This document provides an overview of the historical development and changes to classification systems for periodontal diseases. It discusses the three main paradigms that have influenced classification: the clinical characteristics paradigm from 1870-1920, the classical pathology paradigm from 1920-1970, and the infection/host response paradigm from 1970 to present. The document reviews several influential classification systems and the paradigm each was based on. It also discusses the ongoing challenges in classifying periodontal diseases as understanding of the diseases continues to evolve.

1. CLASSIFICATION SYSTEMS OF
DISEASES AND CONDITIONS
AFFECTING PERIODONTIUM
Presented by:
MISSRIYA

2. CONTENTS
• Introduction
• Definition
• Basis of classification
• Requirements
• Need for classification
• Uses of classification
• Historical development of classification system
clinical characteristic paradigm(1870-1920)
classical pathology paradigm(1920-1970)
infection/host response paradigm (1970 – present)
• Classification – the current situation
• Changes made in the classification system
• Future challenges in the classification of periodontal diseases
• Conclusion
• References

3. INTRODUCTION
• It has been estimated that there are more than 400 diseases affecting
the oral cavity.
• The most common disease of periodontal tissues are inflammatory
process of the gingiva and attachment apparatus of the tooth.
• During the last 25 years significant success has been achieved in
comprehension of the nature of periodontal diseases.
• Epidemiologists have cast new light on the incidence, prevalence,
nature and risk of disease.

4. • Oral microbiologists have elucidated the role of specific types of
microorganisms which induce the disease, and explained the role of
the host during the development and progression of the disease.
• The past 25 years have witnessed more than 10 different periodontal
disease classification systems .
• The lack of agreement on the operational definition of periodontitis
and the categorization of subjects into disease groups constitute a
major problem for researchers and policy makers attempting to
summarize the scientific evidence on periodontitis

5. • DEFINITION
Systematic collection of data or knowledge and its
arrangement in sequential manner in order to facilitate its
understanding or knowledge.
• Classification system are however helping us to understand one
another better and to work more economically, efficiently and
effectively.

6. • Classification system can be classified as follows:
• Topography : periodontitis superficialis, periodontitis
profounda
• Morphology: gingivitis hyperplastica, gingivitis
erosive
• Pathology
• Etiology: gingivitis gravidarum, dilantin gingivitis

7. REQUIREMENTS
• SHOULD NOT BE RIGID
• SHOULD BE ADAPTABLE
• SHOULD RESPOND TO CHANGING
KNOWLEDGE
CONSISTENCY

8. USES OF
CLASSIFICATION
Diagnosis,
prognosis and
treatment planning
Identification of
etiology &
understanding of
pathology
Presenting
information to
patient about his /
her disease
Facilitation and
communication among
the clinicians,
researchers, students,
epidemiological and
public health workers

9. NEED FOR CLASSIFICATION
Logical & systematic separation & organization of the
knowledge about the disease so that one may reason
From the signs & symptoms seen in the patient
Presumed etiologic history
Identification of the condition
Prescribed course of treatment

10. HISTORICAL DEVELOPMENT OF
CLASSIFICATION SYSTEM

11. Largely influenced by paradigms that reflect the understanding of
periodontal diseases during a given historical period.
Placed into 3 paradigms primarily based on:
Clinical characteristic paradigm (1870-1920)
Classical pathology paradigm (1920-1970)
Infection / Host Response Paradigm (1970-
present)

12. • Classification systems in the modern era represent a blend of all three
paradigms.
• With evolution , newer thoughts about periodontal diseases have been
superimposed on a matrix of older ideas that are still considered to be
valid.
• Only those ideas that are believed to be clearly outmoded or incorrect
have been discarded.
• Earlier classification were considered as rigid and fixed entities that
should not be changed.

13. CLINICAL CHARACTERISTICS
PARADIGM(1870-1920)
• Very little was known about the etiology and pathogenesis of
periodontal diseases.
• The diseases were classified on the basis of their clinical
characteristics supplemented by unsubstantiated theories about
their cause.
• Main debate – disease caused by local factors ? Or systemic
factors ?

