In World Workshop 2017, American Academy of Periodontology (AAP) and European Federation of Periodontology (EFP) with expert participants updated the 1999 classification of Periodontal Diseases. Since 1999, new evidences have emerged regarding environmental and systemic risk factors, prompting the experts to develop new classification.

1. New classification
of
periodontal diseases

3. CLASSIFICATION
PERIODONTAL
DISEASES AND
CONDITIONS
PERI-IMPLANT DISEASES
AND CONDITIONS

4. INDEX
PERIODONTAL DISEASES AND CONDITIONS (3 types)
I. Periodontal health, gingival diseases and conditions
1. Periodontal health and gingival health (a. Clinical gingival health on an intact periodontium; b. Clinical gingival health
on a reduced periodontium)
2. Gingivitis: dental biofilm induced (a. Associated with dental biofilm alone; b. Mediated by systemic or local risk factors;
c. Drug-influenced gingival enlargement)
3. Gingival diseases: non-dental biofilm-induced (1. Genetic or developmental disorder; 2. Specific infections; 3.
Inflammatory and immune conditions; 4. Reactive processes; 5. Neoplasms; 6. Endocrine, nutritional and metabolic
diseases; 7. Traumatic lesions; 8.Gingival Pigmentation)
II. Periodontitis
1. Necrotizing Periodontal Diseases (a. Necrotizing Gingivitis; b. Necrotizing Periodontitis; c. Necrotizing Stomatitis)
2. Periodontitis as a Manifestation of Systemic Disease (1.Genetic disorders; 2.Systemic disorders that influence the
pathogenesis of periodontal diseases)
3. Periodontitis (a. Stages; b. Extent and distribution; c. Grades)

5. INDEX
III. Other conditions affecting the periodontium
1. Systemic diseases affect periodontium independent of dental plaque
biofilm induced periodontitis (a. Neoplasms; b. Other disorders)
2. Other Periodontal Conditions (a. Periodontal abscesses; b. Endodontic
Periodontal lesions)
3. Mucogingival Deformities and Conditions (a. Gingival phenotype;
b.Gingival /soft tissue recession; c. Lack of gingiva; d. Decreased vestibular
depth; e. Aberrant frenum/muscle position; f. Gingival excess; g. Abnormal
color; h. Condition of exposed root surface)
4. Traumatic Occlusal Forces (a. Primary occlusal trauma; b. Secondary
occlusal trauma; c. Orthodontic forces)
5. . Prosthesis and Tooth Related Factors that modify or predispose to
plaque-induced gingival diseases/periodontitis (a. Localized tooth related
factors; b. Localized dental prosthesis-related factors)

6. INDEX
Peri-implant Diseases and Conditions
I. Peri-implant Health
II. Peri-implant Mucositis
III. Peri-implantitis
IV. Peri-implant Soft and Hard Tissue Deficiencies
 Explanations

7. INTRODUCTION
• In World Workshop 2017, American Academy of
Periodontology (AAP) and European Federation of
Periodontology (EFP) with expert participants updated the
1999 classification of Periodontal Diseases.
• Since 1999, new evidences have emerged regarding
environmental and systemic risk factors, prompting the
experts to develop new classification.

8. CLASSIFICATION

9. CLASSIFICATION
PERIODONTAL
DISEASES AND
CONDITIONS
PERI-IMPLANT DISEASES
AND CONDITIONS

10. PERIODONTAL DISEASES
AND CONDITIONS

11. PERIODONTAL DISEASES AND CONDITIONS is
divided into 3 categories
I. PERIODONTAL HEALTH, GINGIVAL
DISEASES AND CONDITIONS (all in blue
and red)
II. PERIODONTITIS (all in black)
III. OTHER CONDITIONS AFFECTING THE
PERIODONTIUM (all in yellow)

12. I. Periodontal health, gingival diseases and
conditions
1. Periodontal health and gingival health (a. Clinical gingival health on
an intact periodontium; b. Clinical gingival health on a reduced
periodontium)
2. Gingivitis: dental biofilm induced (a. Associated with dental biofilm
alone; b. Mediated by systemic or local risk factors; c. Drug-
influenced gingival enlargement)
3. Gingival diseases: non-dental biofilm-induced (1. Genetic or
developmental disorder; 2. Specific infections; 3. Inflammatory and
immune conditions; 4. Reactive processes; 5. Neoplasms; 6.
Endocrine, nutritional and metabolic diseases; 7. Traumatic
lesions; 8.Gingival Pigmentation)

