Latest Classification of Periodontal disease.

1. ‘’DEPARTMENTOF PERIODONTICS AND ORAL IMPLANTOLOGY’’
GOVNERNMENTDENATLCOLLEGE& HOSPITAL, SRINAGAR.
Presented By:-
MUMTAZ ALI PG (3nd Year)
Under the esteemed guidance of ;-
Prof. Dr. SUHAIL MAJID JAN (HOD)
Dr. ROOBAL BEHAL (Associate Professor)

2. You ask what is the use of
classification, arrangement, and
systemization???
I answer you : order and
simplification are the first steps
toward the mastery of a subject –
“the actual enemy is the unknown”.
Thomas E. Mann. Thomas E. Mann with Albert Einstein

3. •Helps to develop framework to study the
Aetiology,
Pathogenisis and
Treatment of periodontal disease.
•To differentiate between different diseases process.
•For diagnosis, prognosis & Treatment planning.
•To communicate among
Clinicians,
Researches,
Students ,
Epidemiologist and
Public health workers.
SO WHY DO WE NEED TO CLASSIFY PERIODONTAL DISEASES???
- (ARMITAGE 1999)

4. HISTORY
MAJOR LANDMARKS IN
THE CLASSIFICATION OF
PERIODONTAL DISEASES.

5. Classification of periodontal diseases and conditions, American Academy of Periodontology (1999)

6. DRAWBACKS OF AAP 1999 CLASSIFICATION OF PERIODOTNAL DISEASE;-
American Academy of Periodontolgy (APP) Classification:-
 Quite comprehensive, so many classes and sub classes were included clinically difficult to remember all these
classes and sub-classes.
 Earlier classification system were simple, however they did not include many disease and condition that affect the
periodontium.
 The differentiation between chronic and aggressive periodontitis???
Now recent models of periodontal disease such as;-
Non-linear progression of periodontal disease by -Kronnman, 1997.
Multi-level hierarchical & biological model by -Kronnman 2008.
Biological system model -Offenbaker, and
Recently given contemporary model of host microbial interactions for periodontal disease
progression by -Maley & Chaple2015.
All of them they have one thing in common periodontal disease do not have a liner disease progression. Chronic
disease in its active phase may demonstrate clinical feature which mimic aggressive periodontitis. So sometimes it
is very difficult to differentiate between the aggressive and chronic periodontitis.

7. Another problem with the 1999 classification system was their was no category for gingival
and periodontal health.
Not based on the microbiological features or genetic factor that control the clinical expression
of diseases
Also, all the risk factors are not considered eg. Smoking and Diabetes. (Armitage 1999).
Lastly their was No category for Perimplant diseases and classification . Now Implant therapy
has become an inseparable part of Periodontal therapy and there are so many treatment which
are based on implant therapy, so all the disease and conditions that were associated with the
implant therapy or peri-implant tissue, mucosa they needed to be included in the new
classification so they have been included in the new classification system which was absent in
1999 classification system. (Armitage 1999; Devi and Pradeep 2009)

8. These drawbacks are not the only reason we needed a new classification system, since
1999 a lot of research has been done in the field of periodontics and implantology,
substantial new information has emerge from population studies, basic science
investigations, and the evidence from prospective studies evaluating environmental and
systemic risk factors.
Now 20 years is a very long time and many diseases and conditions they needed to be
redefined that’s why this classification system was the need of the hour .

9. The new classification is a product of the world workshop on classification of periodontal and peri-
implant diseases and conditions, held in Chicago in november 2017.
The world workshop was organized jointly by the American Academy of Periodontology (AAP)
and the European Federation of Periodontology (EFP) to create a consensus knowledge base for
a new classification to be promoted globally.
The new classification updates the previous classification made in 1999.
The research papers and consensus reports of the world workshop were published simultaneously
in june 2018 in the EFP Journal of Clinical Periodontology and the APP’s Journal of
Periodontology.
The new classification was presented formally by the two organisations at the EuroPerio9
congress in Amsterdam in june 2018.
World Workshop
2017 Classification
for Periodontal and
Peri-implant
Diseases and
Conditions.

10. Involved 130 experts & review authors who reviewed the scientific evidence to update the
classification scheme.
4 working groups of the world workshop are:
1. Periodontal health, gingival health and conditions
2.Periodontitis
3. Periodontal manifestation of systemic disease
4. Peri implant health and condition.
The organising committee commissioned 19 review paper and 4 consensus reports
One of the key task of working group was to define what is meant by periodontal health ,
because unless you define health you cannot define disease.
World Workshop
2017 Classification
for Periodontal and
Peri-implant
Diseases and
Conditions.

