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1. CLASSIFICATION OF
PERIODONTAL
DISEASES
INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
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2. INDEX
 INTRODUCTION
 NEED FOR CLASSIFICATION
 DEVELOPMENT & EVOLUTION OF
CLASSIFICATION SYSTEMS
 CONCLUSION
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3. INTRODUCTION
CLSSIFYING PERIODONTAL DISEASES
– A LONG STANDING DILEMMA
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4.  There has been a debate on the diagnosis
and classification of periodontal diseases.
 Diagnosis is defined as the act of
identifying a disease from its signs and
symptoms.
 Classification is defined as the act or
method of distribution into groups.
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5.  Any attempt to group the entire
constellation of periodontal diseases into
an early and widely accepted classification
system is fraught with difficulty,and
inevitably considerable controversy.
 Despite the dilemma,in the past hundred
years,experts have periodically assembled
to develop a new classification system for
periodontal diseases.
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6. NEED FOR CLASSIFICATION
 For the purpose of diagnosis,prognosis and
treatment planning.
 To understand the etiology,pathology of
the diseases of the periodontium.
 For logical,systemic separation and
organization of knowledge about disease.
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7.  Facts can be filed for future references.
 Helps to communicate among
clinicians,researchers,educators,students,
epidemiologists and public health workers.
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8. The development and evolution
of classification systems
 Influenced by paradigms that reflect the
understanding the nature of periodontal
diseases during a given historical period.
 Over time,thoughts that guided the
classification of periodontal diseases can
be placed into three dominant paradigms.
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9.  The dominant paradigms in the historical
development of classification system
primarily based on
 I.Clinical features of the diseases
(1870-1920)
 II.The concepts of classical pathology
(1920-1970)
 III.The infectious etiology of the diseases
(1970-present)
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10.  Classification systems in the modern era
represent a blend of all three paradigms.
 The ideas which are believed to be clearly
outmoded or incorrect have been
discarded.
 The new paradigm rests on a foundation of
the still valid components of the older or
previous paradigms.
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11.  The classification systems should be
viewed as dynamic works-in-progress that
need to be periodically modified based on
current thinking and new knowledge.
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12.  The ancient medical works refer to the
various diseases of teeth & periodontium
but without using any particular
terminology.
 The first specific name for periodontal
disease was introduced by Fauchard in
1723 using the term ‘SCURVY OF THE
GUMS’.
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13. I.CLINICAL CHARACTERISTICS
PARADIGM(1870-1920)
 In the late 1800&early 1900s clinicians
used case descriptions and their personal
interpretation of what they saw clinically
as the primary basis for classifying
periodontal diseases.
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14.  In 1811-1875 John M Riggs lectured on
the treatment of periodontal disease.After
that periodontitis was called “Rigg’s
disease”.
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15.  In 1879 C.G Davis published a paper ,he
believed that there were three distinct
forms of destructive periodontal disease:
 1.Gingival recession with minimal or no
inflammation due to trauma from tooth
brushing or decreased vascular action.
 2.Periodontal destruction secondary to
‘lime deposits’-the gum retires slowly and
the alveolar border deprived of nutrition,at
the point of pressure is consentaneously
absorbed.
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16.  3.Rigg’s disease : loss of alveolus without
loss of gum.the perceived problem was a
necrosed alveolus or death of the
periodontal membrane.
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17.  In 1886 G.V.Black published on
classification based on their clinical
characteristics and his understanding of
their cause into five groups
 1.constitutional gingivitis
 2.painful form of gingivitis(NUG)
 3.simple gingivitis
 4.the destruction of alveolar bone slowly in
even or generalized pattern.(chronic
periodontitis)
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18.  5.Phagedinic periodontitis:the pattern of
alveolar bone destruction is irregular.it
may occur rapidly or slowly.
 In a later publication Black replaced the
term ‘phagedinic periodontitis’ with
‘chronic suppurative pericementitis’.
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19. In the later part of the 19th century
periodontitis went under numerous names:
 Pyorrhea alveolaris
 Riggs disease
 Calcic inflammation of the periodontal
membrane
 Phagedinic pericementitis
The dominant term used for periodontal
disease was pyorrhea alveolaris.
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20. II.CLASSICAL PATHOLOGY
PARADIGM(1920-1970)
 The concept emerged from the debate on
periodontal diseases by the clinical
scholars in Europe and North America
concluded -
There were two forms of periodontal
disease
1.Inflammatory (degenerative)
2.Noninflammatory(dystrophic)
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21.  Gottileb is generally considered to be the
first author who clearly distinguished
various forms of periodontal disease.