13. 1. PERIODONTAL HEALTH AND GINGIVAL
HEALTH
(2 categories))
a. Clinical gingival health on an intact periodontium
b. Clinical gingival health on a reduced periodontium
i. Stable periodontitis patient
ii. Non-periodontitis patient

14. 2. GINGIVITIS: DENTAL BIOFILM INDUCED
(3 categories)
a. Associated with dental biofilm
alone

15. b. Mediated by systemic or local risk factors
i) Systemic risk factors a. Smoking
b. Hyperglycemia
c. Nutritional factors
d. Pharmacological (prescription, non prescription)
e. Sex Steroid hormones
(Puberty, pregnancy, Menstrual cycle, oral contraceptives)
f. Hematological agents
ii) Local risk factors
a. Dental plaque biofilm retention factors
(prominent restoration margins)
b. Oral dryness

16. c. Drug-influenced gingival enlargement

17. 3. GINGIVAL DISEASES: NON-DENTAL
BIOFILM-INDUCED
(8 categories)
1. Genetic or developmental disorder
1.1 Hereditary Gingival fibromatosis
2. Specific infections
2.1 Bacterial infections
a) Necrotizing Periodontal disease
b) Neisseria Gonorrhoeae (gonorrhea)
c) Treponema pallidum (syphlis)
d) Mycobacterium tuberculosis (tuberculosis)
e) Streptococcal gingivitis (strains of streptococcus)

18. b.2 Viral origin-
a) Coxsachie virus (Hand foot and mouth disease
b) Herpes simplex virus; HSV1,2 (primary or recurrent)
c) Varicella zoster virus (chicken pox)
d) Molluscum contagiosum
e) Human papilloma virus
b.3 Fungal-
a) Candidiasis
b) Other mycosis (eg. Histoplasmosis, aspergillosis)

19. 3. Inflammatory and immune conditions
3.1 Hypersensitivity reaction-
a) Contact allergy
b) Plasma cell gingivitis
c) Erythema multiforme
3.2 Auto immune diseases of skin and mucous membrane-
a) Pemphigus vulgaris
b) Pemphigoid
c) Lichen Planus
d) Lupus erythematosis

20. 3.3 Granulomatous inflammatory condition-
a) Crohn’s disease
b) Sarcoidosis
4. Reactive processes
4.1 Epulidus
a) Fibrous epulis
b) Calcifying fibroblastic granuloma
c) Pyogenic granuloma
d) Peripheral giant cell granuloma (or central)

21. 5. Neoplasms
5.1 Premalignant
a) Leukoplakia
b) Erythroplakia
5.2 Malignant
a) Squamous cell carcinoma
b) Leukemia
c) Lymphoma

22. 6. Endocrine, nutritional and metabolic diseases
6.1 Vitamin deficiency
a) Vitamin C deficiency (Scurvy)
7. Traumatic lesions
7.1 Physical and mechanical insults
a) Frictional Keratosis
b) Tooth brushing induced gingival abrasions
c) Factitious injury (self harm)

23. 7.2 Chemical insults
a) Etching
b) Chlorhexidine
c) Acetyl salicylic acid
d) Cocaine
e) Hydrogen peroxide
f) Dentifrice detergent
g) Paraformaldehyde/ calcium hydroxide
7.3 Thermal insults
a) Burn of mucosa

24. 8. Gingival pigmentation
a) Melanoplakia
b) Smoker’s melanosis
c) Drug induced pigmentation
(antimalarial; minocycline)
d) Amalgam tattoo

25. II. Periodontitis
1. Necrotizing Periodontal Diseases (a.
Necrotizing Gingivitis; b.Necrotizing
Periodontitis; c.Necrotizing Stomatitis)
2. Periodontitis as a Manifestation of Systemic
Disease (1.Genetic disorders; 2.Systemic
disorders that influence the pathogenesis of
periodontal diseases)
3. Periodontitis (a. Stages; b. Extent and
distribution; c. Grades)