12. PERIODONTAL DISEASES & CONDITIONS;-
 PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS.
 Periodontal health and gingival health.
 Gingivitis: Dental Biofilm Induced.
Gingivitis: Non Dental Biofilm Induced.
PERIODONTITIS.
Necrotizing Periodontal Diseases.
Periodontitis.
Periodontal manifestation of systemic diseases and conditions.
OTHER CONDITIONS AFFECTING PERIODONTIUM
 Systemic diseases or conditions affecting periodontal supporting tissues.
Periodontal abscess and endodontic periodontal lesions
Mucogingival deformities and conditions.
Traumatic occlusal forces.
Tooth and prosthesis related factors.
PERI-IMPLANT DISEASES AND CONDITIONS;-
Peri implant health
Peri implant Mucositis
Peri implantitis
Peri implant soft and hard tissue deficiencies

13. 1. PERIODONTAL HEALTH AND GINGIVAL HEALTH.
1. Clinical gingival health on an intact periodontium.
2. Clinical gingival health on a reduced periodontium.
• Stable periodontitis patient.
• Non periodontitis patient.
1. Clinical gingival health on an intact periodontium.
Case definition.
No attachment or bone loss.
<10% of sites BOP.
Probing depth ≤ 3mm.
Defining a state of periodontal health is essential to creating a common reference point for the
assessment and evaluation of treatment in periodontal disease and gingivitis.
Based on the World Health Organization’s definition that “Health is a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity,” Working group 1 defined periodontal health as a “State free
from inflammatory periodontal disease that allows an individual to function normally and avoid consequence (mental or
physical) due to current or past disease.”

14. Clinical gingival health on a reduced periodontium.
 Previous attachment and/or bone loss.
•Stable periodontitis patient:
successfully treated periodontitis patient.
• Non periodontitis patient:
( e.g., recession, crown lengthening).
Successfully treated, stable periodontitis patient remain at increased risk of recurrent
progression.
‘’Once Perio always Perio’’ - Glasscoe-Watterson.
Case Defination
 10% of sites BOP
 No probing depth of 4 mm or
greater. (≤ 3mm)

15. 4 levels of health
1. Pristine Periodontal Health, theoretical situation, complete absence of inflammation.
2. Clinical periodontal health.
3. Periodontal disease stability.
4. Periodontal disease remission.

17. Associated with biofilm alone
Mediated by systemic or local risk factors
Systemic risk factors (modifying factors)
Smoking
Hyperglycemia
Nutritional factors
Pharmacological agents (prescription, non prescription, recreational)
Sex steroid hormones
Puberty
Menstrual cycle
Pregnancy
Oral contraceptive
Hematological conditions
Local risk factors (predisposing)
Dental plaque biofilm retention factors (prominent restoration margins)
Oral dryness
Drug influenced gingival enlargement
2. GINGIVITIS – DENTAL BIOFILM INDUCED

18. •Menstrual cycle associated gingivitis
•Oral contraceptive associated
•Ascorbic acid associated
Eliminated.
Clinically difficult to differentiate between them.
Case Definition of gingivitis in treated periodontitis patient;
Treated periodontits <4mm
Reason;= after periodontal surgery practically and clinically it is unrealistic to achieve a 3mm ideal probing
depth 4mm more clinically achievable probing depth.
GINGIVITIS – Dental biofilm induced.
Case definition.
Case Definition of gingivitis in an intact periodontium
Localized gingivitis Generalized gingivitis
Probing attachment loss No No
Radiographic bone loss No No
BOP Score >10%, <30% >30%
Case Definition of gingivitis in reduced periodontium without the history of
periodontis.
Localized gingivitis Generalized gingivitis
Probing attachment loss Yes Yes
Radiographic bone loss Possible Possible
Probing depth (all sites) <3mm <3mm
BOP Score >10%, <30% >30%

19. 2. GINGIVITIS – NON BIOFILM INDUCED GINGIVAL DISEASES

21. 1. Necrotizing Periodontal Diseases.
2. Periodontitis.
3. Periodontal manifestation of systemic diseases and conditions.
PERIODONTITIS.
It is noted that the category of Aggressive Periodontitis no longer exists

22. 1. Papilla necrosis,
2. Bleeding,
3. Pain
1. NECROTIZING PERIODONTAL DISEASES
Are infectious conditions characterized by necrosis of tissue periodntium
“Note”- AAP-1999:- NUG NUP represents different stages of same disease

23. Well defined staging and grading system
Criteria to diagnose periodontitis
2 criteria have been given one out of two must be present
1. Interdental clinical attachment loss >2 non-adjacent teeth.
2. Buccal or oral CAL > 3mm with pocketing >3mm detectable
at >2 teeth
2. PERIODONTITIS
2017, World Workshop defines “periodontitis as a chronic multifactorial inflammatory diseases
associated with dysbiotic plaque biofilms and characterized by progressive destruction of the
supporting apparatus”.
Case Definition
Localized (< 30% of teeth involved)
Generalized (> 30% teeth involved)
Molar/Incisor relation.