14. • In the late 1800s and 1900s clinicians used case descriptions and their
personal interpretation of what they saw clinically as the primary
basis for classifying periodontal diseases.
• Their opinion survived in the literature in the form of written abstract
and summaries of the proceedings of these meetings.

15. John M. Riggs ( 1811-1875) , an
American dentist who lectured so
widely on the treatment of
periodontal diseases that
periodontitis was called as ‘Riggs’
disease by many of his colleagues.

16. C.G DAVIS 1879
According to him 3 distinct forms of periodontal diseases are
• Gingival recession with minimal or no inflammation
• Periodontal destruction secondary to ‘lime deposits”
• “Riggs disease”-loss of alveolus without loss of gums

17. G.V.BLACK 1886
• Constitutional gingivitis
Mercurial gingivitis
Potassium iodide gingivitis
Scurvy
• Painful form of gingivitis
• Simple gingivitis
• Calcic inflammation of peridental membrane
• Phagedenic pericementitis / Chronic
suppurative pericementitis

18. 1. Little or no scientific evidence was used to support the
opinion of clinicians of that time.
2. No generally accepted terminology or classification
system was adopted during this era
3. Terminology was too confusing to be used

19. CLASSICAL PATHOLOGY PARADIGM
(1920-70)
There were at least two forms of destructive periodontal diseases
Inflammatory
Non-inflammatory (Degenerative / Dystropic)
Based on over-interpretation of histopatholgical studies led by
Gottlieb and Orban.

20.  Gottlieb believed that he had discovered histological
evidence of an impairment in the continuous
deposition of cementum (cementopathia)
 Probably widely accepted because they appear to
explain the long-standing and perplexing clinical
observation that some young patients with relatively
clean mouths had massive and localised bone loss
with only minimal or no overt signs of gingival
inflammation

21. GOTTLIEB CLASSIFICATION - 1928
 INFLAMMATORY
Schmutz pyorrhea ( poor oral hygiene)
 DEGENERATIVE OR ATROPIC
Diffuse alveolar atrophy
(systemic or metabolic causes)
Paradental pyorrhea

22. 1. No microbial analysis.
2. Inflammatory process is over- interpretated as
degenerative process.
3. Gingival diseases not included.

23. ORBAN CLASSIFICATION - 1942
•He postulated “ periodontal diseases followed the
same course as the diseases of the other organs.
Minor changes may be present but the basic
pathologic changes however are the same as those of
other organs”.
•According to the principles of general pathology
there are 3 major tissue reactions – Inflammatory,
Dystrophic, Neoplastic.
• Neoplastic changes are not in the therapeutic realm
of periodontics. Environmental factors however
dictate the inclusion of a third category in the
periodontology – “Pathologic reaction produced
by occlusal trauma”.

24. INFLAMMATION
 Gingivitis
Local (calculus, food impaction irritating restoration,
drug actions)
Systemic (pregnancy, endocrine disorders, TB, syphilis,
nutritional disturbances, drug action, allergy, etc)
 Periodontitis
Simplex (secondary to gingivitis) - bone loss, pockets,
abscess, calculus
Complex (secondary to periodontosis) – etiologic factors
similar to periodontitis, have little if any calculus.

25.  DEGENERATIVE
Periodontosis (Attacks young girls and older men, often caries immunity)
Systemic (pregnancy, endocrine disorders, TB, syphilis,
nutritional disturbances, drug action, allergy, etc)
 ATROPHY
Periodontal Atrophy (Recession, no inflammation, no pockets, osteoporosis)
due to local trauma, senile, disuse, following inflammation, idiopathic

26. HYPERTROPHY
Gingival hypertrophy
Chronic irritation, drug action , idiopathic (gingivoma,
elephantiasis, fibromatosis)
TRAUMATISM
Periodontal traumatism – occlusal trauma

27.  Conclusion that some forms of periodontal diseases were
caused by non-inflammatory or degenerative process was
primarily based on over-interpretation of histopathological
studies.
 No scientific basis for retaining the concept that there were
non-inflammatory or degenerative forms of destructive
periodontal diseases.
 No convincing evidence that Gottlieb’s hypothesis
(degenerative nature) was right.