26. 1. Necrotizing Periodontal
Diseases
a. Necrotizing Gingivitis
b. Necrotizing Periodontitis
c. Necrotizing Stomatitis

27. 2. Periodontitis as a Manifestation of
Systemic Disease
Classification under it should be according to
the systemic disease (according to
INTERNATIONAL STATISTICAL
CLASSIFICATION OF DISEASES AND
RELATED HEALTH PROBLEMS (ICD)
codes)
Following are the diseases that cause severe
periodontitis in early stages

28. 2. Periodontitis as a Manifestation of
Systemic Disease
Classification under it should be according to
the systemic disease (according to
INTERNATIONAL STATISTICAL
CLASSIFICATION OF DISEASES AND
RELATED HEALTH PROBLEMS (ICD)
codes)
Following are the diseases that cause severe
periodontitis in early stages:

29. 1.1 Genetic Disorders
1.1.1. DISEASES ASSOCIATED WITH
IMMUNOLOGIC DISEASES
Downs Syndrome Leukocyte adhesion deficiency syndrome
Papillon- Lefevre syndrome Haim-Munk syndrome
Chediak-Higashi syndrome Severe neutropenia
Congenital neutropenia Cyclic neutropenia
Primary immunodeficiency diseases Chronic granulomatous disease
Hyper immunoglobulin E syndrome Cohen syndrome

30. 1.1.2.DISEASES AFFECTING THE ORAL MUCOSA AND
GINGIVAL TISSUE
Epidermolysis bullosa Dystrophic epidermolysis bullosa
Kindler syndrome Plasminogen deficiency
1.1.3.DISEASES AFFECTING THE CONNECTIVE
TISSUES
Ehler-Danlos syndrome (types IV,VIII) Angioedema (C1-inhibitor deficiency)
Systemic lupus erythematosus

31. 1.1.4. Metabolic and endocrine disorders
Glycogen storage disease Gaucher disease
Hypophosphatasia Hypophosphatemic rickets
Hajdu- Cheney syndrome Diabetes mellitus
Obesity Osteoporosis

32. 1.2 Acquired immunodeficiency
diseases
 Acquired neutropenia
 HIV infection
1.3 Inflammatory diseases
 Epidermolysis bullosa acquista
 Inflammatory bowel disease
 Arthritis (rheumatoid arthritis, osteoarthritis)

33. 2. Systemic disorders that influence
the pathogenesis of periodontal
diseases
 Emotional stress and depression
 Smoking (nicotine dependence)
 Medication
 Inflammatory bowel disease
 Arthritis (rheumatoid arthritis, osteoarthritis)

34. 3. Periodontitis
a. STAGES: Based on Severity and Complexity
of Management
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 dentition

35. b. Extent and distribution:
 Localized
 Generalized
 Molar-incisor distribution

36. c. Grades: Risk of rapid progression, anticipated
treatment response
i. Grade A: Slow rate of progression
ii. Grade B: Moderate rate of progression
iii. Grade C: Rapid rate of progression

37. 3. OTHER CONDITIONS AFFECTING THE
PERIODONTAL SUPPORTING TISSUES
1. Systemic diseases affect periodontium independent of dental plaque biofilm
induced periodontitis (a. Neoplasms; b. Other disorders)
2. Other periodontal conditions (a. Periodontal abscesses; b. Endodontic
Periodontal lesions)
3. Mucogingival Deformities and Conditions (a. Gingival phenotype; b.Gingival
/soft tissue recession; c. Lack of gingiva; d. Decreased vestibular depth; e.
Aberrant frenum/muscle position; f. Gingival excess; g. Abnormal color; h.
Condition of exposed root surface)
4. Traumatic Occlusal Forces (a. Primary occlusal trauma; b. Secondary
occlusal trauma; c. Orthodontic forces)
5. . Prosthesis and Tooth Related Factors that modify or predispose to plaque-
induced gingival diseases/periodontitis (a. Localized tooth related factors; b.
Localized dental prosthesis-related factors)

38. 1. Systemic diseases affect periodontium
independent of dental plaque biofilm
induced periodontitis
 Classification under it should be
according to the systemic disease
 Following are the diseases:

39. a. NEOPLASMS
• PRIMARY NEOPLASTIC DISEASE OF
PERIODONTAL TISSUE
Oral squamous cell carcinoma Odontogenic tumors
Other primary neoplasms of periodontal tissues
• Secondary metaplastic neoplasms of
periodontal tissues

40. b. OTHER DISORDERS THAT MAY AFFECT
PERIODONTAL TISSUES
Granulomatosis with polyangitis
Langerhans cells histiocytosis
Giant cell granulomas
Hyperparathyroidism
Systemic sclerosis (scleroderma)
Vanishing bone disease (Gorham- Stout syndrome)

41. 2. Other periodontal conditions
a. Periodontal abscesses
b. Endodontic Periodontal lesions

42. 3. Mucogingival
Deformities and
Conditions
a. Gingival phenotype
b. Gingival /soft tissue recession
c. Lack of gingiva
d. Decreased vestibular depth
e. Aberrant frenum/muscle position
f. Gingival excess
g. Abnormal color
h. Condition of exposed root surface

43. 4. Traumatic Occlusal
Forces
a. Primary occlusal trauma
b. Secondary occlusal trauma
c. Orthodontic forces

44. 5. Prosthesis and Tooth Related Factors that modify or
predispose to plaque-induced gingival
diseases/periodontitis
A. Localized tooth related factors
1. Tooth anatomic factors
2. Root fractures
3. Cervical root resorption, cemental tears
4. Root proximity
5. Altered passive eruption
B. Localized dental prosthesis-related factors
1. Restoration margins placed within supracrestal attached tissues
2. Clinical procedures related to fabrication of indirect restorations
3. Hypersensitivity/toxicity reactions to dental materials

45. Peri-implant Diseases and
Conditions

46. II. Peri-implant Diseases
and Conditions
I. Peri-implant Health
II. Peri-implant Mucositis
III. Peri-implantitis
IV. Peri-implant Soft and Hard Tissue
Deficiencies

47. EXPLANATION regarding
gingivitis

48.  New terminologies including
Periodontal health and gingival health
are introduced.
 Periodontal health divided into intact
and reduced periodontal health.

49. Intact periodontal health means
 Patient with no clinical attachment
loss or radiographic bone loss
 Less than 10% sites with bleeding on
probing and pocket depth ≤3mm

50. Reduced periodontium
means:(two conditions)
1. Due to non- periodontitis conditions
like gingival recession and crown
lengthening procedures.
Less than 10% sites with bleeding on
probing and pocket depth ≤3mm

51. Reduced periodontium means:
2. In successfully treated periodontitis
patients, pocket probing depth upto
4mm and no bleeding on probing (BOP)
at 4mm site is considered as gingival
healthy state.

52.  Gingival inflammation is more
appropriate term for gingival
inflammation in periodontitis patient
rather than gingivitis; as patient cannot
be defined as case of periodontitis and
gingivitis at same time.

53. EXPLANATION regarding
Periodontitis

54.  Diagnosed Periodontitis patient is considered as
periodontitis throughout the life and based on
response of periodontal therapy divided into
a. Controlled (healthy/stable)
b. Remission (showing gingival inflammation)
c. Uncontrolled (unstable or recurrent periodontitis)

55. 1. Necrotizing Periodontal Diseases
 Term ‘Necrotizing Stomatitis’ has been
introduced.
 It is caused by extension of necrosis beyond
the mucogingival junction.
 Term ulceration has been retracted from
classification as it is considered secondary
to necrosis.

56. 2. Periodontitis as a Manifestation of
Systemic Disease
 Classification under it should be
according to the systemic disease
 It include the diseases that cause
severe periodontitis in early stages

57. Neoplasms
 10% of squamous cell carcinoma
arises in gingiva and resemble
localized periodontitis or acute
periodontitis with redness, swelling,
increased pocket depth and bone
loss

58. Emotional stress, Depression,
Hypertension
 Animal studies have revealed that stress
and depression may potentiate
periodontal breakdown
 Evidences regarding association
between hypertension and periodontal
disease is inconclusive

59. Medications
 Cytotoxic drugs given for malignancies cause
neutropenia, that can cause destructive periodontitis,
however more studies are awaited.
 Other drugs like Bisphosphonates and anti
inflammatory therapy (anti TNF therapy, NSAIDS)
decrease level of destructive periodontitis.

