost like A67 millimeter pocket from six from the buckle, and about seven ish from the palatal on these tooth. And when we open to see what's happening there, it had like a very nice shelf of composite. Obviously, no matter how good the patient is brushing, these can create issues on that side. Okay. Sub gingival crown margins. I'm not going to go too much into your restorative and prosthetic course here. But obviously you understand that wherever you're placing your crown margins, if you're violating as we're going to talk in the next slide, the biologic width, you will have constant inflammation. I've heard like, oh, if we do violate that and we get inflammation and resorption, it's like we're doing a natural crown lengthening. No, that's not how it works. Okay. So don't think like that because this is very unpredictable. Patients may just stay with chronic marginal you know gingival inflammation like that a lot of bleeding sensitivity. And then trying to fix that may cause more destruction around the teeth. It's very very important how you design your margins, how much sub gingival you may be able to get. Because again, I'm not here to teach you the restorative things, but there are designs, especially in the esthetic area, that you can get slightly in the circular area with. So inserting into the biologic width that we're going to learn here but not violating that okay. So there's different ways to approach it. But you have to be very, very careful when you do that. And the solution is not just deliver your crowns. And then said, oh, we should have done different design, we should have done a crown lengthening or we should have done anything like that. So regarding the biologic width, I'll tell you what. All the textbooks and everything. Right. Again, as with everything in dentistry, we have disputed that as well. But what I need you to know as a biologic width, we call it about three millimeters. Because in this landmark study on the 60s, they measured in cadavers this tissue like how much is the epithelial attachment? How much is the connective tissue attachment. You remember from the anatomy. You're having this junctional epithelium the connective tissue and then the bone right on. And they averaged about a millimeter. So 0.97 the same with connective tissue a little bit longer like 1.07. And they said okay let's put about half a millimeter or a millimeter of a cellular area, which brings up to three millimeters. And everybody is thinking about those three millimeters. Again, I'm not going to give you a lecture on that. Now that's another three hour topic. But keep in mind that this was done on cadavers. So it's completely different compared to live human beings. These are averages. And a lot of studies have shown that the biologic width may vary from like one two millimeters to even six millimeters. Right. So without confusing you more what I need you to take back from that. Sure. That's a nice guide and have it in your mind because it's a lot of cases fall under this category. But you always need to measure before you do a procedure and understand how much the biologic width is on that specific side, because it can change from 2 to 2 and side to side, especially if you go to more advanced cases, you can see different measures from one side to the other side. But keep in mind this one. This is what you will see most commonly happening. It's a good as a guideline, but again, keeping in mind that there can be exceptions and areas going with deeper or shallower biologic width. Questions on this one. Nope. Yes. Yes, you can measure the biologic width, but you need to anesthetize the patient because if you want to get through the junctional epithelium and the connective tissue, that's painful. So you can't do it without anesthesia. So usually when you're let's say prepping a tooth you understand the patient. The patient is numb. So you can easily do your bone sounding and measure the biologic width. If you're doing an esthetic case, for example, in the front and you're having other factors that you need to change the architecture, again, you need to numb the patient and take those measures and see how much this distance is from the crest of the bone to your gingival margin, and then know how deep your sulcus so you can. But you need to anesthetize the patient. And especially with the esthetic cases where how things look matter a lot. There are specific markers that you mark on the tissue where everything is so that you know how you do your procedure. If you need to do a crown lengthening there. You're welcome. Yeah. Yes. So? You know, on the spot if you follow. Okay. The question is if if you feel the bone and how you know that you're correct. It all depends how you place your probe. Because obviously if let's say your probe comes like this and you come this way, you may end up like that, okay? So you need to just follow the anatomy of the tooth and you will always reach the bone. If you do the technique correctly, you will always reach the no matter how thick the tissue is. If it's thicker, you just need to push a little bit more. Anything else. Extra cost to the tissue fibers here. Yes, I know, I know, I know, we don't do it like routinely, but yes, this is something a very valid point. Like you, you damage those things, especially if there is no disease or so. So that's not something that every time a