24. The new classification of periodontitis is modelled after the oncology system of staging and
grading enabling a more multi-dimensional approach that incorporates not only severity of
disease but rate of progression, the multifactorial etiology of the disease, its level of
complexity for disease management and identification of risk for future disease recurrence or
progression. This approach individualizes the diagnosis and case definition thus aligning it
with the principles of personalized or precision medicine.11
STAGING A PERIODONTITIS PATIENTS
GOAL
1. Classify the patient on the basis of severity and extend of diseases by
measuring the extend of destroyed and damaged tissue attributable to
periodontitis.
2. Assess specific factors that may manage long term function and esthetics of
patients dentition.

25. GRADING OF PERIODONTITIS PATIENTS
GOAL
1. Estimate future risk of periodontitis progression and
responsiveness to standard therapeutic principles to guide
intensity of therapy and monitoring
2. Estimate Potential health impact of periodontitis on systemic
disease and the reverse to guide systemic monitoring and co-
therapy with medical colleagues.

26. Procedural Steps in Diagnosing a patient

30. Localized/Generalized periodontitis
Stage I/II/III/IV, Grade A/B/C.
So When We Are Giving Diagnosis to a patient we have to write;--

31. Stage 1 Grade B
Staging
PD = ≤ 4 mm
BOP = Yes
RBL < 15% & generally horizontal
CAL 1-2 mm
Biofilm = Slight–Heavy
Grading
No tooth loss due to periodontitis
Moderate Rate of Progression
Non-Smoker
Non-Diabetic
Examples:
Stage 2 Grade B
Staging
PD ≤ 5 mm
BOP = Yes
RBL = 15% - 33% / mostly horizontal
CAL 3-4 mm
Biofilm = Slight–Heavy
Grading
No tooth loss due to periodontitis
Moderate Rate of Progression
Smoker <10 cigs per day
If Diabetic HbA1c <7.0%
Eg. 1
Eg. 2

32. Stage 3 Grade B
Staging
PD ≥ 6 mm
BOP = Yes
RBL = Horizontal ≥ 50% / Vertical ≥ 3 mm
CAL ≥ 5 mm
Biofilm = Slight–Heavy
Grading
Tooth loss due to periodontitis ≤ 4 teeth
Moderate Rate of Progression
Furcation Involvement = Class II or III
If Smoker <10 cigs per day
If Diabetic HbA1c <7.0%
Moderate ridge defect Stage 4 Grade C
Staging
PD ≥ 6 mm
BOP = Yes
RBL = Horizontal ≥ 50% / Vertical ≥ 3 mm
CAL ≥ 5 mm
Biofilm = Slight–Heavy
Grading
Tooth loss due to periodontitis ≥ 5 teeth
Furcation Involvement = Class II or III
Moderate ridge defect
Need for complex rehabilitation
Bone loss exceeds expectations given biofilm
Rapid Rate of Progression
Smoker >10 cigs per day
If Diabetic HbA1c >7.0%
Eg. 3
Eg. 4

33. The 2017 classification system for periodontal diseases and conditions also includes systemic diseases
and conditions that affect the periodontal supporting structures. Certain rare disorders like Papillon-
Lefevre syndrome, leukocyte adhesion deficiency, etc., have severe periodontitis as on of the early clinical
features such conditions are grouped as “Periodontal manifestation of systemic diseases”.
The primary diagnosis for such periodontal conditions should be classified under the systemic disease
based on the world Health Organization’s International Classification of Disease (ICD).
PERIODONTAL MANIFESTATION OF SYSTEMIC DISEASES AND CONDITIONS.

34. OTHER CONDITIONS AFFECTING PERIODONTIUM
 Systemic diseases or conditions affecting periodontal supporting tissues.
Periodontal abscess and endodontic periodontal lesions
Mucogingival deformities and conditions.
Traumatic occlusal forces.
Tooth and prosthesis related factors.