28. Etiology plays secondary & accessory part in
classification
Clinical assessment lack sufficient precision to
serve as a foundation for classification
The most valid basis for classification is therefore
one based on general pathology
WHO expert committee on the dental health in 1961
suggested

29. WHO CLASSIFICATION - 1961
GINGIVITIS
Acute Acute ulcerative gingivitis
Acute non-specific gingivitis
Chronic Chronic gingivitis
Chronic hyperplastic gingivitis
PERIODONTITIS
Acute periodontal abscess, ulcerative periodontitis
Chronic
Periodontitis simplex (marginal horizontal bone loss)
Periodontitis complex (irregular bone loss)

30. Acute & chronic conditions are easily identified.

31. 1. Degenerative & neoplastic process are left out.
2. Considered only inflammatory periodontal
diseases.
3. Not considered periodontal traumatism.
4. Systemic diseases not included.

32. McPHEE & COWLEY - 1966
I.GINGIVITIS
A. Acute gingivitis
Acute specific:- Ulceromembrane gingivitis,
Herpetic gingivitis, coccal gingivitis
Acute non-specific gingivitis
All periodontitis is a complex phenomenon involving a wide range of
interactions between the parasitic population of the mouth & the host tissues.

33. B. Chronic gingivitis
Chronic non-specific
Chronic edematous gingivitis
Chronic hyperplastic gingivitis
Chronic atrophic gingivitis
II. PERIODONTITIS
A. Acute non-specific
Periodontal abscess
B. Chronic non-specific
1. Periodontitis simplex (horizontal bone loss)
2. Periodontal complex (vertical bone loss)

34. 1. Based entirely on inflammation.
2. Simplified :- considered both specific & non-
specific inflammatory changes.
3. Also considered host responses. In small % of
cases, lab procedures may define an alteration
in host responses, which may be a factor or the
presence of infection predominantly by over
particular group of organisms.

35. Not stated about periodontal traumatism.

36. 1ST WORLD WORKSHOP IN
PERIODONTICS
1966-Ann Arbor, Michigan
• The term “ CHRONIC MARGINAL PERIODONTITIS”
was accepted.
• PERIODONTOSIS – A DISEASE ENTITY ???
Loe – suggested it be called periodontitis complex – no
support
Emslie – further research
• Failed to produce a definite system of classification of
periodontitis

37. INFECTION/ HOST RESPONSE
PARADIGM (~1970 - PRESENT ERA)
W.D. Miller was an early proponent of the
infectious nature of periodontal diseases.
The author also recognized that certain
systemic conditions (e.g. diabetes,
pregnancy) could modify the course of
the disease.

38.  Despite an extensive amount of work on the microbiology of
periodontal diseases from approximately 1880-1965 , very little
headway was made in establishing bacterial infections as the
foundation upon which periodontal diseases should be classified.
 Preoccupation with notion that some forms of destructive
periodontal diseases were degenerative in nature.
 It was not until the classical experimental gingivitis studies
published by Herald Loe and his colleagues from 1965-1968

39.  After which that the Infection/ host response paradigm began to
move in the direction of becoming the dominant paradigm.
 1976-1977 – demonstration of microbial specificity at sites with
periodontosis.
 1977-1979 – neutrophils from patients with juvenile periodontosis
had defective chemotactic and phagocytic activity
 Previous assumptions of degenerative forms of destructive disease
were doubted

40. PRITCHARD 1972
1)Inflammation with surface destruction
a)NUG
b)Herpetic gingivostomatitis
c)Desquamative gingivitis
d)Oral ulcers
2)Disease affecting the surface or gingiva
a)inflammation without destruction
b)Marginal gingivitis
c) Generalized diffuse gingivitis
d)Gingival enlargement