patient comes, oh, let me measure your biologic with the patient. You start poking them. Right. But for specific procedures that especially, you know that you will require a surgical approach. You will cut through this area anyways. Right. So knowing in advance how much you need, that's not going to do like any additional harm. On the other hand, when you're prepping, there are sometimes people that are prepped and they just cut off all the gingiva. That's if this probe is a damage. This is a massacre, right? So it's better to know in the beginning what's happening on that side. Specific points around the tooth where you. Know, you go through 60. Because keep in mind and we're going to move on with that. Keep in mind that, I mean, if you have a true, you know, virgin tooth that you need to prep for whatever reason, it you still go through 60, but it may be easier for you to identify that. But if you're having a decayed tooth or a fractured tooth, you have an irregular margin. So you need to go around to the whole tools to figure this out, okay. Root fractures obviously we talked about those again previously. So root fractures are usually associated with deep isolated pockets like we have had in these tooth. The probing is everywhere else were fine. We just had like a very deep nine eight nine millimeter pocket on the medial. And obviously if you barely can see it here, there's a fracture, a crack line. And when you extract and you try to stain it, you will see that the crack line extending all the way down. So obviously this can create let's say you're having a very deep pocket on this tooth. The way you would diagnose that, you would say that a localized tooth related factor that predisposes to that periodontal destruction, and it's a vertical root fracture. That's how you would write it down. And finally cervical root resorption and segmental tears. So for cervical resorption it can be a case like that. That was a very young patient of mine about 15 or 16 years old. And he had also this soft tissue lesion. And the parents were obviously concerned. But these tooth had a cervical resorption on that tooth. It caused the periodontal issue inflammatory response with a combination with another soft tissue lesion. That biopsy showed that it was just inflammatory. Or you can have a more severe case of cervical root resorption. That's one case out of a lifetime. Again, I only had one patient like that. We thought initially that was caries. But all these patients teeth had a root resorption surgically. The whole dentition like it just very rare thing. And obviously you can see how the gingiva can change usually with inflammatory approach but also with a lot of sometimes repair don't have issues if the patient is more susceptible to Bourdon theories as well. And regarding segmental teres. So this can be tricky. And they come more and more interpretation of the clinician. So they usually look like a very thin line you see like that. Yet sometimes we say maybe it's part of the bone. Maybe. But it's not like a true clear fracture. So that was a tooth that had segmental tear as you see here. So it's as you see, all the area over here was just detached. And it shows like a weird thing. Is it bone, is it tooth. Is it fracture. And obviously there usually you have deeper dental pockets because it's something attached like a foreign body creating inflammation. And usually the teeth with those cement alters cannot be maintained because they're more prone to further tear and having periodontal issues. Yes. The previous case? Yes. This one, right? Yeah. I mean. Do you expect. Yeah. Yeah, yeah. So again that's another discussion. Like for all those things, if you want to assess why this happened, as she correctly mentioned you see some internal staining here. And this is very typical picture of intake of tetracycline either for the patient when it's actually a male when she was a kid or when he was in the uterus when his mom was pregnant with him. So. Sure he denied that for your reference, but obviously excessive forms of internal bleaching can cause that. If you want to hear other things, there are etiologies of case series that specific feline herpes virus that cats have, people can get and they get those things. So there have been reports with that. He he happened to have two cats. I don't know if this is the case, but sometimes those things just happen idiopathic and you can't know you're suspecting things that may have contributed or made it more exacerbated and exaggerated, as you see. But I don't have like that what it was. Okay. All right, let's move on. So this is everything okay? Yeah okay. So gingival deformities and conditions around teeth now. So this is a big category that comes very very frequently because as you can see here. And we're going to go step by step. It has to do with how the gingival tissue is around the teeth. So first when you can see very often is like having gingival recession. And we talked about gingival recession is when the free gingival margin is displaced more quickly. You see the gingival margin used to be here about a couple of millimeters above the CG. It's displaced more quickly exposing the root surface. So you're having the facial recession. So we said we're going to have facial recession. You're going to have palatal lingual recession. You can have intra proximal recession as you see