60. 3. Periodontitis
Terms Chronic and Aggressive
Periodontitis have been eliminated in
this classification (due to lack of clear
cut demarcation between two) and only
term Periodontitis has been used

61. A person is said to have Periodontitis
when:
 Interdental clinical attachment loss
(CAL) is measurable at ≥2 non-
adjacent teeth
 Buccal clinical attachment loss (CAL)
of ≥3mm with pocket depth >3mm is
measurable at ≥2 teeth

62. In this clinical attachment loss (CAL)
occurring due to non-periodontal
conditions is excluded like:
 gingival recession due to trauma
 Caries extending to cervical region of
tooth
 Drainage of endo lesion through
marginal periodontium resulting in
periodontitis
 Distal of 2nd molar due to extraction
or malpositioning of 3rd molar

63. Stage and Grading in
Periodontitis
 Stage depicts the extent and severity
of disease
 Grading depicts the rate of
progression of periodontitis

64. Stage I.
 Severity: Interdental clinical attachment loss: 1-2mm
Radiographic bone loss: Coronal third (<15%)
No tooth loss due to periodontitis
 Complexity: Max probing depth ≤4mm
Mostly Horizontal Bone Loss
 Extent and Distribution: Localized- <30% teeth involved;
Generalized; or
Molar/incisor pattern

65. Stage II.
 Severity: Interdental clinical attachment loss: 3-4mm
Radiographic bone loss: Coronal third (15%-33%)
No tooth loss due to periodontitis
 Complexity: Max probing depth ≤5mm
Mostly Horizontal Bone Loss
 Extent and Distribution: Localized- <30% teeth involved;
Generalized; or
Molar/incisor pattern

66. Stage III.
Stage III.
Severity: Interdental clinical attachment loss: ≥5mm
Radiographic bone loss: Extending to middle third of root and beyond
Tooth loss due to periodontitis: ≤4
Complexity: In addition to Stage II: Probing depth ≥6mm
Vertical Bone Loss ≥3mm
Furcation involvement class II, III
Moderate Ridge defects
Extent and Distribution: Localized- <30% teeth involved;
Generalized; or
Molar/incisor pattern

67. Stage IV.
 Severity: Interdental clinical attachment loss: ≥5mm
Radiographic bone loss: Extending to middle third of root and beyond
Tooth loss due to periodontitis: ≥5 teeth
 Complexity: In addition to Stage III -Need for complex rehabilitation due to
- Masticatory insufficiency
-secondary occlusal trauma (tooth mobility degree ≥2)
-Severe Ridge defects
-Bite collapse, drifting, flaring
- < 20 remaining teeth (10 opossing pairs)
 Extent and Distribution: Localized- <30% teeth involved;
Generalized; or
Molar/incisor pattern

68. GRADING
 Indicate rate of progression of
periodontitis, responsiveness to
treatment and impact on systemic
health.

69. GRADE A: Slow rate
 Radiographic bone loss/CAL: No loss over 5 years
 %bone loss: <0.25
 Heavy deposition of biofilm with lower levels of destruction
 Risk factors:
• Smoking: Non-smoker: <10 cigarettes/day
• Diabetes: no diagnosis of diabetes

70. GRADE B: Moderate rate
 Radiographic bone loss/CAL: <2mm over 5 years
 %bone loss: 0.25 to 1.0
 Destruction proportionate with amount of biofilm
 Risk factors:
• Smoking: <10 cigarettes/day
• Diabetes: HbA1c <7.0%

71. GRADE C: Rapid rate
 Radiographic bone loss/CAL: ≥2mm over 5 years
 %bone loss: >1.0
 Destruction more than expected than with amount of biofilm; clinical
patterns suggestive of early onset disease or/and period of rapid
progression
 Risk factors:
• Smoking: ≥10 cigarettes/day
• Diabetes: HbA1c ≥7.0%

72. Diabetes
 Diabetes associated periodontitis is not
a distinct disease. It along with smoking
are modifying factors; so diagnosed
under Periodontitis
 Level of glycemic control and smoking
influence the grading of periodontitis.

