Periodontitis is a chronic, slowly progressing disease which mainly results in the destruction of tooth supporting apparatus. Earlier it was classified as Chronic and Aggressive periodontitis with different clinical features and etiology. Current classification ( 2017) of periodontal disease involves periodontitis with is further divided into 4 stages and 3 grades depending on severity and rate of disease progression respectively. Diabetes meelitus and smoking are the validated risk factors for the progression of periodontitis.

1. PERIODONTITIS
BY- DR.OINAM MONICA DEVI

2. Contents
• Definition
• Clinical features
• Changes in the nomenclature of case definition of Periodontitis
• Chronic Periodontitis
• Aggressive Periodontitis
• The most recent Case definition of Periodontitis
• References

3. Definition
Clinical definition of periodontitis
• Periodontitis is a chronic multifactorial inflammatory disease associated with
dysbiotic plaque biofilms and characterised by the progressive destruction of
the tooth-supporting apparatus.
• Periodontitis is characterised by inflammation that results in the loss of
periodontal attachment.
• While the formation of bacterial biofilm initiates gingival inflammation, the
disease of periodontitis is characterised by three factors:
1. The loss of periodontal-tissue support, manifested through clinical
attachment loss (CAL) and radiographically assessed alveolar bone loss
2. The presence of periodontal pocketing
3. Gingival bleeding.

4. Signs and symptoms of periodontitis can include:
• Swollen or puffy gums
• Bright red, dusky red or purplish gums
• Gums that feel tender when touched
• Gums that bleed easily
• Pink-tinged toothbrush after brushing
• Spitting out blood when brushing or flossing your teeth
• Bad breath
• Pus between your teeth and gums

5. Armitage 1999
Chronic Periodontitis
(A. Localized
B. Generalized (> 30% of
sites are involved)
Aggressive Periodontitis
(A. Localized
B. Generalized (> 30% of
sites are involved)
Periodontitis as a
Manifestation of Systemic
Diseases
A. Associated with
hematological disorders
B. Associated with genetic
disorders
C. Not otherwise specified
Necrotizing Periodontal Diseases
A. Necrotizing ulcerative gingivitis
B. Necrotizing ulcerative periodontitis
Periodontitis Associated With Endodontic
Lesions
A. Combined periodontic-endodontic
lesions
The classification to define Periodontitis used for the longest period
was by American Academy of Periodontology (AAP) 1999

6. • Chronic periodontitis has been defined as "an infectious disease resulting
in inflammation within the supporting tissues of the teeth, progressive
attachment loss, and bone loss.”
• Site-specific disease
• Slight (mild) periodontitis: No more than 1 to 2 mm of clinical
attachment loss
• Moderate periodontitis: 3 to 4 mm of clinical attachment loss
• Severe periodontitis: 5 mm or more of clinical attachment loss
Chronic Periodontitis

7. Clinical Diagnosis
Detection of chronic
inflammatory changes in
the marginal gingiva
Presence of periodontal
pockets
Loss of clinical
attachment
It is diagnosed radio graphically by: Localized or generalized loss of
alveolar supporting bone, horizontal or vertical

8. Localized periodontitis: less than 30% of the sites demonstrate attachment loss and
bone loss
A. Clinical view of anterior teeth
showing minimal plaque and
inflammation
B. Radiographs showing presence of
localized, vertical, angular bone loss on
the distal side of the maxillary left first
molar
C. Surgical exposure of the
vertical, angular defect
associated with the chronic
plaque accumulation and
Carranza, 11th ed

9. Generalized periodontitis: less than 30% or more of the sites demonstrate
attachment loss and bone loss
A. Clinical view showing minimal
plaque and inflammation
B. Radiograph showing severe,
generalized, horizontal pattern of
bone loss
Carranza, 11th ed

10. Lang et al in 1999 defined aggressive periodontitis on the basis of:
Aggressive Periodontitis

11. • A striking feature is lack of clinical inflammation despite the presence of
deep periodontal pockets and advanced bone loss.
• The plaque that is present forms a thin biofilm on the teeth and rarely
mineralizes to form calculus.
• Rate of bone loss about three to four times faster than in chronic
periodontitis.
Localized Aggressive Periodontitis

12. • Distolabial migration of the maxillary incisors with concomitant
diastema formation.
• Increasing mobility of the first molars.
• Sensitivity of denuded root surfaces to thermal and tactile stimuli, and
• Deep, dull, radiating pain during mastication, probably because of
irritation of the supporting structures.