over here okay. So in these tooth when you would know down you would. Uh, you wouldn't write down the specific amount of recession, both in the battle side majorly digitally, etcetera. You need to be familiar with the classification of the recession. This is the one that has been used very, very widely, still being used. And the next one I have is the more recent one from Cairo. So let me show you here. So something to keep that in mind and have it easier. How it works for class one and two you do not have inter proximal attachment loss or bonus. You have facial recession for the class one. It extends before you reach the gingival junction. For class two it reaches to the gingival junction or beyond. For class three you have intra proximal attachment loss and obviously facial recession. But this inter proximal attachment loss is less than your facial recession okay. And the class four is when you're having again intra proximal attachment loss and facial recession. But their intra proximal one is equal or more than that. So what is the relevance. And the difference in that is it depends on what you're going to be doing in each category and how successful your treatment will be. If your patient says, here I have recession, you can propose, let's say, a soft tissue graph to cover that. And because you have good intra proximal attachment loss, no attachments actually there, you know that you can be 100% successful the moment you start losing bone. And approximately you know that you cannot cover the recession fully because it's all about biology. The graph needs blood supply. Blood supply comes from the preparation of the area and left and right medial distally from the inter proximal levels. If they're reduced, you can't just bring the gingiva where it used to be before because the bone is not there and you can't grow that back. Okay. So if a patient comes here and says, I want to cover this root, I said, sure, but you may we may succeed up to 78%, depending on how much the attachment loss is there. If a patient comes here and says, I want to cover these roots, I said, I can't do that, right, because there is nothing to support that. And if I was even able to cover something would be usually up to 10%. Okay. So that's the importance to classify that because you need to know if you can do something and how successful you can be. There are times that patients are being sent like, I have recession, I want to cover it up and they're like that. And I say, yes, you do, but I can't do anything for you, right? So being realistic with that. So we have the newer one from the from Cairo. So just make it easier for you. He just merged the class one and two that we saw before those two. He merged those two into one saying you know I have facial recession. It doesn't matter how much before at or beyond the micro gingival junction, you just do not have attachment loss into approximately the type two. You have into proximal attachment loss, which is less than the facial recession. And the class three is you're having intra proximal attachment loss, which is more either with the presence of deeper pockets into proximately or with reverse architecture or anything like that. So it's exactly the same thing. And success rate of soft tissue grafting is the same as we said, 100% on the top after like 70 or so percent on the the second one, depending on how much in the proximal attachment you have. And obviously here you're not expecting any root coverage, especially if you're having a personal issue going on. Clear. Should we learn both? Yes. I'm telling you which things you shouldn't learn. But yes, because when you classify that, you will say that's recession type 1 to 3, or according to Kyra or Miller, class one, two, 3 or 4. Come on. I made it so easy. I did not. I mean, if I tell you you have a tool that has recession five millimeters and no inter proximal attachment loss, you know, right away it's type one. You don't have to think about it. Yeah. Already. Like when I go got lost. Like there. There. Yeah. So it depends. You can have a deeper pocket and you can have an active periodontal disease, or you can have a shallow pocket. Just reverse architecture because of however disease was treated before. It's not like necessarily active burden of disease for you to have. Remember active dental whatever we say active we can't know how activity is when we see that. But you need to have findings like apart from attachment loss, you need to have deep pockets. The bone loss obviously inflammation bleeding on probing. So you need to have all those to say okay, we actually having periodontal disease that we need to treat first before we decide about recession. Clear. What's up? You're in the. Yep. Even though you have the. Yep yep yep. Because that's an additional thing that is there. That's not how normally the gingiva look. Right. You see something that's not that's why we learned the normal anatomy right. You see something that you need to diagnose and say okay I'm missing tissue facially that's caused that's called recession. Now if this necessarily means that you will do something that's a different discussion. And another topic that I may give you that lecture next year, but not now okay. But it's the same thing. Like if you're seeing a dental finding like caries or it carries a small fracture, a cheap tooth, I mean, if the tooth is