41. 3) Disease affecting the deeper structures
A)Inflammation without destruction
B)Marginal gingivitis
C)Generalized diffuse gingivitis
D)Gingival enlargement

42. 1. Considered the rate of destruction
2. Considered topography,morphology,etiology

43. 1. Rate of bone destruction is considered
2. Not included systemic modifiers of periodontal disease

44. WORLD WORKSHOP IN PERIODONTICS ,1977
 Convincing argument were provided
 No scientific basis for retaining the concept – degenerative or non
inflammatory forms of destructive periodontal disease
JUVENILE
PERIODONTITIS,
BUTLER,1969

45. R.C.PAGE AND H.E.SCHROEDER 1982
PERIODONTITIS – inflammatory disease of the periodontium
characterised by presence of periodontal pockets and active bone
resorption with acute inflammation.
PRE PUBERTAL PERIODONTITIS
Generalised
Localised
JUVENILE PERIODONTITIS
RAPIDLY PROGRESSING PERIODONTITIS
ADULT TYPE PERIODONTITIS
ACUTE NECROTISING ULCERATIVE GINGIVO- PERIODONTITIS

46. 1. Based on infection / host paradigm
2. Simplified, convenient and uncomplicated.

47. 1. Gingival disease not included
2. No definite criteria behind dividing the disease except
the age limitation.

48. AMERICAN DENTALASSOCIATION
CLASSIFICATION - 1982
• The system developed by the American Dental Association classification
system is primarily based on the severity of attachment loss.
• The clinician uses the clinical and radiographic data gathered and
classifies the patient into one of the four Case Types.
• These Case Types are commonly required for insurance billing.

49. • CODE NO. CASE TYPE DESCRIPTION
• 04500 I Gingivitis (No attachment loss,
Bleeding may or may not be present, Pseudo pockets may be present)
• IA Gingivitis with complicating
factors (systemic diseases, physical disabilities)

50. • 04600 II Early Periodontitis (Bleeding
on probing may be present in the active phase, probing depth or
clinical attachment loss of 3-4 mm, Localized areas of recession,
possible Class I furcation invasion areas, most commonly Horizontal
bone loss, Alveolar bone level is 3-4 mm from the CEJ area)
• IIA Early Periodontitis with
complicating factors.

51. • 04700 III Moderate periodontitis. probing
depth or clinical attachment loss of 4 - 6 mm, bleeding on probing,
Grade I and/or II furcation invasion areas, Tooth Mobility of Class I,
horizontal or vertical bone loss, alveolar bone level is 4-6 mm from the
CEJ area, Crown to root ratio is 1:1 (loss of 1/3 of supporting
alveolar bone)
• IIIA Moderate periodontitis
with complicating factors.

52. • 04800 IV Advanced periodontitis
(Bleeding on probing, probing depth or clinical attachment loss over
6 mm, grade II / III furcation invasion, mobility of class II / III,
horizontal & vertical bone loss, alveolar bone level is ≥ 6 mm from
the CEJ area, crown to root ratio is 2:1 or more (loss of over 1/3 of
the supporting alveolar bone)
• IVA Advanced periodontitis with
complicating factors.

53. 1. Used for insurance purpose.
2. Emphasizes case type of complexity that in
turn relates to extent & complexity of the
treatment.

54. AMERICAN ACADEMY OF
PERIODONTOLOGY-1986
I. Juvenile Periodontitis
A. Prepubertal
B. Localized juvenile periodontitis
C. Generalized juvenile periodontitis
II. Adult Periodontitis
III. Necrotizing Ulcerative Gingivo-Periodontitis
IV. Refractory Periodontitis

55. • This classification also followed same criteria - according
to age limits to divide them.
• Refractory periodontitis category was included
• It was complicated by adding pre-pubertal under the
juvenile periodontitis category.

