Periodontal Classification

The original, current and update

Why classify?
Up to date classification allows clinicians to be aware of the full range of periodontal diseases and condition which can effect the patient.

Knowledge of current classification helps provide a basis for subsequent diagnosis and management.

This classification can help to develop frameworks to study aetiology, pathogenesis and treatment.

Historically
Year proposed 1806 1942 1966 1977 1986 Body responsible Joseph Fox Orban AAP AAP AAP Classification Record of gum disease First classification recognised by AAP Chronic marginal periodontitis Juvenile periodontitis Prepubertal periodontitis Localised juvenile Generalised juvenile Adult periodontitis Necrotizing ulcerative periodontitis Refractory peridontitis Periodontitis levis Periodontitis gravis Early onset periodontitis Periodontitis associated with systemic disease Refractory periodontitis Early onset periodontitis Adult periodontitis Necrotizing ulcerative peridontitis New classification

1989 1989

Nyman & Lindhe AAP

1993

European Workshop

1999

International Workshop

International workshop for classification of periodontal disease

In 1999 the classification was changed due to previous lack of consensus. New categories added were
Gingival disease Necrotising periodontal disease Abscesses Periodontitis with endodontic lesions Developmental or acquired deformities and conditions

What changed in 1999?

Adapted categories

Chronic periodontitis
Used to be adult periodontitis Addition descriptions added depending on extent and severity

Aggressive periodontitis
Replaced early onset periodontitis Distinction made from chronic periodontitis and managed differently Features to separate from generalised and localised form

What changed in 1999?

Excluded categories

Refractory periodontitis
The term can be a descriptor and applied to any disease non-responsive to treatment

Recurrent periodontitis
Denotes return of disease not a separate entity

Poorly controlled diabetes and tobacco smoking

Both are significant modifiers of all forms of

What changed in 1999?

Categories added

Gingival disease categories introduced

Systemic disease of periodontal status

Necrotizing periodontal disease

Periodontal abscesses

Development or acquired lesions

New classification gingival diseases Dental plaque-induced gingival diseases

1. Gingivitis associated with dental plaque only a. Without other local contributing factors b. With local contributing factors 2. Gingival diseases modified by systemic factors a. associated with the endocrine system 1) puberty-associated gingivitis 2) menstrual cycle-associated gingivitis 3) pregnancy-associated a) gingivitis b) pyogenic granuloma gingivitis 4) diabetes mellitus-associated

b. associated with blood dyscrasias 1) leukaemia-associated gingivitis 2) other 3. Gingival diseases modified by medications 1) drug-influenced gingival enlargements 2) drug-influenced gingivitis gingivitis a) oral contraceptive-associated b) other 4. Gingival diseases modified by malnutrition a. ascorbic acid-deficiency gingivitis

New classification gingival Non-plaque-induced gingival lesions diseases

1. Gingival diseases of specific bacterial origin a. Neisseria gonorrhoea-associated lesions b. Treponema pallidum-associated lesions c. streptococcal species-associated lesions d. other 2. Gingival diseases of viral origin a. herpesvirus infections 1) primary herpetic gingivostomatitis 2) recurrent oral herpes 3) varicella-zoster infections b. other 3. Gingival diseases of fungal origin a. candidal infections 1) generalized gingival candidosis b. linear gingival erythema c. histoplasmosis d. other 4. Gingival lesions of genetic origin a. hereditary gingival fibromatosis b. other

5 . G in g iv a l m a n ife s ta tio n s o f s y s te m ic c o n d itio n s a . m u co cu ta n e o u s d i rd e rs so 1 ) l ch e n p l n u s i a 2 ) pem phi oi g d 3 ) p e m p h i u s vu l a ri g g s 4 ) e ryth e m a m u l fo rm e ti 5 ) l p u s e ryth e m a to su s u 6 ) d ru g - i d u ce d n 7 ) o th e r b . a l e rg i re a cti n s l c o 1 ) d e n ta l re sto ra ti m a te ri l ve as a ) m e rcu ry b) ni cke l c ) a cryl c i d ) o th e r 2 ) re a cti n s a ttri u ta b l to o b e a ) to o th p a ste s/ d e n ti ce s fri b ) m o u th ri se s/ m o u th w a sh e s n c ) ch e w i g g u m a d d i ve s n ti d ) fo o d s a n d a d d i ve s ti 3 ) o th e r 6 . Tra u m a tic le s io n s ( fa c titio u s , ia tro g e n ic , a c c id e n ta l) a . ch e m i l i j ry ca n u b . p h ysi l i j ry ca n u c . th e rm a l i j ry n u 7 . F o re ig n b o d y re a c tio n s