chipped very slightly on one corner, it doesn't necessarily mean that you're going to build it up or do a crown or something like that, but that's something that you see and you need to identify. Okay. So second thing will be lack of attachment is tissue. So what does it mean. It means that you either have no masker or mucosa present. So you just have the alveolar mucosa or you do have muscular mucosa but it is not attached. So how can this be. It's if your the amount of muscular mucosa that you have present is equal or less than the probing that you have on that side. Should I say that again? Yes, yes. Okay. Let me go to this picture. So you can have no masticate or mucosa or lack of attached tissue if you just have alveolar mucosa. Remember we have first the muscular mucosa and then the alveolar mucosa separated by the mucus gingival junction. Okay. If you do not have the mask or mucosa. So a nice tissue and you just have alveolar mucosa. That's a straightforward we don't have tyrannized tissue over there right. You could have let's assume you have. Yeah. The mucus gingival junction is let's say right here you could have some muscular mucosa being present 123 whatever millimeters. But if on that side your probing is reaching to the mucus gingival junction or beyond, even if you do have this nice tissue there, it's not attached on the tooth. So it's exactly the same diagnosis. Make sense? So. Usual? Yeah. No. It's okay. We can do it again. Let's go here. So this is very evident. So you see where the tear. Nice tissues here. They mask. Sorry. The mucus. Gingival junction okay. So this is all nice tissue. Muscular mucosa. This is alveolar mucosa right. So let's assume your mucus gingival junction was going up to here and then down there okay. So these tooth would have no cure. Nice tissue. So you would diagnose I have a lack of cure. Nice tooth. Number 25. Clear. Now let's say your mask at mucosa is as we see over here. And let's assume these measures are three millimeters. Okay. If you're probing here and your probe stops here in one millimeter, you are having two millimeters of nice tissue being attached on the tooth. Perfect. I'm fine with that. Okay. And that's usually what you see. But let's say you're having three millimeters here and your probe is four millimeters. So it goes to the junction and beyond. So you're actually in the alveolar mucosa. Even if this thing is present it's not attached. So again this is considered lack of attached tyrannized tissue. You may have it but it's not attached. So it doesn't offer anything because what's the benefit of the tissue versus the alveolar mucosa. We learned about the that in the anatomy know the junctional epithelium the connective tissue attachment. Everything that you have over there that's supporting the attachment apparatus of the tooth are clear. So that's what you're going to do. So when if you're having so much of your anticipation this actually is not three. This is at least like 5 or 6mm. In order for you to not have any of those tissue being attached, it means that you have deep pockets in all those sides. Right? So that's shows a periodontal disease. Or you can have very thin. You can have only one millimeter, one millimeter, one millimeter of mass or a mucosa over there. And you always get a circular area right. You always have a sulcus even without having a deep pocket. Again, if you're having one millimeter of here, nice tissue. Usually that's how much you sulcus is. None of this is attached okay. Now again I'm not going to go into treatment. Now does this mean that you need to do something. Not necessarily. It depends on the case, but it's something that you need to recognize because there are more. There are areas that may be more prone to inflammation, tissue destruction, loss, recession, etcetera. Clear. Yeah. Okay. So and as I have here, we also consider that as a bio type within your classification we call it like phenotype because it's what we see which makes sense. So what we see here we usually have a thicker or a thinner could be combinations but the patterns of both. And that's why I have all those things here are pretty much similar. With the thicker bio type you're having thicker tissue could be a little bit more flatter architecture, but you're having a lot of bone underneath, maybe more square teeth, more resistant to trauma of inflammation. But if you're getting inflammation, you more probably having increased probing depth. That's why we said here you will have deeper pockets if you're getting any periodontal issue. On the other hand, with a thinner bio type you can see more triangular teeth. It's so thin that you can even see the probe going through. It's as a thinner tissue. You may have underlying deficiencies. As we talked about in our first second lecture or fenestration or anything more prone to recession, inflammation and causing recession because of any kind of trauma or inflammation of because of bacteria being present clear just to know how you would see those clinically decreased vestibular depth. When people are dentate, you may not see that too frequently, but it can happen, especially in the lower arch. Usually this may be accompanied with recession and lack of tissue. So usually to find that it means that the tissue has gone so apical you don't have enough vestibule. So again this one would require a specific