56. WORLD WORKSHOP OF AMERICAN
ACADEMY OF PERIODONTOLOGY 1989
Princetown,California
REFINEMENT OF PAGE & SCHROEDER (1982) AND AAP (1986).
BASED ON
• Age
• Rate of disease progression
• Presence / absence of inflammation
• Extend and pattern of attachment loss
• Presence/ absence of miscellaneous signs and symptoms, including
pain, ulceration and amount of observable plaque and calculus

57. CLASSIFICATION
ADULT PERIODONTITIS
PERIODONTITIS
ASSOCIATED WITH
SYSTEMIC DISEASES
EARLY ONSET
PERIODONTITIS
NECROTIZING ULCERATIVE
PERIODONTITIS
REFRACTORY
PERIODONTITIS
Pre pubertal - generalized / localized
Juvenile – generalized / localized
Rapidly progressive periodontitis
Down syndrome
Diabetes type 1
Papillon – lefevre syndrome
AIDS
Other diseases

58. 1. Inclusion of Periodontitis Associated with
Systemic Disease
2. Refractory periodontitis category
3. Ease with which patients can be placed into age
based criteria
4. Organized the early onset periodontitis category

59. 1. Did not include gingival diseases category.
2. Periodontitis categories had non validated age-
dependent criteria.
3. Extensive overlap in the clinical characteristics of the
different categories of periodontitis.
4. Extensive crossover in rates of progression of the
different categories of periodontitis.
Rapidly Progressive
Pre- pubertal Heterogeneity existed
Refractory group

60. RANNEY , 1993
• Periodontal diseases that progress from marginal gingiva are
infectious diseases caused by bacteria.
• Inflammatory conditions restricted to gingiva – GINGIVITIS.
• Extend deeper to involve periodontal ligament, cementum &
alveolar bone - PERIODONTITIS

61. • Although gingival & periodontal diseases are of local
origin, systemic influences can be seen
• Some gingival abnormalities produced primarily by
systemic conditions as well.
• No periodontitis has been documented of purely systemic
origin
• Accepts occlusal trauma as a physiological adaptation
rather than a disease.

62. CLASSIFICATION
1. GINGIVITIS-
PLAQUE INDUCED
• A. Non aggravated
• B. Aggravated by
hormones ,drugs
systemic diseases.
2. NECROTISING
ULCERATIVE
GINGIVITIS
• A. Unknown
systemic
determinants
• B. Related to HIV
3. GINGIVITIS, NON
PLAQUE INDUCED
• A. Associated with
skin disease
• B. Associated with
allergy
• C. Associated with
infections

63. 4. ADULT
PERIODONTITIS
• A. Non-
aggravated
• Systematically
aggravated
5.EARLY ONSET
PERIODONTITIS
• A. Localised
neutrophil
abnormality
• B. Generalised
neutrophil
abnormality or
immunodeficient
• C. Related to
systemic diseases
• D. Unknown
systemic
determinants
6. NECROTISING
ULCERATIVE
PERIODONTITIS
• A. Systemic
determinants
unknown
• B. Related to
HIV
• C. Related to
nutrition
7.
PERIODONTAL
ABSCESS

64. merits
This system includes not only forms of gingivitis &
Periodontitis other than those caused by plaque but
also by modifying factors.
eg. Systemic aggravating factors, general diseases
status, viral infections & so on.

65. • Eliminated the “Refractory Periodontitis” category
since it was heterogeneous group & it was impossible
to standardize the treatment that necessarily would
have to be given prior to making diagnosis.

66. EUROPEAN WORKSHOP ON
PERIODONTITIS 1993
ADULT
PERIODONTITIS
• Onset 4th decade
• Slow rate of
progression.
• No host
response
EARLY ONSET
PERIODONTITIS
• Onset prior to 4th
decade
• Rapid onset of
progression
• Defect in host
response
NECROTIZING
PERIODONTITIS
• Tissue response
with attachment
and bone loss
DEMERITS
Lacked adequate categorization of broad spectrum of periodontal
diseases.
Gingival diseases not included.

