new classification periodontal disease2017 included

1. Presented by
Mansi Gandhi

2. CONTENTS
 Introduction
 Need for classification
 Three paradigms of the disease classification
 Clinical features paradigm (1870-1920
 Classical pathology paradigm (1920-1970)
 Infection/Host response paradigm (1970-present)
 Critics and critical analysis for the recent
classification


 Conclusion
 References

3. Our basic understanding of periodontal diseases and the
concepts of etiopathogenesis have evolved and substantially
changed during the past centuries.
Classifying periodontal diseases is essential to provide a
framework to scientifically study the etiology, pathogenesis and
treatment of disease in an orderly fashion.
(ARMITAGE 1999)

4. Disease classification is useful for the purpose of diagnosis,
prognosis and treatment planning. To provide maximum
assistance in diagnosis & treatment planning diseases
have been classified mainly on the basis of three criteria:-

5. NEED FOR
CLASSIFICATION

6. Systems of classifications of disease have arisen allowing clinicians to
develop structures which can be used to identify diseases in relation to
aetiology, pathogenesis and treatment . It allows us to organize effective
treatment of our patients’ diseases.
Once a disease has been diagnosed and classified, the aetiology of the
condition and appropriate evidence-based treatment is suggested to the
clinician.
Common systems of classification also allow effective
communication between health care professionals using a
common language.
Early attempts at classification were made on the basis of the
clinical characteristics of the diseases or on theories of their
aetiology. These attempts were unsupported by any evidence
base

7. The initial classification systems were based on the clinical features of the
diseases (1870–1920), then came the concepts of classical pathology
(1920–1970), and presently we are following the infectious etiology of the
diseases (1970–present).
The most important landmark in our current understanding of periodontal
diseases was the work done by Lӧe et al. (1986) on
the natural history of periodontal disease, where they observed the
progression of periodontal diseases
naturally without interfering. Their observations showed that the natural
history of periodontal disease, in
some but not all patients, results in tooth loss.

8. Classification of periodontal diseases can be placed into three
dominant paradigms primarily:

9. CLINICAL FEATURES OF THE DISEASE
1870-1920

10. Riggs, practicing in Hartford, Connecticut, seemed
to have been the first practitioner to limit his practice
to the treatment of periodontal disease.
He gave clinical
demonstrations and exerted important influence
on the development of clinical periodontics.
Followed was a period of development of techniques
and instruments for local curettage, debridement,
depuration and scaling and the introduction of periodontal
surgery
John M. Riggs (1875)

11. Riggs was convinced that the disease was local and
that pyorrhea alveolaris started
•with inflammation of the gingiva, which
•through apical extension would include the alveolar bone
•and lead to pocket formation,
•causing increased mobility and terminal loss of the support of
the tooth.

12. G V Black (1886), based on his understanding of clinical features of
different periodontal diseases published the following classification
Constitutional gingivitis: These included scurvy, mercurial gingivitis, and
potassium iodide gingivitis.
Painful form of gingivitis:
which is a painful condition with necrosis of gingiva and tooth supporting
structures.
Simple gingivitis: describe the condition where local deposits caused
inflammation ofthe periodontal membrane.
Calcic inflammation of the peridental membrane: In this condition the
calculus deposition was associated with an even or generalized pattern of
destruction of alveolar bone which progressed through a long duration
of time.
Phagedenic pericementitis: This condition shared many features with the
Calcic inflammation of the peridental membrane (presently called as
periodontal ligament) except that the calculus deposition was less
and there was an irregular pattern of alveolar bone destruction.

13. CLASSICAL PATHOLOGY
PARADIGM, 1920-1970
This concept was introduced by GOTTLIEB AND ORBAN.
Two forms of destructive periodontal disease.