treatment approach. A periodontist would tell you what to do that, but you identify that and you say to the patient and Farnam again, if a funeral attachment is very high, may act as a contributing factor to existing issues with inflammation, recession and lack of care and tissue. You know this down because again, if I see this patient, my approach of treating that would be different compared to somebody who wouldn't have an abandoned frame over there. Okay. You would need to eliminate it and know what kind of surgical technique you would have regarding gingival excess. So one thing that you can have is what we call the pseudo pocket. And as a reminder you have the normal circular area we said about before. You see how you probe and you stop right above the junction. So that's the normal sulcus. You have a true periodontal pocket as you see over here. So you're probing and you're having a deep pocket. And depending on where your free gingival margin is you can calculate how much attachment loss. We went over that a little bit briefly last time. But just as a reminder the probing depth is being measured from the gingival margin to where your probing your probe is ending. Okay then to see how much attachment loss you have, you need to identify where your key is, because the attachment loss is measured from where from the siege to the depth of your probing. So if your gingival margin is at the whatever you're probing equals your attachment loss. If your free gingival margin is more coronary to the edge, then whatever you're probing is minus this part that is above the CG to find your true attachment loss. Okay, so if you're having a nine millimeter pocket and your free gingival margin, as it says here is three millimeters above the CG, your true attachment loss is six not nine. Right. And if your free gingival margin is more likely to the CG that means you have recession. So you're adding the recession and the probing to end up with your final attachment loss. Make sense? You may need to read that again and again to have it in your mind, but that's the super basic thing to identify the attachments. Okay. Now what is a pseudo pocket. And I'm going to become like this typical Greek person. That's a Greek word. Pseudo means a lie. So it's not a true pocket. Okay. Well it means that you're getting a deep number like more than three millimeters, but you're attachment. It's still at the siege. Right. So whatever you're probing is above the siege. So yes, you're having a deeper number, but you haven't actually lost attachment. So this case can happen because of inflammation medication and stuff like that. So those patients do not need scaling and root learning because there is no root exposed to do a root planning for right. Yes. They need scaling sub gingival scaling to clean that maybe additional treatment, maybe gingivitis, maybe a bunch of other things. But that's a different thing to identify. Make sense. Good inconsistent gingival margin. Obviously we know how gingival margin should look versus an area where things are inconsistent. You write it down. This is more important in esthetic cases, especially if you're planning to do restorations or grafts. It helps you to establish a proper architecture on those areas. Excessive gingival display this is what patients call I have a gummy smile okay. Which means that they show more gingiva. Again, this goes into another whole topic of addressing those excessive gingival displays. Depending on what the patient has, you may need several different techniques, from gingivitis to crown lengthening to lip repositioning to orthographic surgeries. Right. So it's completely different. We're not going to go into those now. Gingival enlargement this kind of have has a lot of things included. Like you can have the enlargement because of inflammation medication hormonal changes the mouth breathing, the fibro mitosis. We went over those things in previous lectures as well. So obviously here you can have enlarged tissue. This may not be true pockets or here you may still have three pockets but you also have enlargement. So every case is being treated differently. The goal today is not for you to know how you will be treating those. You will learn that down the road. The goal for you here is to recognize and identify, okay, what is going on here? And if I can do something, what this will be, you will learn about that or if I need referral, what I'm expecting for this to happen. Okay. Mouth breathing. You can see mainly on the on the anterior area the altered passive eruption. This is also part of the gummy smile. So there's a lot of things that can play a role there. Regarding abnormal color. We do know the normal pigmentation that's considered totally normal compared to something somebody that has a melanoma for example. Right. So needing to identify those. So a similar thing is similar things actually can happen around the edentulous ridges okay. When you're not having teeth and you are seeing that pretty much is the same thing apart from the first one, which I'm going to talk to you about, about that right now. So this is when we call like ridge resorption. Ridge deficiency. This is different compared to the bone loss that we are saying around teeth that are, you know, having periodontal disease or so this is like you're taking removing teeth and the ridge reserves naturally over there