A. Chronic periodontitis

New classification periodontal diseases

F. Periodontitis associated with endodontic lesions

Combined periodontic-endodontic lesions

a. Localized b. Generalized

B. Aggressive periodontitis
a. Localized b. Generalized

G. Developmental or acquired deformities and conditions

a. Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis 1. Tooth anatomic factors 2. Dental restorations/appliances 3. Root fractures 4. Cervical root resorption and cemental tears b. Mucogingival deformities and conditions around teeth 1. Gingival/soft tissue recession
a. facial or lingual surfaces b. interproximal (papillary)

C. Periodontitis as a manifestation of systemic diseases

a. Associated with haematological disorders 1. Acquired neutropenia 2. Leukaemias 3. Other b. Associated with genetic disorders 1. Familial and cyclic neutropenia 2. Downs syndrome 3. Leukocyte adhesion deficiency syndromes 4. PapillonLefvre syndrome 5. ChediakHigashi syndrome 6. Histiocytosis syndromes 7. Glycogen storage disease 8. Infantile genetic agranulocytosis 9. Cohen syndrome 10. EhlersDanlos syndrome (Types IV and VIII) 11. Hypophosphatasia 12. Other c. Not otherwise specified (NOS)

2. 3. 4. 5.

Lack of keratinized gingiva Decreased vestibular depth Aberrant fraenum/muscle position Gingival excess
a. pseudopocket b. inconsistent gingival margin c. excessive gingival display d. gingival enlargement

D. Necrotizing periodontal diseases

a. Necrotizing ulcerative gingivitis (NUG) b. Necrotizing ulcerative periodontitis (NUP)

E. Abscesses of the periodontium

a. Gingival abscess b. Periodontal abscess c. Pericoronal abscess

6. Abnormal colour c. Mucogingival deformities and conditions of edentulous ridges 1. Vertical and/or horizontal ridge deficiency 2. Lack of gingiva/keratinized tissue 3. Gingival/soft tissue enlargement 4. Aberrant fraenum/muscle position 5. Decreased vestibular depth 6. Abnormal colour d. Occlusal trauma 1. Primary occlusal trauma 2. Secondary occlusal trauma

Chronic periodontitis
Commonly seen in adults (can be seen in children and adolesants) Subgingival calulus is usually present Slow to moderate rate of progression Can be associated with local factors
Tooth shape and form Iatrogenic cause

Can be modified by systemic disease

Diabetes mellitus

Can be modified by other factors

Smoking Emotional stress

Localised form up to 30% of sites Generalized form greater then 30% of sites Degree of disease
Slight: 1-2mm clinical attachment loss Moderate: 2-4mm CAL Severe: >=5mm CAL

Chronic

Comparison of chronic and aggressive forms of Periodontitis

Localised aggressive

Generalised aggressive

Mostly seen in adults (can occur in children) Slow to moderate rates of progression

Usually affects < 30 yrs of age (pts maybe older) Rapid rate of progression (episodic periods of Microbial deposits Microbial deposits Microbial deposits progression) consistent with not consistent with sometimes consistent severity of destruction severity of destruction with severity of Variable distribution Periodontal Periodontal destruction of periodontal destruction localised destruction affects at destruction to permanent first least 3 permanent molars and incisors teeth in addition to permanent first molars and incisors Frequent subgingival Subgingival calculus Subgingival calculus calculus

Usually occurs in adolescents, circumpubertal onset. Rapid rate of progression

Problems and changes for the future

Complicated classification which may discourage its use.

No categories for historical/previous disease

Removal of localised juvenile Periodontitis

Strong association with AA Marked effect on polymorphonuclear cells Strong family history

Only based on the disease visible.

Host related effects Bacterial infection Possibilities of gene therapy