67. 1999 CLASSIFICATION
–SITUATION

68. – The 1989 and European classification gained widespread
acceptance and use through out the world.
– Overtime various problems with the application of the
classifications arose.
– As observed by Armitage , the criticisms largely depended on
age of onset and rate of progression.
– Due to various shortcomings of the previous classification, the
classification was revised in 1999 .

69. INTERNATIONAL WORKSHOP FOR CLASSIFICATION OF
PERIODONTAL DISEASES AND CONDITIONS 1999
Oak Brook, Illinois
I – GINGIVAL DISEASES –
A. Plaque Induced
B. Non- Plaque induced
II – CHRONIC PERIODONTITIS
A. Localized
B. Generalized
III – AGGRESSIVE
PERIODONTITIS
A- Localized
B- Generalized
IV – PERIODONTITIS AS A
MANIFESTATION OF SYSTEMIC
DISEASE
V – NECROTISING PERIODONTAL
DISEASES
VI – ABCESSES OF
PERIODONTIUM
VII – PERIODONTITIS
ASSOCIATED WITH ENDODONTIC
LESIONS
VIII – DEVELOPMENTAL OR
ACQUIRED DEFORMITIES AND
CONDITIONS

70. CHANGES IN THE CLASSIFICATION SYSTEM FOR PERIODONTAL DISEASES- 1999
 Addition of a gingival disease component
 Replacement of “Adult Periodontitis” with “Chronic Periodontitis”
 Elimination of “Refractory Periodontitis” as a Separate Entity
 Replacement of “Early-Onset Periodontitis” with “Aggressive Periodontitis”
 Further Subclassification of “Periodontitis as a Manifestation of Systemic Diseases”
 Replacement of “Necrotizing Ulcerative Periodontitis” with “Necrotizing Periodontal
Diseases”
 Addition of Categories for “Periodontal Abscess” and “Periodontic-Endodontic Lesion
 Addition of a Category for “Developmental or Acquired Deformities and Conditions”
(Wiebe,Putins. The periodontal disease classification system of the AAP –An u

71. Papapanou PN, Sanz M, et al. Periodontitis: Consensus report of Workgroup 2 of
the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant
Diseases and Conditions. J Clin Periodontol. 2018;45(Suppl 20):S162–S170.
Although this classification has provided a workable framework
that has been used extensively in both clinical practice and
scientific investigation in periodontology during the past 19
years, the system suffers from several important shortcomings,
Including
Substantial overlap and lack of clear pathobiology‐based
distinction between the stipulated categories,diagnostic
imprecision, and implementation difficulties.

72. Since the 1999 workshop, substantial new information has
emerged from population studies, basic science investigations,
and the evidence from prospective studies evaluating
environmental and systemic risk factors.
The analysis of this evidence has prompted the 2017 workshop
to develop a new classification framework for periodontitis.
Caton J, Armitage G, Berglundh T, et al. A new classification scheme
for periodontal and periimplant diseases and conditions – Introduction
and key changes from the 1999 classification. J Clin Periodontol.

73. • The workshop agreed that, consistent with current knowledge on
pathophysiology, three forms of periodontitis can be identified:
necrotizing periodontitis, periodontitis as a manifestation of systemic
disease, and the forms of the disease previously recognized as “chronic”
or “aggressive”, now grouped under a single category, “periodontitis”.
• In revising the classification, the workshop agreed on a classification
framework for periodontitis further characterized based on a
multidimensional staging and grading system that could be adapted over
time as new evidence emerges.
Caton J, Armitage G, Berglundh T, et al. A new classification scheme for
periodontal and periimplant diseases and conditions – Introduction and key
changes from the 1999 classification. J Clin Periodontol. 2018;45(Suppl 20):S1–
S8

74. • The 2017 World Workshop Classification system for periodontal and
Peri-implant diseases and conditions was developed in order to
accommodate advances in knowledge derived from both biological and
clinical research that have emerged since the 1999 International
Classification of Periodontal Diseases.