we lose the bone, bone and everything, especially if you do not do ridge preservation techniques. So you can either have a horizontal resorption which means basically lingual that consider horizontal right. So parallel to the ground okay. And that's considered a class one. You can have vertical ridge resorption which means that the bone has resolved in the apical coronal direction okay. So you see instead of the crest being here it has resolved like that. Or you could have a combination of both which is pretty frequent, especially if you're having infections on T that were extracted. Traumatic areas. ET cetera. Especially if you don't do preservation. So this is class three. So remember that class one horizontally. Class two vertically class three both. Clear. Okay. Lack of care. Nice tissue. The same thing. Obviously you identify that because depending on what you want to do in terms of rehabilitation, either it's a fixed or removable may have an issue. So you need to identify those. For example a case like that where there was no cure. Nice tissue. Patient one in an implant. We didn't have enough tissue. But you can do, for example, like soft tissue grafts to enhance the amount of tissue present and have a better soft tissue profile in those areas. Gingival enlargement. You can see that even if you don't have teeth and can be contributed to many things apart from the medication and everything, even like bad prosthesis, etcetera. So you identify those, especially if you want to do like removable on cases like that. It may not be easy if you're having that much like flabby and large tissue urban attachment. Similar thing, especially if you're planning for any removable. Those muscular attachments may be on your way, and you may need to eliminate those decreased vestibular depth. That's way more frequent in the loss patients, especially on the mandible when the bone the ridge reserves. So something that you identify because all those things can have impact on your procedures and what you will be ending doing. Right. If you're trying in a flat ridge like this, making, let's say, a removable denture, it may not work for the patient, right? So you may want to explore different treatment options for the patient. And the same thing with the abnormal color we can have normal pigmentation in the patient's right. It doesn't mean because we don't have teeth we don't have the normal pigmentation. But obviously if you're having other areas either white color, darker color or anything that you need to investigate further, it's something to consider as well and write down, because some of those may even require a biopsy or something like that. Questions with that. Okay. Do you want to have a break because this occlusal trauma is intense okay. 9:00 eight minutes nine eight minutes. Okay. Let's go. You got two extra minutes. You're having. What? When? Excellent. You're going to all right in here. Because in case you haven't realized it, I'm going to confuse you even more. Now about why but a. Why. You will see better. Why? Why? So I didn't say that. That was when I was a second or third whatever dental student. The professor came in and said, okay, today we'll talk to you about occlusion, which means confusion. And I said, great. I'll try to again make it as simple as possible and hopefully I'm able to do that. So what does occlusal trauma mean. And now we're talking from a periodontal perspective okay. So I don't know what the test is going to be about. But we're talking about a personal perspective okay. About confusion. So it's the injury to the periodontal that is caused by occlusal forces which forces like exceed the reparative capacity of the attachment apparatus. What does this thing mean? You're having forces on the teeth that the teeth themselves cannot resist and adjust on them. And that's has some clinical signs of injury on the teeth in the period on you. Okay. All right. So it could have those forces can have an injury on all the parts of the mascot or a system with teeth, TMJ, muscles, attachment apparatus. And as a reminder, the attachment apparatus with the cement, the PDL and the alveolar bone. So there are two concepts behind the occlusal trauma which kind of contradict are so so weird, right? What's right and what's wrong? In my opinion, it's the truth is somewhere in between. Okay. And I'm going to make it as simple as possible. So Glickman was the first one who said, okay, we have two zones here of on the gingiva. He called the zone of irritation the top part, which is the area that includes the marginal and intra dental gingiva. And he said that whatever inflammatory process you get here is because of bacterial plaque, not because of occlusal trauma, which is true. Right? Whatever we've been hearing that occlusal trauma can cause recession. It's not proven right. You cannot just start losing gingiva because of the occlusal trauma on this marginal tissue. Okay. And then he said that we have the zone of destruction, which includes the attachment apparatus of the PDL, the roots and Mendham and the bone. And that is the area where excessive occlusal forces have an impact on clear. So and all this, you know, it's being separated with those transect fibers that we learned. So if you are having like an inflammatory lesion gingival it can either spread outside the crest of the bone and inside like in the PDL