13. • Vertical loss of alveolar bone around the first molars and incisors,
beginning around puberty in otherwise healthy teenagers.
• Radiographic findings may include an “arc-shaped loss of alveolar bone
extending from the distal surface of the second premolar to the mesial
surface of the second molar”.
Radiographic Findings

14. • Usually affects individuals <30 yrs; may be older.
• A poor antibody response to the pathogens present.
• “Generalized interproximal attachment loss affecting at least three
permanent teeth other than first molars and incisors”.
• Periods of advanced destruction followed by stages of quiescence of
variable length (weeks to months or years).
Two types of gingival responses seen:
Destructive Stage Quiescence Stage
Generalized Aggressive Periodontitis

15. • Patients often have small amounts of bacterial plaque. inconsistent with
the amount of periodontal destruction.
• Qualitatively, P. gingivalis, A. actinomycetemcomitans, and Bacteriodes
forsythus frequently are detected in the plaque.
1. Generalized juvenile periodontitis
(emphasis on a possible relationship with LAP)
2. Severe periodontitis
(emphasis on the advanced destruction in comparison with patient age)
3. Rapidly progressing periodontitis
(emphasis on the fast rate of progression of lesions in these forms).
GAP represents the most heterogeneous group and includes the most severe
forms of periodontitis.
They comprise forms originally described as:

16. Can range from severe bone loss associated with minimum number of teeth to
advanced bone loss affecting the majority of teeth in the dentition.
Radiographically

17. American Academy of Periodontology Task Force Report on the Update
to the 1999 Classification of Periodontal Diseases and Conditions
• This update addresses specific areas of concern with the current classification: 1.
Attachment level, 2. Localized versus generalized periodontitis.
1. Use of attachment levels in diagnosis of periodontitis
• In clinical practice, measurement of CAL is challenging, and time consuming.
• Measuring the location of CEJ when the gingival margin is located coronal to the CEJ is
difficult and may involve some guesswork when the CEJ is not readily evident via
tactile sensation.
• The clinician may chart probing depths alone or probing depths with a single recession
measure at the mid-facial or mid-lingual and only when recession is actually present.
American Academy of Periodontology Task Force Report on the Update to the 1999 Classification of Periodontal Diseases and
Conditions. J Periodontol 2018; 86 (7), 835–38.

18. • Another common error occurs when gingival margin measures are charted as ‘‘0 mm’’
when in fact the gingival margin is not right at the level of the CEJ, resulting in
attachment levels that are incorrectly charted as being equal to probing depth.
• In general, a patient would have periodontitis when one or more sites had bleeding on
probing, radiographic bone loss, and increased probing depth or clinical attachment
loss.
American Academy of Periodontology Task Force Report on the Update to the 1999 Classification of Periodontal Diseases and Conditions.
J Periodontol 2018; 86 (7), 835–38.

19. The New Classification from the 2017 World Workshop on Periodontal and Periimplant
Disease and Conditions (“the World Workshop”) reviewed the scientific
evidence and reached four main conclusions:
1. There is no evidence of a specific pathophysiology that enables the differentiation
of cases as “aggressive” or “chronic” periodontitis or provides guidance for different kinds of
intervention.
2. There is little consistent evidence that aggressive and chronic periodontitis are different
diseases. But there is evidence that multiple factors, and the interactions between them,
influence clinically observable disease outcomes (phenotypes) at the individual level.
3. On a population basis, the average (mean) rates of periodontitis progression are consistent
across all observed populations in the world. However, there is evidence that specific
segments of the population exhibit different levels of disease progression.
4. A classification system based only on disease severity fails to capture important
dimensions of an individual’s disease, including complexity and risk factors.

20. Classification of periodontitis based on stages defined by severity
Papapanou et al., 2018

22. • Borderland between gingivitis and periodontitis.
• Represents the early stages of attachment loss.
• Patients with stage I periodontitis, if they show a degree of clinical attachment loss
at a relatively early age, may have heightened susceptibility to disease onset.
• Early diagnosis may be a challenge in general dental practice: periodontal probing
to estimate early clinical attachment loss – the current gold standard for defining
periodontitis – may be inaccurate.
• Assessment of salivary biomarkers and/or new imaging technologies may increase
early detection of stage I periodontitis.