In 1920s he classified periodontal disease
into four groups.
 1.Schmutz pyorrhea:
due to accumulation of deposits on the
teeth and was characterised by
inflammation,shallow pockets, and
resorption of alveolar crest.
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22.  2.Alveolar atrophy or diffuse atrophy:
Non inflammatory disease exhibiting
loosening of teeth,elongation of and
wandering of teeth in individuals who were
free of caries & dental deposits,pockets are
formed in later stages
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23.  3.Paradental-pyorrhoe:
Irregularly distributed pockets varying
from shallow to extremely deep.this may
be started as Schmutz-pyorrhoe or diffuse
atrophy.
 4.Occlusal trauma:
A form of physical overload was believed
to result in resorption of the alveolar bone
and loosening of teeth.
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24.  Mc Call & Box in 1925 introduced a term
‘periodontitis’ to denote those
inflammatory diseases in which the
gingiva,bone & periodontal ligament are
involved.
 Periodontitis was sub classified on the
basis of presumed etiologic factors into
1.simplex periodontitis:due to local
bacterial factors
2.complex periodontitis:due to systemic
etiologic factors.
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25.  Becks (1931) made a distinction between
PARADENTITIS,a disease ‘which
originates from the gum tissue in the form
of gingivitis’ and GENUINE
PARADENTOSIS ‘which originates in the
bony alveolus,perhaps in the form of an
osteopathy’.
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26.  Orban & Weinmann (1942) used the term
periodontosis to designate this ‘non
inflammatory disease’.
 Periodontosis was considered a separate
disease entity,distinctly different from
periodontitis,which was considered as the
sequel of gingivitis of deeper periodontal
structures and therefore of a inflammatory
origin.
 It is not mentioned specifically that it was
a disease entity particular to young
patients.
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27.  Orban classified periodontal diseases
according to the “pathologic” categories of
Inflammation
Degeneration
Atrophy
Hypertrophy
Traumatism.
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28. *Inflammation
I.gingivitis(little or no pocket formation)
A.local-
calculus,foodimpaction,irritating restorations,drug
action etc.
B.systemic-
pregnancy,diabetes,tuberculosis,syphilis,nutritional
disorders,drug action,allergy,hereditary,idiopathic
etc.
II.periodontitis
A.simplex(secondary to gingivitis)-bone
loss,pockets,abscess can form:cases have calculus.
B.complex(secondary to periodontosis)-etiologic
factors similar to periodontitis:cases have little,if
any calculus.
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29. *Degeneration
I.Periodontosis)
A.Systemic disturbances
1.Diabetes
2.Endocrine dysfunctions
3.Bood dyscrasias
4.Nutritional disturbances
5.Nervous disorders
6.Infectious diseases(acute &chronic)
B.Hereditary
C.Idiopathic www.indiandentalacadem

30. *Atrophy
I.Peridontal atrophy(recession,no
inflammation,no pockets)
A.Local trauma(eg;from tooth brush)
B.Presenile
C.Senile
D.Disuse
E.Following inflammation
F.Idiopathic
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31. *Hypertrophy
I.gingival hypertrophy
A.Chronic irritation
B.Drug action
C.Idiopathic
*Traumatism
I.Periodontal traumatism
A.Occlusal trauma
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32.  During 1950 & 1960s the importance of
dental plaque as the major etiologic factor
for periodontal diseases became more and
more evident.
 The ultimate proof of association between
plaque and gingival inflammation was
shown by Loe and coworkers in their
experimental gingivitis
studies(1965,1966).
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33. In 1966 the workshop in periodontics
concluded the report:
 ‘Evidence to support the conventional concept of
periodontosis is unsubstantiated.It was the
consensus of the section that the term
periodontosis is ambiguous and it should be
eliminated from nomenclature.Nevertheless,the
committee is aware that some evidence exists to
indicate that a clinical entity different from adult
periodontitis may occur in adolescents and young
adults’.
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34.  Soon after the workshop a study was
published by Butler(1969) introducing the
JUVENILE PERIODONTITIS instead of
periodontosis.
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35. III.Infection/Host response
Paradigm(1970-present)
 In1876 Robert Koch published the
experimental proof of the germ theory of
disease and established the koch’s
postulates.
 Miller (1890) was an early advocate of this
paradigm that would come to dominate the
field nearly a hundred years later.
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36.  Harald & loe in 1965-1968 studied on
experimental gingivitis and concluded
there is a significant relationship between
plaque flora and development of gingivitis.
 The next major discovery in periodontal
microbiology was the preliminary
demonstration in 1976-1977 of microbial
specificity at sites with periodontosis.
