Introduction Landmarks in periodontal classification Need for classification Classification 1989 – with limitation Classification 1993 – with limitation Classification 1999 – changes made from 1989 classification and its limitation Consensus report 2017classification Classification 2017 Key features in 2017 classification Gingival and periodontal health – induced and reduced periodontium Gingivitis – biofilm induced Gingivitis – non biofilm induced Conclusion References

1. CLASSIFICATION OF PERIODONTAL AND PERI-IMPLANT DISEASE
& CONDITION-2017
Dr. BEENA VIJAYAN PARVATHY
1st YEAR POST GRADUATE
Dept of Periodontics and Implantology

2.  Introduction
 Landmarks in periodontal classification
 Need for classification
 Classification 1989 – with limitation
 Classification 1993 – with limitation
 Classification 1999 – changes made from 1989
classification and its limitation
 Consensus report 2017classification
 Classification 2017
 Key features in 2017 classification
 Gingival and periodontal health – induced and reduced
periodontium
 Gingivitis – biofilm induced
 Gingivitis – non biofilm induced
 Conclusion
 References
CONTENTS

3. INTRODUCTION
A classification scheme for periodontal and peri-implant diseases and conditions is
necessary for clinicians to
Properly diagnose and treat patients
Scientists to investigate etiology, pathogenesis, natural history, and treatment
of the diseases and conditions
Clinicians to design appropriate therapeutic strategies
Developing framework to study the etiopathogenesis.
This seminar summarizes the proceedings of the World Workshop on the
Classification of Periodontal and Peri-implant Diseases and Conditions; along with
drawbacks of older classifications and need for newer one.

4. Landmarks in periodontal classification

5. NEED FOR CLASSIFICATION
Classification systems are not rigid or fixed entities
Every classification system has to be evolved based on understanding of disease at
the time the classifications were proposed.
The classifications are needed to be modified periodically based on CURRENT
THINKING and KNOWLEDGE

6. REVISITING CLASSIFICATION OF
PERIODONTAL DISEASES
Periodontal disease
classifications went from
1977
2 categories
1986
4 categories
1989
1999
8 categories
(Gingival diseases classified)
5 categories
(The category of Periodontitis associated with
systemic disease)

7. Classification 1989 – Limitation
OVERLAPPING AMONG CATEGORIES
ABSENCE OF GINGIVAL DISEASE COMPONENT
INAPPROPRIATE EMPHASIS ON AGE & ONSET
OF DISEASE & RATE OF PROGRESSION
UNCLEAR CLASSIFICATION CRITERIA
A
B
C
D
IMPACT OF SYSTEMIC DISEASE ON
PERIODONTAL TISSUES  UNEXPLAINED

8. Classification 1993 – Limitation

9. AAP CLASSIFICATION OF PERIODONTAL DISEASES
1999

10. AAP & European classification schemes were amended in 1999 WWP -with these
changes
•Gingival disease category introduced
•“Adult Periodontitis” replaced by “Chronic
Periodontitis” ( “Refractory” category removed )
•“Early onset periodontitis” replaced by “Aggressive
periodontitis”
•Impact of systemic diseases/conditions
expanded and defined
•“Necrotizing Periodontal Diseases” introduced
•Periodontal abscess & Endo- Perio lesions added
•A category of developmental & acquired lesions
introduced
LIMITATIONS
 Etiology
 Multiple appointment –to diagnose
 Absence of implantology
 Risk factors –smoking & diabetes not included.

11. AAP convened a World Workshop in 2017 to address problems
associated with 1999 classification

12. OUTLINE TO 2017
CLASSIFICATION  2015 PREPARATION STARTED
 BY EFP AND AAP IN CHICAGO FROM NOV 9 TO 11
 FORMED 4 WORK GROUPS & GAVE CASE
DEFINITIONS
 FINALLY THEY PUT FORWARD 19 REVIEW PAPERS
( BASED ON 4 CONSENSUS REPORT )

13. Periodontal diseases and Conditions
Periodontal health,
Gingival diseases
and Conditions
Periodontal
health &
Gingival
health
Gingivitis:
Dental
Biofilm –
Induced
Gingival
diseases:
Non-
Dental
Biofilm-
Induced
Periodontitis
Necrotizing
Periodontal
diseases
Periodontitis
as a
manifestatio
n of
systemic
disease
Other conditions affecting the
periodontium
Systemic
diseases or
conditions
affecting
the
periodontal
supporting
tissues
Periodontal
abscess &
Endodontic
-
Periodontal
lesions
Mucogingival
deformities &
conditions
Traumatic
occlusal
forces
Tooth &
Prosthesis
related
factors