23. • Stage II represents established periodontitis in which a carefully performed
clinical periodontal examination identifies the characteristic
damages that periodontitis has caused to tooth support.
• At this stage of the disease process, however, management remains relatively
simple for many cases as application of standard treatment principles.
• Careful evaluation of the stage II patient's response to standard treatment
principles is essential, and the case grade plus treatment response may guide
more intensive management for specific patients.

24. • At stage III, periodontitis has produced significant damage to the
attachment apparatus.
• In the absence of advanced treatment, tooth loss may occur.
• The stage is characterized by the presence of deep periodontal lesions that extend to
the middle portion of the root.
• Management is complicated by the presence of deepintrabony defects, furcation
involvement, history of periodontal tooth loss/exfoliation, and presence of localized
ridge defects that complicate implant tooth replacement.
• In spite of the possibility of tooth loss, masticatory function is preserved.
• Treatment of periodontitis does not require complex rehabilitation of function.

25. • Periodontitis causes considerable damage to the periodontal support and may cause
significant tooth loss, and this translates to loss of masticatory function.
• In the absence of proper control of the periodontitis and adequate rehabilitation, the
dentition is at risk of being lost.
• This stage is characterized by the presence of
1. Deep periodontal lesions that extend to the apical portion of the root
2. History of multiple tooth loss
3. Tooth hypermobility due to secondary occlusal trauma & the sequelae of tooth loss
4. Posterior bite collapse
5. Drifting
• Case management requires stabilization/restoration of masticatory function.

26. Classification of periodontitis based on grades
Papapanou et al., 2018

27. •Grading a periodontitis patient involves estimating the future risk of periodontitis
progression and the likely responsiveness to standard therapeutic principles.
•This estimate guides the intensity of therapy and secondary prevention after
therapy.
• Grading adds another dimension and allows the rate of progression to be
considered, using direct and indirect evidence.

28. • Direct evidence is based on the available longitudinal observation: for
example, in the form of older diagnostic-quality radiographs.
• Indirect evidence is based on the assessment of bone loss at the worst-
affected tooth in the dentition as a function of age.
• The periodontitis grade can then be modified by the presence of risk factors.
• Clinicians should approach grading by assuming a moderate rate of
progression (grade B) and look for direct and indirect measures of whether
there is a higher disease progression that would justify the application of
grade C.
• Grade A is applied once the disease is arrested.

30. Risk Factors
• Currently validated risk factors for Periodontitis include
1. Smoking
2. Diabetes
• Smoking and Diabetes are termed as Grade modifiers since they are
considered to influence the rate of progression of Periodontitis.
• Emerging risk factors like obesity, specific genetic factors, physical
activity, or nutrition may one day contribute to assessment of Periodontitis.

31. Papapanou et al., 2018
Classification of necrotizing periodontal diseases (NPD)

32. Classification of periodontal abscesses based on the etiologic factors involved
Papapanou et al., 2018

33. The main features to identify periodontitis
• Loss of periodontal tissue support due to inflammation is the primary
feature of periodontitis.
• A threshold of interproximal, CAL of ≥2 mm or ≥3 mm at ≥2 non‐adjacent
teeth
• Presence of interproximal tissue loss through radiographic assessments of bone
loss
• Clinically meaningful descriptions of periodontitis should include the
proportion of sites
1. Bleed on probing
2. The number and proportion of teeth with probing depth over certain
thresholds (commonly ≥4 mm and ≥6 mm)
3. Teeth with CAL of ≥3 mm and ≥5 mm

34. Definition of a periodontitis case
• In the context of clinical care, a patient is a “periodontitis case” if:
1. Interdental CAL is detectable at ≥2 non‐adjacent teeth
2. Buccal or oral CAL ≥3 mm with pocketing ≥3 mm is detectable at
≥2 teeth
The observed CAL cannot be ascribed to non‐periodontitis‐related causes
such as:
1) Gingival recession of traumatic origin
2) Dental caries extending in the cervical area of the tooth
3) The presence of CAL on the distal aspect of a second molar and
associated with malposition or extraction of a third molar
4) An endodontic lesion draining through the marginal periodontium
5) the occurrence of a vertical root fracture