area. So he said that if you do not have occlusal forces usually you're having these spreading to the gingiva. We will learn about the inflammatory process and starting with the crest of the bone. And that's why you start having horizontal bones. But if you're having additional excessive occlusal forces that are exceeding the reparative capacity of the tooth, then this goes to this area of the destruction in combination with the inflammatory process from bacteria. So that's when it's this area is being affected. And that's why you will start seeing angular bone loss. That was the concept behind that. And he had a histology here showing this is a tooth without occlusal trauma. Obviously we do have bone loss. But you see it's horizontal on these tooth. But these two has occlusal trauma. And you see you're having an angular defect a little bit less medially but more distally which can also be seen histologically. Make sense? Yeah. It made sense to me as well. And then where? How came I said that doesn't exist? So what he said is that I don't. He didn't have the proof that those forces are a co factor to form angular defects. Is this true? Yes, because you can have angular defects on teeth affected with period disease, even if they do not have occlusal excessive occlusal forces. Right. So he's not totally wrong with that. So I don't know why they are you to be honest. But whatever. So he tried to do some research and showing that he can have angular defects in teeth that do not have excessive forces, and that you could have either a horizontal or angular bone loss independent of if you're having these excessive forces. And that's what he did here. Like you see I have this tooth which doesn't have that's a minus doesn't have occlusal forces. But I do see that the perio issue with an angular defect is on these tooth without excessive forces. And this one that had some occlusal forces didn't have that. So you know how exactly those experiments were done. I wasn't there to know this. But on the other hand, depending on the amount of forces, the magnitude of forces, the direction of forces, this can have a completely different impact on the teeth. Right? So as I told you, the truth lies somewhere in between, right? Yes. I've seen many, many times teeth that are having excessive occlusal forces, having those super sharp angular defects around them. I've seen teeth with excessive forces that just have horizontal bone loss and widen. PDL. Right. So it's in between. You can have both. I have this to you as a concept of how things work histologically and clinically, and understanding kind of the path of physiology of occlusal trauma. Clear with those two opinions. All right. So what you need to know about the pathology of occlusal trauma is that you're getting the injury. You're getting a repair and then adaptive remodeling. So with the injury you're starting having those excessive forces that caused the injury the teeth I mean the downtime tries to get repaired. In which way if the forces cannot be diminished, the tooth shifts or drifts away, tries to remodel over there and you're having various areas of pressure and tension around the tooth in order to try to adapt in this area and what you see clinically, you can see widening of the PDL, some angular bone loss, but usually no periodontal pockets unless you have an independent periodontal problem. I need you to realize that you can see radiographic on a tooth that has an radiographic has an angular defect, and you cannot probe on that tooth. You can see radiographic like bone loss and radiologic. That's completely different than having an angular defect because of perio disease. Those angular defects caused by those excessive forces are, as I call in, a kind of protected, closed aseptic environment, not communicated with the inflammatory process. And whatever you see, radiographic it's not actually true bone loss. It's the mineralization of the bone because of the inflammation happening in the PDL, because of the forces. What's actually happening when you're doing ortho. Right. That's what you would see. If you take that force away, the bone will mineralized. Again. That's completely different than having an angular bone loss because of true dental. True bacterial. What's the word? And biofilm induced inflammatory process. I don't have the right word in my mind now that starts developing, exceeding and progressing to the periodontist, causing maybe an angular bone loss. In that case, what you see radiographic as angular bone loss, that bone is lost. It's not that you're having a mineralized bone. The bone is lost if you're having a true like bone loss on that side. So that's why it's important to understand that if you're not having an underlying periodontal issue, you may see angular bone defects, radiographic, which are not true. Korea don't sell boneless. It's just mineralization. It shows as a defect and darker because the matrix is lost, classification is lost and radiographs just show shadows. Different levels of shadowing there depending on how thick the tissues clear. Yes. The two with the bone is just the minerals. Yep. That's of course if you served by an x ray. But then you're saying you. Can't get in there. You don't get a deep pocket, you don't get it deep. And that's something that differentiates because some another mistake that people do. Let me diagnose