15. Key features of 2017 classification
DEFINITIONS
Case definitions, Definition of Gingival and periodontal health
STAGES
Severity & Complexity
STAGE 1 to STAGE 4
GRADING
Rate of progression
Grade A, B ,C
 Classification of Periimplant diseases and conditions
 Re categorization of various forms of periodontitis

16. Term plaque induced replaced by dental biofilm induced
Systemic risk factors – smoking , hyperglycemia , hematological condition, nutritional factor ,
were added
Mycobacterium tuberculosis – added to specific infection
Specific infections –disscused in detail

17. Terminology
Case Definitions
Case definitions are guidelines that should be applied using sound clinical judgement to arrive at the most appropriate
clinical diagnosis.
Clinical periodontal health
Is defined as no bleeding on probing and no anatomical loss of periodontal structures.
Gingivitis
Is defined as a nonspecific inflammatory reaction to a nonspecific accumulation of plaque that is confined to the
gingival tissue, with no underlying destruction of the attachment apparatus.
Periodontitis
Covers the major plaque‐associated periodontal diseases, and treatment outcomes are expected to be either
periodontal disease stability or periodontal disease remission/control.
Periodontal disease stability
It is defined as a state in which the periodontitis has been successfully treated and clinical signs of the disease do not
appear to worsen in extent or severity despite the presence of a reduced periodontium.
Periodontal disease remission/control
It is defined as a period in the course of disease when symptoms become less severe but may not be fully resolved.

19. Gingival Health
Intact Periodontium Reduced Periodontium
Clinical Gingival Health
Pristine Gingival Health
Stable Periodontitis
HEALTH
CAL – YES
PPD < 4mm
BOP <10 % sites
ABL-YES
GINGIVITIS
CAL – YES
PPD < 4mm
BOP >10 % sites
ABL-YES
Non Periodontitis
HEALTH
CAL – YES
PPD < 3mm
BOP <10 % sites
ABL-YES
GINGIVITIS
CAL – YES
PPD < 3mm
BOP >10 % sites
ABL-YES
HEALTH
CAL – NIL
PPD < 3mm
BOP <10 %
sites
ABL-NIL
GINGIVITIS
CAL – NIL
PPD < 3mm
BOP >10 %
sites
ABL-NIL
<10% of sites BOP
No probing depth of 4mm or greater.(≤3mm)
REFERENCE: Trombelli
L,Farina .Plaque-
induced
gingivitis:case
definition and
diagnostic
consideration.J
Periodontal2018

20. Intact Periodontium
Absence of BOP, erythema and edema, patient symptoms and attachment and bone loss. Physiological bone level
range from 1.0 to 3.0mm apical to CEJ.
Clinical gingival health is generally associated with an inflammatory infiltrate and a host response consistent with
homeostasis.

21. Reduced Periodontium
Stable periodontitis patients:
Successfully treated periodontitis patient
Non periodontitis patients:
Eg :- Recession, Crown lengthening
In presence of increased clinical attachment and bone level, successfully treated, stable periodontitis patient remain at
increased risk of recurrent progression.
Reference:
Periodontal health Niklaus P.La:ng; P.Mark Bartold Jclin Periodontal.2018;
45(Suppl20):S9-S16

23. Health to Reduced Periodontium

24. Initiation of gingivitis
By accumulation of dental
plaque
Biofilm( >days /weeks)without
Disruption or removal
Due to loss of symbiosis
between
Biofilm and hosts immune-
inflammatory response.
Development of incipient dysbiosis

25. Gingivitis case can objectively, accurately defined and graded using a BOP score assessed as proportion of
bleeding sites (dichotomous) when stimulated by a standardized dental probe with a controlled force (0.25N)
to the apical end of the sulcus at six sites on all teeth present
LIMITATION
Characteristics of probe
Examiner variability
Patient related factors
Bleeding on Probing , if standardised , is the most relevant indicator of periodontal health
PPD and PAL alone are not indicators of periodontal health or disease rather should be correlated with BOP
Tooth mobility is not a good sign to define health/disease
Radiographs are not good indicators of clinical periodontal health on a reduced periodontium

26. CLASSIFICATION OF DENTAL BIOFILM INDUCED GINGIVITIS AND MODIFYING
FACTORS
 Associated with bacterial dental biofilm only
 Mediated by Systemic /Local risk factors :-
 Systemic condition:
a. Sex steroid hormone
o Puberty
o Menstrual cycle
o Pregnancy
o Oral contraceptives
b. Hyperglycaemia
c. Leukaemia
d. Smoking
e. Malnutrition
 Oral factors enhancing plaque accumulation
a. Prominent subgingival plaque accumulation
b. Hyposalivation/Oral dryness
 Drug influenced gingival enlargements.