14. CLASSICAL PATHOLOGY PARADIGM
(1920–1970).
 This paradigm was dominated by the pathology of the disease process.
•Almost all the classification systems given during this period used terms like
atrophic, degenerative, dystrophic etc.
•These classification systems were based on the ‘principles of general pathology’
as presented by Orban et al. (1958)

15. The first widely accepted classification system was given by Gottlieb, who
classified periodontal diseases into four types
Schmutz-Pyorrhӧe:
a periodontal condition that was caused due to the accumulation of deposits on
the teeth, leading to inflammation, shallow pockets, and resorption of the
alveolar crest.
Alveolar atrophy or diffuse atrophy:
a non inflammatory disease in which minimal local factors, i.e. deposits were
present on the teeth, deep pockets were seen in later stages with the loosening
of teeth and eventually leading to tooth loss.
Paradental-Pyorrhӧe:
characterized by irregularly distributed pockets varying from shallow to
extremely deep.
Occlusal trauma:
ctz by alveolar bone resorption and tooth mobility due to increased occlusal
physical overload.

16. Orban in 1942 proposed a classification based on classical pathology
paradigm.
This classification was accepted by the American Academy of Periodontology
(AAP) and gained wide acceptance.
Orban’s classification of periodontal diseases
Inflammation
I. Gingivitis (little or no pocket formation: can include ulcerative form
Vincent’s)
1. Local (calculus, food impaction, irritating restorations, drug action, etc.).
2. Systemic
Pregnancy
Diabetes and other endocrine dysfunctions
Tuberculosis
Syphilis
Nutritional disturbances
Drug action
Allergy
Hereditary
Idiopathic

17. II. Periodontitis
Simplex (secondary to gingivitis).
Complex ( secondary to periodontosis).
Degeneration
Periodontosis (as a rule attacks young girls and older men; often caries
immunity
A. Systemic disturbances
1. Diabetes
2. Endocrine dysfunctions
3. Blood dyscrasias
4. Nutritional disturbances
5. Nervous disorders
6. Infectious diseases (acute & chronic)

18. B. Hereditary
C. Idiopathic
Atrophy
Periodontal Atrophy (Recession, no inflammation, no pockets;
osteoporosis.)
1. Local trauma (e.g., from toothbrush)
2. Presenile
3. Senile
4. Disuse
5. Following inflammation
6. Idiopathic
Hypertrophy
Gingival Hypertrophy
1. Chronic irritation (see inflammation)
2. Drug action (e.g.. Dilantin sodium)
3. Idiopathic (e.g.. g-ingivoma, elephantiasis. fibromatosis)
Traumatism
I. Periodontal Traumatism
A. Occlusal trauma

19. Based on the classical pathology paradigm many classifications were given
during this time period. These include classification by
Fish 1944 , Goldman et al. 1956 , Goldman and Cohen 1968 , Grant et
al. 1968

20. DRAWBACKS FROM 1920-1970
1. Almost all the classifications used from 1920-1970 included
disease categories labeled as ‘dystrophic’, atrophic or
degenerative.
2. Classification system were dominated by the Classical
Pathology paradigm which is based on principles of general
pathology.
3. There was no scientific basis for retaining the concept that
there were non-inflammatory or degenerative forms of
destructive periodontal disease.

21. INFECTION/ HOST RESPONSE PARADIGMS
(1970–present)
This paradigm started with the classical ‘experimental gingivitis’ studies published
by Harald Löe and his colleagues from 1965 to 1968 .
Their research work showed that host response is an important factor in
determining the disease progression and its outcome.
Along with this, research done on neutrophils from juvenile periodontitis
(periodontosis) cases showed their defective chemotactic and phagocytic
functions which supported this concept

22. Page and Schroeder in 1982 proposed a new classification system
which was based on infection/host response paradigm.
•Prepubertal periodontitis
•Generalized
•Localized
•Juvenile periodontitis
•Rapidly progressing periodontitis
•Adult type periodontitis
•Acute necrotizing ulcerative gingivo-periodontitis.