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37.  This finding is coupled with demonstration
in 1977-1979 that neutrophils from
patients with juvenile periodontitis had
defective chemotactic and phagocytic
activities,marked the beginning of the
dominance of infection/host response
paradigm.
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38.  In 1982 Page & Schroder defined
periodontitis as an inflammatory disease of
the periodontium characterised by the
presence of periodontal pockets and active
bone resorption with acute inflammation.
 They suggested four different forms of
periodontitis.
1.prepubertal periodontitis
2.juvenile periodontitis
3.rapidly progressive periodontitis
4.adult periodontitis
5.ANUG/P
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39.  In 1986 the AAP adopted the following
classification
I.Juvenile periodontitis
 A.prepubertal periodontitis
 B.localized juvenile periodontitis
 C.generalized juvenile periodontitis
II.Adult periodontitis
III.NUG/P Necrotizing ulcerative gingivo
periodontitis.
IV.Refractory periodontitis
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40.  In 1988 Jhonson et al presented a more extensive
classification to detect the groups and individuals
at high risk for periodontal disease.
I.Childhood periodontitis
II.Juvenile periodontitis
-localized,generalized
III.Post juvenile periodontitis
IV.Adult onset periodontitis
-slowly progressive
-rapidly progressive
V.periodontitis associated with systemic
diseases(diabetes,scurvy,immunodeficiencies,
immunosupressive states,blood dyscrasias)
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41. VI.Traumatic periodontitis
eg:gingival recession and loss of
attachment as a result of abrasion during
oral hygiene practice(tooth
brushing,woodsticks,charcoal,brick dust)
VII.Iatrogenic periodontitis
due to inappropriate
restorations or inappropriate
instrumentation of the gingival crevice.
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42.  The next major landmark in classification
emerged from the 1989 World Work Shop
in clinical periodontics follows as:
I. Adult periodontitis
II.Early onset periodontitis
A.Prepubertal periodontitis
-localized,generalized
B. Juvenile periodontitis
-localized,generalized
C. Rapidly progressive periodontitis
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43. III. Periodontitis associated with systemic
diseases
IV.Necrotizing ulcerative Periodontitis
V.Refractory Periodontitis
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44.  The short comings of 1989 classification:
1.considerable overlap in clinical
characteristics of the different disease
categories
2.Absence of gingival diseases
3.Inappropriate emphasis on age of onset of
disease and rates of progression
4.Inadequate or unclear classification criteria
5.Rapidly progressive & prepubertal
perodontitis and refractory periodontitis
were heterogenous category
6.The periodontitis categories had non
validated age dependent criteria
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45.  In 1993 Ranney et al recommended the
elimination of refractory periodontitis and
periodontitis associated with systemic
diseases.he suggested to consider these in
specific context rather than treating them
as a unique category.
 Ranney proposed four major categories
I. Adult periodontitis
II. Early onset periodontitis
III. Necrotizing ulcerative Periodontitis
IV.periodontal abcess
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46.  In 1993 first European Work Shop on
periodontology given a statement on the
basis of the reports produced by
papapanou.
 ‘There is a insufficient knowledge to
separate truly different diseases (disease
heterogenicity)from differences in the
presentation/severity of the same
disease(phenotypic variation).
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47.  1993 classification
I.Adult periodontitis
II.Early onset periodontitis
III.Necrotizing periodontitis
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48.  The need for a revised classification
system for periodontal diseases was
emphasized during the 1996 World Work
Shop in periodontics.
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49.  On October 30 – November 2nd 1999, the
International Work Shop for a
classification of periodontal diseases and
conditions was held and a new
classification was agreed upon.
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50. Classification of periodontal diseases &conditions
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51. Gingival diseases
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57. Conclusion
 The classified system proposed by ‘1999
international work shop for a classification
of periodontal diseases and conditions’ has
corrected some of the problems associated
with the previous system that had been in
use since 1989.
 Nevertheless the new system is far from
perfect and will need to be modified once
there are sufficient new data to justify
revisions. www.indiandentalacadem

58.  Since it is probable that essentially all
dentists & periodontists in the world are
convinced that most periodontal diseases
are infections,it is unlikely that the
Infection/Host response paradigm will be
replaced in the near future.
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59. References
1.Clinical periodontology-Carranza 9th
edition.
2.Critical issues in periodontal diagnosis-
Periodontology 2000;vol 39:2005.
3.Controversies in periodontology-
Periodontology 2000;vol30:2002.
4.Classification & Epidemiology of
periodontal diseases-Periodontology
2000;vol2:1993.
5.Annals of periodontology 1999.
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60. Thank you
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