27. Dental Plaque Biofilm-Induced Gingivitis
Inflammatory lesion – resulting from interaction between dental plaque biofilm and host’s
immune inflammatory response.
Inflammation – does not extends to periodontal attachment (cementum , PDL, alveolar bone )
These inflammation confined to gingiva & not extend beyond mucogingival junction
Gingival inflammation on reduced periodontium in a successfully treated periodontitis patient
(recurrent periodontitis cannot be ruled out).
Its reversable by reducing levels of dental plaque at and apical to the gingival margin.

29. Mediated By Systemic Risk
Factors(Modifying)
 Sex Steroid Hormone :-
 Tissue response within periodontium – modulated by-
o Androgen
o Oestrogen
o Progestins
 For endocrinotropic condition: - plaque bacteria and elevated steroid hormone levels – produces gingival
inflammation
 PUBERTY:
o Incidence & severity of gingivitis influenced by :-
• Biofilm level
• Dental caries
• Mouth breathing
• Crowding of teeth
• Tooth eruption
o Gingival inflammation  in circumpubertal age in both gender – without any increase in plaque level
 puberty associated gingivitis

30.  MENSTRUAL CYCLE
o Studies shows GCF flow increases by 20% (ovulation).
o Over 75% women – have menstrual cycle induced gingival inflammation
PREGNANCY
o Gingival probing depth increases
o Bleeding on probing/ bleeding on brushing
o GCF flow elevated
ORAL CONTRACEPTIVE
o Gingivitis due to oral contraceptive in premenopausal women is similar
to plaque induced gingivitis
o Current dose of oral contraceptive is less than the original dose .

31. Hyperglycemia
o Gingivitis – consistent feature in type I Diabetes Mellitus in children
o Level of glycaemic control  determine the severity of gingival inflammation
Leukemia
o Oral manifestation – in acute leukemia
o Signs of inflammation in gingiva  swollen glazed & spongy tissue
 red to purple in color
o Gingival bleeding –common sign
o Bleeding  due to thrombocytopenia & clotting factor deficiency persist as myelodysplasia-initial sign

32. Smoking
o Major lifestyle related environmental risk factor
o Inhaled cigarette smoke
Capillaries absorb via pulmonary alveolar epithelium
Thus enters systemic circulation
o Direct exposure of inhaled cigarette smoke
To periodontal tissue
Vasoconstriction of periodontal microvasculature & gingival fibrosis
o Plaque accumulation  exaggerated in smokers

33. Malnutrition
o Depletion of plasma ascorbic acid (Vit C) have effect on periodontium
o Scurvy (infants from low socio-economic families ,
institutionalized elderly & alcoholic ) developed risk for this condition
 compromised antioxidant micronutrient defenses to oxidative stress.
o These effects are similar to plaque induced gingivitis
Mediated By Local/Oral
Factors(Predisposing)
 Prominent subgingival plaque accumulation
 ANATOMY, SUBGINGIVAL RESTORATIONS
 increase plaque accumulation
 promote gingivitis

34.  HYPOSALIVATION
o Hyposalivation  Xerostomia  Sjogren's syndrome,
uncontrolled DM ,due to medications like antihistamine ,
decongestants, antidepressant, antihypertensive, Mouth breathing
o Cause  dental caries
taste disorders ,
halitosis,
inflammation of mucosa, tongue, gingiva
o Dryness in mouth  Plaque control is difficult ,
 Gingival inflammation worsen

35. Drug Influenced Gingival Enlargements
o DRUGS LIKE  antiepileptic – phenytoin , sodium valproate
 calcium channel blockers (nifedipine , verapamil ,
diltiazem , amlodipine, felodipine )
 Immunoregulating drugs (cyclosporine)
 High dose oral contraceptive
o Enlargement commonly seen in – anterior teeth region
o Prevalence in younger individuals
o Onset within 3months of use
o First observed at papilla
o No attachment loss or tooth mortality
o With or without bone loss
Phenytoin Induced
Nifedipine Induced
Cyclosporine Induced

36. CLASSIFICATION OF NON DENTAL BIOFILM INDUCED GINGIVITIS

37. GENETIC/DEVELOPMENTAL DISORDERS
Hereditary Gingival Fibromatosis
 Generalised fibrous gingival enlargement
 Rare disease
 Genetic basis –mutation of son of sevenless gene
SPECIFIC INFECTION
Bacterial Origin:
 Necrotising Periodontal Disease:
 Common term encomposing NG,NP,NS
 FLORA contain-treponema spp., selenomonas spp., fusobacterium spp., prevotella intermedia
 Ulceration with central necrosis of papilla-tissue destruction-forms crater.
 Associated condition –smoking, stress, poor nutrition, HIV, poor oral hygiene
 Others
• Gonorrhoeaª- Fiery red mucosa, white pseudomembrane with or without symptoms.
• Syphilis- Ulceration(fiery red,edematous,painful mucosa ), chancres(asymptomatic),inflamed gingiva.