23. AAP 1986
(A)JUVENILE PERIODONTITIS –
Prepubertal
Localizedjuvenile periodontitis
Generalized juvenile periodontitis
(B)ADULT PERIODONTITIS
(C)NECROTIZING ULCERATIVE GINGIVO- PERIODONTITIS
(D) REFRACTORY PERIODONTITIS

24. Based on the classification given by Page and Schroeder (1982),
American Academy of Periodontology (AAP) in 1986 adopted a new
classification system.
Further, AAP at the World Workshop in Clinical Periodontics at Princeton
in 1989 amended the classification system with a few refinements.
1989 AAP classification of periodontal diseases was based upon
following factors,
1. Presence ⁄ absence of clinically detectable inflammation.
2. Extent and pattern of attachment loss.
3. Patient’s age at onset.
4. Valuation of progression.
5. Presence ⁄ absence of miscellaneous signs and symptoms, including
pain, ulceration and amount of observable plaque and calculus.

26. Drawbacks of AAP 1989 classification system:
1. One major drawback of this classification was that it heavily
depended upon the age of the patient.
2. Classification did not include a gingivitis or gingival disease category.
3. There was considerable overlap between different categories within
the classification system.
4. Different forms of periodontitis proposed in the classification shared
many microbiological and host response features, which suggested
extensive overlap and heterogeneity among the categories .
5. The refractory periodontitis was also a heterogeneous category as the
criteria for this condition were difficult to relate clinically while placing
the patient in this category.

27. As a result of these drawbacks, Ranney in 1989 proposed a different
classification and he suggested that
“refractory periodontitis” category should be eliminated since it was a
heterogeneous group and it was impossible to standardize the treatment
that necessarily would have to be given prior to making the diagnosis

28. American Academy of Periodontology (AAP) world workshop 1999
Classification of Periodontal
Diseases and Conditions:
In 1999 an international workshop for classification of periodontal diseases
and conditions was held at Oak Brook (Illinois, USA) in which a group of
internationally acknowledged experts produced a generally
accepted and scientifically founded classification of periodontal diseases.

34. Highlights of 1999 classification system
1. Addition of a gingival disease component.
2. Replacement of “Early-Onset Periodontitis” with “Aggressive
Periodontitis”
3. Replacement of “Adult Periodontitis” with “Chronic Periodontitis”
4. Elimination of the ‘Prepubertal Periodontitis’ category
5. Elimination of the ‘Prepubertal Periodontitis’ category
6. Replacement of “Necrotizing Ulcerative Periodontitis” with
“Necrotizing Periodontal Diseases”
7. Addition of “Periodontal Abscesses” and “Periodontitis Associated
with Endodontic Lesions” as new entities
8. Addition of new category “developmental and acquired deformities
and conditions”

35. UPDATE OF AAP,1999 TO BE REVISED IN 2017
• The Academy announced that an update to the 1999
Classification would commence in 2017.
Three specific areas of concern:-
• ATTACHMENT LEVEL
• CHRONIC versus AGGRESSIVE PERIODONTITIS
• LOCALIZED versus GENERALIZED PERIODONTITIS

44. CONCLUSION

45. REFERENCES
1. Clinical periodontology. Newman, Takei, Klokkevold, Carranza. 10thedition. P100-109
2. Clinical periodontology. Carranza, Newman. 8thedition. P 58-61
3. Clinical periodontology. Carranza. 6thedition. P192-200.
4. New classification of periodontal diseases. Plancak D et al. Acta Stomat Croat 2001; 35(1):
89-93
5. The periodontal disease classification system of the AAP- an update. Wiebe CB, Putnins EE.
J Can Dent Assoc 2000; 66: 594-597
6. Periodontal diagnosis and classification of periodontal diseases. Armitage GC. Perio 2000
2004; 34: 9-21
7. Diagnosis and classification of periodontal disease. Highfield J. Aus Dent J 2009; 54: (1
Suppl): S11-S26
8. Development of a classification system for periodontal diseases and conditions. Armitage
GC. Ann Periodontol 1999; 4: 1-6