35. Diagnosis of Periodontitis
A periodontitis diagnosis for an individual patient should encompass three
dimensions:
1. Definition of a periodontitis case based on detectable CAL loss at two
non‐adjacent teeth
2. Identification of the form of periodontitis: necrotizing periodontitis,
periodontitis as a manifestation of systemic disease or periodontitis
3. Description of the presentation and aggressiveness of the disease by stage
and grade

36. Characterization of periodontitis by stage and grade
• Stage is largely dependent upon the severity of disease at
presentation
• Staging, further includes a description of extent and distribution
of the disease in the dentition.
• Grade provides supplemental information about biological features of the
disease including
1. A history‐ based analysis of the rate of periodontitis progression
2. Assessment of the risk for further progression;
3. Analysis of possible poor outcomes of treatment
4. Assessment of the risk that the disease or its treatment may negatively
affect the general health of the patient.

37. Different forms of periodontitis
• Based on pathophysiology, three clearly different forms of periodontitis have been
identified:
(A) Necrotizing periodontitis
(B) Periodontitis as a direct manifestation of systemic diseases
(C) Periodontitis
• Differential diagnosis is based on history and the specific signs and symptoms of
necrotizing periodontitis, or the presence or absence of an uncommon systemic
disease that alters the host immune response.
• The remaining clinical cases of periodontitis which do not have the local
characteristics of necrotizing periodontitis or the systemic characteristics of a rare
immune disorder with a secondary manifestation of periodontitis should be
diagnosed as “periodontitis” and be further characterized using a staging and
grading system.

38. Difference between acute periodontal lesions and other forms of
periodontitis
• Periodontal abscesses, lesions from necrotizing periodontal diseases
and acute presentations of endo‐periodontal lesions, share the following
features that differentiate them from periodontitis lesions:
(1) Rapid‐onset,
(2) Rapid destruction of periodontal tissues, underscoring
the importance of prompt treatment
(3) Pain or discomfort, prompting patients to seek urgent care.

39. Difference in the pathophysiology between periodontal abscesses and
other periodontitis lesions
• The first step in the development of a periodontal abscess is bacterial
invasion or foreign body impaction in the soft tissues surrounding the
periodontal pocket.
• Pathophysiologically, this lesion differs in that the low pH within an
abscess leads to rapid enzymatic disruptionof the surrounding connective
tissues and, in contrast to a chronic inflammatory lesion, has a greater
potential for resolution if quickly managed.

40. Difference in the pathophysiology between necrotizing periodontal
diseases and other periodontitis lesions.
• Yes. Necrotizing gingivitis lesions are characterized by the presence
of ulcers within the stratified squamous epithelium and the superficial layer
of the gingival connective tissue, surrounded by a non‐specific acute
inflammatory infiltrate.
• Necrotizing periodontal diseases are strongly associated with impairment of
the host immune system, as follows
(1) In chronically, severely compromised patients
(2) in temporarily and/or moderately compromised patients

41. Difference in the pathophysiology between endo‐periodontal lesions
and other periodontitis or endodontic lesions.
• The term endo‐periodontal lesion describes a pathologic communication
between the pulpal and periodontal tissues at a given tooth that may be
triggered by a carious or traumatic lesion that affects the pulp and,
secondarily, affects the periodontium; by periodontal destruction that
secondarily affects the root canal; or by concomitant presence of both
pathologies.
• No distinct pathophysiology between an endo‐periodontal and a
periodontal lesion has been identified.
• The communication between the pulp/root canal system and the
periodontium complicates the management of the involved tooth.

42. References
1. Newman, Takei, Klokkevold, Carranza. Carranza’s, clinical periodontology, 10th ed; 632-34.
2. Newman, Takei, Klokkevold, Carranza. Carranza’s, clinical periodontology, 13th ed; 1880-1916.
3. Papapanou, P. N., Sanz, M., Buduneli, N., Dietrich, T., Feres, M., Fine, D. H., … Tonetti, M. S.
Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification
of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol 2018;89: S173-82.
4. American Academy of Periodontology Task Force Report on the Update to the 1999 Classification
of Periodontal Diseases and Conditions. J Periodontol 2015; 86 (7), 835–38.
5. Sanz M, Tonetti M. New classification of periodontal and peri-implant diseases. EFP 2019.
6. 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 ;89:S159-72.

43. THANK YOU