a patient from radiographs. No no okay. Because yes they can give you information but you can't know what's happening until you see them clinically. And if you see a radiograph and you see full of angular defects or let's say two tooth and angular defect, you will say, oh, I have theories on this tooth. And if you go and you have nothing, that's a thing. This tooth most probably has occlusal trauma. And usually you have also widening of the PDL tooth mobility etcetera. So what happens with that injury phase. You have slight areas of tension and pressure. So pressure and they go like in opposite directions okay. So you start having we said that I think last time or two weeks ago I don't remember when you're pressing you're having bone resorption. That's how it also works right. Why. Because we need space there for the tooth to move wherever we're pressing. It's not that I'm pressing. So I have less space. So whenever wherever you're moving away you're having bone apposition. So depending on where you are in the lighter areas you can have some bone resorption wherein of the PDL, some PDL fibers elongating a position of bone. If this pressure becomes greater, then you will start seeing that kind of. Those two areas may even merge together. But what ends up happening is that the PDL gets way more widened. You're getting all those injuries to the fibroblast compression of the fibers, vascular changes. So depending on the amount of pressure you can even have increased bone sometimes even tooth resorption okay. So those two areas kind of merge depending on how much pressure you're having. And that's where you're having more exacerbated clinical signs clear with the injury okay. When the injury happens then the body says okay we need to repair whatever happens here. So they try to repair this with new connective tissue cells and fibers, bone and cement them. They try to form new bone. And this repair process happens as long as the reparative capacity is more than the traumatic forces. Okay. Every Tuesday morning. I need to check with their schedule since last year. So as long as every part of capacity of the president you exceeds the traumatic forces, you keep having continuous repair on those on these injuries that is happening now. If you're ending up to the point that the forces exceed the reparative capacity of the president, you, then that's when the president is being remodeled. And your the forces may not having like, you know, having injury but you may be having more like of those fondling the angular defects the bone PDL. So that's when you're seeing more exacerbated symptoms. Again assuming there is no burden is present, there is no pocket formation because of the occlusal trauma. If if they I hope they ask this question in your exam, there is no pocket formation because of occlusal trauma. It's only if you're having an already existing underlying periodontal disease. Make sense. All righty. And regarding the movements we're having these like tipping movements. And again the zones of pressure and tension depending how you having the forces the tooth may be having this tipping movement with excessive forces. And you're getting those alterations. And again you do not get an attachment loss. But when you're taking that force away then these whole. Periodontal tissues can get regenerate again. The time you remove the excessive force then everything will regenerate again. And then you can have the bodily movement where these areas of pressure retention or kind of merge together. This can happen with ortho treatment. We actually had a discussion during the break here. How you may shift the teeth either bodily or tipping them left and right. So again, assuming inflammation is controlled, you're not expecting any clinical attachment loss on that side. Okay. That's how we work now down to the period part, which things you need to know. We have two parts of occlusal trauma the primary two subcategories the primary and the secondary. What I need you to keep in mind, what we call primary occlusal trauma is you're having excessive forces, but you're having normal bone levels and normal attachment levels, okay. You're having excessive forces on a normal periodontal. And obviously here you can see an extreme case that apart from mobility, we had excessive wear because of the forces and everything. And what I need you to keep in mind the primary occlusal trauma does not cause gingivitis. The primary occlusal trauma does not cause burden. Titus, you do not have bone loss or attachment loss because of a primary occlusal trauma. You are not having changes on those attachment levels and you do not have pocket formation. You only have mobility and radiographic changes which are completely different from what we know as peridotite is what we learned either chronic or those staging. Is it clear? Okay. And now you're having the secondary occlusal trauma where you're having again excessive. They used to say normal. But you will see that they change it with the new classification, which is good because how can you measure the normal forces anyway. You're having excessive occlusal forces, but you have underlying bone loss and attachment loss. And why do we say that secondary. Because if your bone support has been reduced in the attachment, then obviously the forces may be more traumatic compared to having a good periodontal suppor