35. SYSTEMIC DISEASES OR CONDITIONS AFFECTING PERIODONTAL SUPPORTING
TISSUES.
Certain diseases that may affect the periodontal supporting tissue
independent of plaque induced periodontitis for example squamous cell
carcinoma it can destroy periodontal supporting tissues independent of
plaque induced periodontitis.
Need to be identified by their ICD codes.

36. Shortcomings of APP-1999;-
1. No clear distinction between gingival and periodontal abscess.
2. Periodontal abscess was classified as acute and chronic; however ,
an abscess by definition is an acute lesion.
3. Inclusion of Pericorontitis and periapical abscess in the
classification together with periodontal abscess might not be
appropriate.
AAP-1999
Gingival Abscess
Periodontal Abscess
Pericoronal Abscess
Periapical Abscess.
PERIODONTALABSCESS
2017 World workshop, the periodontal abscess has been defined as a “localized accumulation of pus located
within the gingival wall of the periodontal pocket/sulcus, resulting in a significant tissue breakdown”.

37. ENDODONTIC PERIODONTAL LESIONS

38. Mucogingival deformities have been
classified as on 5 parameters.
1. Recession REC Keeping in mine Cairos
classification system is used that classifies
RT1, RT2 RT3
This has been done keeping in mind the
drawbacks of Miller’s classification
2. GT- Gingival thickness
3. KTW - Keratinised tissue width
4. CEJ wether detectable clinicaly or not
5. Step at CEJ +/-
MUCOGINGIVAL DEFORMITIES AND CONDITIONS
The most common mucogingival deformities observed are recession and lack of keratinized tissue. In the
World workshop 2017 classification , a treatment –oriented classification of mucogingival deformities has
been proposed. Periodontal biotype plays a very important role in the occurance and treatment of
mucogingival deformities.
‘’Gingival biotype have been replaced by gingival phenotype’’
Done because phenotype includes both the genetic aspect of the tissue as well the environmental factors.

39. TRAUMATIC OCCLUSAL FORCES

40. PERIODONTAL DISEASES & CONDITIONS
OTHER CONDITIONS AFFECTING PERIODONTIUM
Tooth and prosthesis related factors.

41. Peri implant health
Peri implant Mucositis
Peri implantitis
Peri implant soft and hard tissue deficiencies
PERI-IMPLANT DISEASES AND CONDITIONS.

42. PERI IMPLANT HEALTH
• Absence of clinical signs of inflammation
• Absence of BOP/suppuration on gentle probing
• No Increasing probing depth as compared to previous
reading
• Absence of crestal bone loss after completion of bone
remodeling after implant placement.

43. •Presence of clincal signs of inflammattion.
•Presence of BOP/suppuration.
•With or without presence of peri-implant pockets
compared to previous reading.
•No crestal bone loss after completion of bone
remodeling after implant placement.
PERI IMPLANT MUCOSITIS

44. • Presence of clinical signs of inflammation
• Presence of BOP/suppuration.
• Increase in peri-implant pockets depth compared to
previous reading.
• Crestal bone loss once completion of bone remodeling
after implant placement
If we not have the previous data we can use # criteria to
identify peri-implantitis
1. Presence of BOP/ Suppuration
2. Presence of pockets >6mm
3. Presence of crestal bone loss 3mm or more from the
most crestal part of intraosseous part of the implant
PERI -IMPLANTITIS

45. Normal healing following tooth loss leads to diminished dimensions
of both the alveolar process or ridge that results in both hard and soft
tissue deficiencies.
Severe loss of periodontal support,
Extraction trauma,
Endodontic infections,
Root fractures,
Thin buccal bone plates,
Pneumatization of maxillary sinuses.
Exposure of cervical portion of implant due to soft tissue or hard tissue
deficiencies.
HARD AND SOFT TISSUE DEFICIENCIES

46. Key Changes from 1999 Classification;
I. Newer classication was proposed based on ICD ( International classication of Diseases)
II. Gingival health condition is added in the newer classication. A previous successfully treated periodontitis was considered
as gingival health with reduced periodontum.
III. Necrotizing periodontal diseases of bacterial origin added in non-plaque induced gingival conditions. Linear gingival
erythema was removed in fungal diseases. Viral diseases were elaborated extensively in newer classifcation. Gingival
pigmentation like drug induced gingival pigmentation, amalgam tattoo etc., was introduced in newer classication.
IV. Aggressive and Chronic Periodontitis terms were removed and categorized under a single category" Periodontitis“
V. Newer classifcation system based on multidimensional staging and grading system.
VI. Staging is largely not only depends on severity but also depends the complexity of the disease management. Clinical
attachment loss (CAL) determines the staging of the disease. If the CAL is not available, Radiographic bone loss (RBL)
should be used. Tooth loss due to periodontitis alters the staging of the periodontal disease. Stage I, II are Mild and
Moderate. Stage III, IV are Severe and Extremely severe.