75. • New classification system was developed by
- Joint European Federation of Periodontology (EFP) and
- American Academy of Periodontology (AAP) management committee (2017 )
- 19 review papers & 4 consensus report.
Aim :
 To adopt a reductionist model in order to create a system that could be implemented
in general dental practice, the environment where over 95% of periodontal disease is
diagnosed and managed.
 To create a system that captured and distinguished the severity and extent of
periodontitis (a reflection of the amount of periodontal tissue loss) on one hand, as
well as a patient’s susceptibility for periodontitis (as reflected by the historical rate
of periodontitis progression).
which was held in Chicago on November 9 to 11, 2017

76. • To accommodate the current periodontal status of a patient (probing pocket depth
[PPD], and percentage of bleeding on probing [BOP]).
• This system of classification is a live system to be regularly updated by a task
force to accommodate future advances in knowledge, either clinical or biological
(for example, biomarkers), as it emerges.

77.  In order for a clinician or student to understand periodontal assessment and
diagnosis in the context of the 2017 classification system, it is critical to
understand that,
Determine the type of Periodontal Disease
Determine the patients current disease status
Determining the patients risk factor profile

78.  PERIODONTAL DIASEASES AND CONDITIONS
 PERI-IMPLANT DIASEASES AND CONDITIONS
Classification of periodontal and peri-implant diseases and conditions 2017

79. CLASSIFICATION OF PERIODONTAL AND PERI-IMPLANT DISEASES AND CONDITIONS 2017
 PERIODONTAL DIASEASES AND CONDITIONS
Periodontal health, gingival disease and Conditions
Periodontitis
Other Conditions affecting periodontium

80.  PERI-IMPLANT DIASEASES AND CONDITIONS
 Peri-implant Health
 Peri-implant Mucositis
 Peri-Implantitis
 Peri-implant Soft and Hard Tissue Deficiencies

81.  For the first time, the 2017 classification system gives clear definitions of
periodontal health and gingivitis for:
 Patients with an intact periodontium
 Patients with a reduced periodontium due to causes other than periodontitis
 Patients with a reduced periodontium due to periodontitis.
KEYCHANGES

82. • It agreed that BOP should be the primary parameter to set thresholds for gingivitis
• In the 2017 classification system, the distinction between Chronic And Aggressive
Periodontitis has been removed on the basis that there was little evidence from
biological studies that chronic and aggressive periodontitis were separate entities,
rather than variations along a spectrum of the same disease process.
• The exception was Classical Localised Juvenile (Aggressive) Periodontitis, where a
clearly defined clinical phenotype exists, however, there was unease about including
this as a distinct and separate entity within the classification system.
• The only other distinct types of periodontitis that the 2017 classification system
recognises are Necrotising Periodontitis and Periodontitis as a Manifestation of
Systemic Disease.

83. STAGING AND GRADING OF PERIODONTITIS
According to BSP implementation group staging and grading system needed to be:
• Sufficiently simple and pragmatic to be adopted by clinicians,
• It should be based upon parameters that are readily available in the surgery,
• Which could be measured with reasonable reproducibility as part of appropriate routine clinical care
for the majority of patients.
Principle of the staging process at the initial assessment:
Patients cannot regress to a lower stage of periodontitis due to
treatment, therefore, periodontal parameters that are significantly
affected by treatment ( BOP and PPD) cannot be employed to
determine disease stage.
• Once a patient has been diagnosed with periodontitis, Staging and Grading should be performed .

84. Primary Goal in staging and grading patients with periodontitis
Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new
classification and case definition. J Clin Periodontol. 2018;45(Suppl 20):S149–S161

85. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new
classification and case definition. J Clin Periodontol. 2018;45(Suppl 20):S149–S161

86. Scoring codes for the BPE. British Society of Periodontology. The Good Practitioners Guide to

87. Establishing a periodontal diagnosis as part of a comprehensive periodontal examination

88.  The diagnostic pathway includes the following stages:
Determination of the type and extent
of periodontal disease and, in the
case of periodontitis, its staging and
grading.
Identification of current
health/disease status (via PPD
and BOP).