38. Viral infection
 Coxsackie Virusesª:
 Cause- herpangina & HFMD
 Primarily seen in children
 Occurs in childhood
 HSV-1ª & HSV -2ª:
 Primarily involve anogenital infection
 rarely oral infection
 Herpetic Gingivostomatitis:
 form vesicles  rupture  coalesce  leave fibrin coated ulcers
 Mistaken as aphthous ulcerations
Fungal infection
Candidiasis:
 Oral thrush
 Erythematous
 Plaque like
 Nodular

39. INFLAMMATORY & IMMUNE CONDITION
Hypersensitivity Reactions:
o Contact allergyª:
 Redness & sometime lichenoid reaction
 Due to dental restoration, dentifrices, mouthwash and food
 Type IV hypersensitivity reaction
Autoimmune Disease of Skin and Mucous Membrane:
o Pemphigus vulgarisª:
 Desquamative gingivitis
 Vesiculo-bullous lesion of free and attached gingiva
 Intraepithelial bullae
Granulomatous Inflammatory Condition(Orofacial Granulomatosis):
o Crohns diseaseª:
 Cobblestone appearance – oral mucosa
 Linear ulceration
o Sarcoidosisª:
 Gingival swelling
 Nodules &Loosening of teeth
 Swelling of salivary gland

40. REACTIVE PROCESSES
Epulis:
o Fibrous Epulis
 Exophytic smooth surface pink masses- on gingiva
o Calcifying Fibroblastic Granuloma
 Pedunculated red or pink mass – derived from interdental papilla
o Pyogenic Granuloma(Vascular Epulis)
 Ulcerated , smooth red to pink in color .
•Conditions marked “ª” have associated systemic involvement or are oral manifestations of systemic conditions.
•This helps the other health care providers involved in diagnosis and treatment.
•This kind of patient-centered care has been referred to as Precision Dental Medicine(PDM).

41. 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 an Reduced Periodontium Without
History of Periodontitis
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%

42. A female patient of 18yrs with no relevant medical/drug history came with a complaint of pain in gums.
Pt. had
Probing pocket of 2mm in lower anteriors
No Clinical Attachment and bone loss
Bleeding on Probing Score of 28.7%
This gingival condition/case can be diagnosed as localized gingivitis on a intact periodontium.

43. A female patient of 50yrs with no relevant medical/drug history came with a complaint of bleeding gums.
Pt. had
Probing pocket of 2-3mm
With Clinical Attachment and no bone loss
Bleeding on Probing Score of 48.2%
Recession: Present
This gingival condition/case can be diagnosed as generalized gingivitis on a reduced periodontium.

44. This classification aims to provide the right care at the right time.
Classification systems are not rigid and fixed entities.
 Every classification system has evolved based on understanding of disease at the time the
classifications were proposed
 They are dynamic work in progress that need to be modified periodically based on Current
thinking and Knowledge
 New classification in 2017 was made with strongest available scientific evidence
Conclusion

45. REFERENCES
1. Jack G. Catson , Gary Armitage , Panos N. Papapanou , Mariana Sanz Et Al – introduction and key changes from
1999 classification – JCP 2018
1. Trombelli L,Farina .Plaque-induced gingivitis:case definition and diagnostic consideration.J Periodontal2018
;45(Suppl 20):S44–S67.
3. Periodontal health Niklaus P.La:ng; P.Mark Bartold Jclin Periodontal.2018;45(Suppl20):S9-S16.
4. Jack G. Caton, Gary Armitage, Tord Berglundh, Iain L.C. Chapple, Søren Jepsen, Kenneth S. Kornman, Brian L.
Mealey, Panos N. Papapanou, Mariano Sanz, Maurizio S. Tonetti; J Periodontol. 2018;89(Suppl 1):S1–S8.
5. Ilain L.C Chapple , Brain L. Mealey , Thomas E. Van Dyke et al – periodontal health and gingival condition on
intact and reduced periodontium – JCP 2018.
6. Palle Holmstrup , Jacqueline Plemons , Joerg Meyle – Non Dental Plaque Induced Gingival Disease – 2018 JCP

46. THANK YOU