47. XIII. Traumatic occlusal force, replacing the term excessive occlusal forces. There is insufficient evidence to
prove occlusal trauma progress the clinical attachment level (CAL).
XIV. The prosthesis- related factors expanded in the newer classifcation. Biological width assess through
histology .Other methods like transgingivisal probing asses supra crestal attachment. Hence Biological width
term was replaced with supracrestal attachment.
XV. Clinical procedures involved in the fabrication of indirect restorations was added because the new data
indicates that these procedures may cause recession & loss of clinical attachment.
XVI. A new classification of Peri-implant health, Peri-implant mucositis and Periimplantitis was added the
newer classification.

48. VII. Grading of Periodontal disease provides the progression rate of disease, the response to treatment of
periodontal disease and the effect of systemic health on periodontal disease. Only Smoking and Diabetes are
considered potential risk factors that alters the staging of periodontal disease. Grading includes three
levels(grade A – low risk, grade B – moderate risk, grade C – high risk for progression)
VIII. Periodontitis is considered as localised if <30% of the teeth are involved and generalized when >30%
teeth are involved.
IX. Those systemic disorders, those result in the early onset of severe periodontitis classi􀃶ed based on the
primary systemic disease. It quoted as “Periodontitis as a Manifestation of Systemic Disease”. Example,
Periodontis as a manifestation of Papillon Lefèvre Syndrome.
X. Other Systemic conditions affect the periodontal apparatus indepent of dental plaque induced
periodontitis are considered as “Systemic Diseases or Conditions Affecting the Periodontal Supporting
Tissues” Examples: Neoplastic diseases of Periodontum.
XI. Inter proximal attachment loss, incorporate of the assesment of root and cement-enamel junction
decides the treatment of gingival recession.
XII. The Periodontal biotype was replaced by Periodontal phenotype.

49. Disadvantages of Newer classification:
The classification is very extensive and more complicated than 1999 classification and the
time will decide how it will be helpful to the general dentist and Periodontist to choose
optimal treatment plan to the patient.

50. REFERENCES
1. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol. 1999;4:1–6.
2. Albandar, J.M., Rise, J., Gjermo, P. and Johansen, J.R. Radiographic quantification of alveolar bone level changes. A 2-year longitudinal study in man.
Journal of Clinical Periodontology 1986;
3. American Academy of Periodontology. Consensus report. Discussion section I. Proceedings of the world workshop in clinical periodontics. Chicago,
American Academy of Periodontology, 1989:123-124.
4. Armitage, G.C. Periodontal diseases: diagnosis. Annals of Periodontology 1996; 1:37-215.
5. Armitage, G.C. Development of a classification system for periodontal diseases and conditions. Annals of Periodontology 1999; 4:1-6.
6. Armitage, G.C. Classifying periodontal diseases--a long-standing dilemma. Periodontology 2000 2002; 30:9-23.
7. Armitage, G.C. Periodontal diagnoses and classification of periodontal diseases. Periodontology 2000 2004 34:9-21
8. Lindhe, J., Haffajee, A.D. and Socransky, S.S. Progression of periodontal disease in adult subjects in the absence of periodontal therapy. Journal of Clinical
Periodontology 1983; 10:433-442.
9. Loe, H. Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 1993; 16:329-334.
10. Newman, M.G., Takei, H.H. and Klokkevold, P.R. Carranza‘s Clinical Periodontology. St. Louis, Saunders Elsevier; 2006.
11. Page, R.C. and Schroeder, H.E. Discussion. Periodontitis in Man and Other Animals. A Comparative Review. Basel, S. Karger: 1982; 222-239.
12. Papapanou, P.N., Wennstrom, J.L. and Grondahl, K. A 10-year retrospective study of periodontal disease progression. Journal of Clinical Periodontology
1989; 16:403-411.
13. Pini-Prato, G. The Miller classification of gingival recession: limits and drawbacks. Journal of Clinical Periodontology 2011; 38:243- 245.
14. Textbook of clinincal periodontology. Carranza. 11th edition.
15. Kornman K, Papapanou PN. 4-step approach to implementing the new staging and grading system for periodontitis. Paper presented at EuroPerio 9.
Proceedings of the European Federation of Periodontology, 2018 June 20-23, Amsterdam, The Netherlands.

51. THANK YOU
2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions
Participants (Photo from https://perio.org)