89. The final diagnosis would embed all of these components in a ‘diagnostic statement’, for
example:
DIAGNOSIS Generalised Periodontitis; Stage IV, Grade B; Currently Unstable.
Risk factors:
Current smoker >10 cigarettes per day
Sub-optimally controlled diabetes.
Finally, relevant risk factors should be documented immediately below the diagnostic statement

90. • A 19-year-old female presented in good general health.
• Non-smoker.
• On Intraoral examination : Moderate levels of oral hygiene
signs of gingival inflammation(redness, and oedema ).
No overt interproximal recession or CAL
Periodontal diagnosis in the context of the BSP implementation plan for the 2017
classification system of periodontal diseases and conditions: presentation of a pair of
young siblings with periodontitis .C. Walter et al on behalf of the British Society of
Periodontology. British Dental Journal | Volume 226 No. 1 | January 11 2019

91. The full periodontal chart demonstrated
• deep pockets up to 8 mm in all sextants,
• all molars-furcation involvement (grade II furcations in all maxillary molars and 46)
• several pockets >4 mm that bled on probing ( indicating unstable periodontitis)

92. The periapical radiographs show evidence of significant
bone loss due to periodontitis on all teeth, with the
possible exception of 23, 24, 44,45
Given the history (that is, lack of systemic disease explaining loss of periodontal tissues, for
example, Papillon-Lefèvre- Syndrome) and the clinical and radiological findings
(interproximal attachment loss/ alveolar bone loss due to periodontitis, no papillary necrosis
consistent with necrotising periodontal disease), a diagnosis of PERIODONTITIS was made.

93. • For every patient diagnosed with periodontitis, staging and grading should be
performed as the next step.
• Bone loss reached into the middle third of the root in many teeth, but did not extend
into the apical third on any tooth.
• Hence, the patient is with stage III periodontitis.
• Maximum bone loss of approximately 60% is seen at 14, 15 and 16.
• As the patient is 19 years of age, the numerical value of the highest percentage of bone
loss exceeds the numerical value of her age (percentage of bone loss/age ratio >1),
which results in an assignment of grade C.
• At least 24 out of 28 teeth (>30%) are affected by bone loss due to periodontitis,
resulting in an extent classification of ‘generalised’ periodontitis.
Therefore, the definitive diagnosis according to the 2017 classification is:
Generalised periodontitis; stage III/grade C;
currently unstable.

94. 1. Caton J, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and periimplant
diseases and conditions – Introduction and key changes from the 1999 classification. J Clin
Periodontol. 2018;45(Suppl 20):S1–S8
2. Chapple ILC, Mealey BL, et al. Periodontal health and gingival diseases and conditions on an intact
and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the
Classification of Periodontal and Peri‐Implant Diseases and Conditions. J Clin Periodontol.
2018;45(Suppl 20):S68–S77.
3. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann
Periodontol. 1999;4:1–6.
4. Papapanou PN, Sanz M, et al. Periodontitis: Consensus report of Workgroup 2 of the 2017 World
Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. J Clin
Periodontol. 2018;45(Suppl 20):S162–S170
5. British Society of Periodontology. The Good Practitioners Guide to Periodontology. 2016. Available at
http://www.bsperio.org.uk/publications/good_practitioners_guide_2016.pdf
6. Tonetti M S, Greenwell H, Kornman K S. Staging and grading of periodontitis: Framework and
proposal of a new classification and case definition. J Clin Periodontol 2018; 45 Suppl 20: S149–
S161.
7. Wiebe,Putins. The periodontal disease classification system of the AAP –An update
8. Periodontal diagnosis in the context of the BSP implementation plan for the 2017 classification
system of periodontal diseases and conditions: presentation of a pair of young siblings with
periodontitis .C. Walter et al on behalf of the British Society of Periodontology. British Dental Journal |
Volume 226 No. 1 | January 11 2019
References