73. Periodontal abscesses
 Term gingival abscess, pericoronal abscess are
not used as separate terms in recent
classification
 Thus only ‘Periodontal abscess’ term has been
used.

74. Mucogingival Deformities
and Conditions
Gingival phenotype
(gingival thickness and
width) has been recognized

75. Mucogingival Deformities
and Conditions
 New classification of Gingival Recession has been introduced
 Recession type-1: No interproximal CAL loss, interproximal
cementoenamel junction (CEJ) not visible
 Recession type-2: Interproximal CAL loss, interproximal CAL loss equal or
less than buccal CAL loss
 Recession type-3: Interproximal CAL loss, interproximal CAL loss greater
than buccal CAL loss

76. TRAUMATIC OCCLUSAL
FORCES
 Traumatic occlusal force replaces the term
‘excessive occlusal force’ used in previous
classification
 Any occlusal force resulting in injury to tooth
and/or periodontal attachment apparatus is called
traumatic occlusal forces

77. TRAUMATIC OCCLUSAL
FORCES
 Traumatic occlusal force do not cause attachment
loss, recession or non-carious cervical lesions (no
reported evidence)
 It causes adaptive mobility in teeth with normal
support and progressive mobility in teeth with
reduced support, thus requiring splinting.

78. OCCLUSAL TRAUMA
 Occlusal trauma is injury to periodontal ligament, cementum and alveolar
bone due to occlusal forces. It is a histological term. Symptoms are
progressive tooth mobility, widened periodontal ligament (radiographically),
adaptive tooth mobility (fremitus), root resorption, pain, discomfort on
chewing.
 Primary occlusal trauma resulted in tissue injury in normal periodontium
due to traumatic forces resulting in adaptive mobility, which is not
progressive.
 Secondary occlusal trauma results in tissue injury in reduced periodontium,
causing progressive mobility, tooth migration, pain that require splinting.

79. ORTHODONTIC FORCES
 Animal studies suggested that certain orthodontic
forces can result in gingival recession, root
resorption, alveolar bone loss, pulpal disorders.
 Good plaque control can result in successful
orthodontic tooth movements even in reduced
healthy periodontium

80. Prosthesis and Tooth Related Factors that
modify or predispose to plaque-induced
gingival diseases/periodontitis
 Prosthesis and tooth related factors have been expanded in
new classification
 Term ‘Biologic width’ replaced by ‘Supracrestal tissue
attachment.’ Histologically it consist of junctional epithelium
and supracrestal connective tissue attachment.
 ‘Altered tooth eruption’ has been introduced under tooth
related factors

81. Prosthesis and Tooth Related Factors that
modify or predispose to plaque-induced
gingival diseases/periodontitis
 Data indicated that procedures
involved in fabrication of indirect
restorations can cause gingival
recessions and loss of clinical
attachment.

82. Peri-implant Disease and
Conditions
 It has been introduced
 Bleeding on probing differentiate between
peri-implant healthy and inflamed mucosa
 Bone loss differentiate between peri-
implant mucositis and peri-implantitis

83. Peri-implant Disease and
Conditions
 Peri-implant health: Absence of all clinical signs of
inflammation like bleeding on probing (BOP), swelling,
redness. It can occur around implants with healthy and
reduced bone.
 Peri-implant mucositis: Inflammation in soft tissues around
implants with no bone loss. Condition is reversible. Main
causative agent is plaque. It can be reversed by eliminating
plaque. It precedes Peri-implantitis

84. Peri-implant Disease and
Conditions
 Peri-implantitis: Inflammation in soft tissues
around implants with loss of supporting bone.
BOP and/or suppuration, bone level ≥3mm apical
to most coronal part of intra-osseous part of
implant are diagnostic features of peri-implantitis.
Risk of peri-implantitis is higher in patients having
history of periodontitis.

85. Ridge Deficiencies
 After tooth loss, normal healing results in reduced dimensions of alveolar
ridges. It results in both hard and soft tissue ridge deficiencies.
 Large ridge deficiencies occur due to:
 Local cause: Traumatic extractions, severe periodontal bone loss, thin
buccal bone, injury, tooth malpositioning, endodontic infections,
removable/faulty prosthesis.
 Systemic causes: medications and systemic diseases causing
osteoporosis.