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Classification of periodontal diseases

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For an appropriate diagnosis and therapy of periodontal diseases, a universal classification is unalterable. Due to new scientific findings in the fields of periodontics and implantology the European Federation of Periodontology (EFP) and the American Academy of Periodontology (AAP) initiated the workshop „World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions“ to acquire a new classification, in which periodontal and peri-implant diseases and conditions were defined. This new classification was first presented at the EuroPerio9 in June 2018, thus replacing the previous classification from 19991.
The classification of periodontal and peri-implant diseases and conditions is divided into four subgroups. The first three subgroups describe periodontal diseases and conditions. The fourth subgroup defines peri-implant diseases and conditions. The individual subgroups are presented below.
The first subgroup “Periodontal health, gingival diseases/conditions” illuminates the condition of the healthy periodontium for the first time and thus also includes patients after a successful periodontal treatment. In addition, bleeding on probing (= BOP) was determined to be the primary parameter for the identification of gingivitis2, 3, 4. Furthermore, it has been described that a sole gingivitis may be converted to a healthy state with the help of suitable and individually adapted prophylactic measures. On the other hand, the periodontitis patient, even with successful therapy, requires lifelong supportive follow-up in order to prevent the disease from flaring up again2, 5.
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Periodontal health, gingival diseases/conditions

  1. Periodontal health and gingival health3
    1. Clinical gingival health on an intact periodontium
    2. Clinical gingival health on an reduced periodontium
      1. Stable periodontitis patient
      2. Non-periodontitis patient
  2. Gingivitis – dental biofilm-induced6
    1. Associated with dental biofilm alone
    2. Mediated by systemic or local risk factors
    3. Drug-influenced gingival enlargement
  3. Gingival diseases – non-dental biofilm induced 7
    1. Genetic/developmental disorders
    2. Specific infections
    3. Inflammatory and immune conditions
    4. Reactive processes
    5. Neoplasms
    6. Endocrine, nutritional and metabolic diseases
    7. Traumatic lesions
    8. Gingival pigmentation

The second subgroup "Forms of periodontitis" describes three forms of periodontitis, which include necrotizing diseases, periodontal disease as a manifestation of systemic disease and periodontitis. In the category “periodontitis” the forms “chronic” and “aggressive” were merged2, 8-12.
For a detailed definition of periodontitis, the newly developed classification introduced a multidimensional staging and grading system known from oncology2, 12. The staging describes the severity of the disease and the complexity of the treatment (see Table 1)2 and is supplemented by indicating whether it is a localized, generalized or a molar-incisor pattern. The grading gives additional information regarding biological characteristics and rate of progression (see Table 2). With the help of this system, individual patient-related factors may be included in the diagnosis2.

Forms of periodontitis

  1. Necrotizing periodontal diseases13
    1. Necrotizing gingivitis
    2. Necrotizing periodontitis
    3. Necrotizing stomatitis
  2. Periodontitis as manifestation of systemic diseases14, 15
    Classification of these conditions should be based on the primary systemic disease according to the International Classification of Diseases and Related Health Problems (ICD) Codes.
  3. Periodontitis9, 10, 11
    1. Stages: Based on Severity and Complexity of Management
      Stage I: Initial Periodontitis
      Stage II: Moderate Periodontitis
      Stage III: Severe Periodontitis with potential for additional tooth loss
      Stage IV: Severe Periodontitis with potential for loss of the dentition
    2. Extend and distribution: localized; generalized; molar-incisor distribution

      Parodontitis-Stage Stage I Stage II Stage III Stage IV
      Severity Interdental CAL at site of the greatest loss 1–2 mm 3–4 mm ≥ 5 mm ≥ 5 mm
      Radiographic bone loss Coronal third (< 15 %) Coronal third (15-33 %) Extending to mid-third of root and beyond Extending to mid-third of root and beyond
      Tooth loss No tooth loss due to periodontitis Tooth loss due to periodontitis of ≤ 4 teeth Tooth loss due to periodontitis of ≥ 5 teeth
      Complexity Local Maximum probing depth of ≤ 4mm, mostly horizontal bone loss Maximum probing depth of ≤ 5mm, mostly horizontal bone loss In addition to Stage II complexity:
      Probing depth ≥ 6mm
      Vertical bone loss ≥ 3mm
      Furcation involvement Class II or III
      Moderate ridge defect
      In addition to Stage III complexity:
      Need for complex rehabilitation due to:
      Masticatory dysfunction,
      Secondary occlusal trauma (tooth mobility degree ≥ 2)
      Severe ridge defect, Bite collapse, drifting, flaring,
      Less than 20 remaining teeth (10 opposing pairs)
      Extend and distribution Add to stage as discriptor For each stage, describe extent as localized (< 30% of teeth involved), generalized or Molar/incisor pattern
      Table 1: Parodontitis-Stages: CAL = clinical attachment loss8

    3. Grades: Evidence or risk of rapid progression, anticipated treatment response
      1. Grade A: Slow rate of progression
      2. Grade B: Moderate rate of progression
      3. Grade C: Rapid rate of progression

      Periodontitis grades Grade A Slow rate of progression Grade B Moderate rate of progression Grade C Rapid rate of progression
      Primary criteria Direct evidence of progression Longitudinal data (radiographic bone loss or CAL) Evidence of no bone loss over 5 years Evidence of bone loss < 2mm over 5 years Evidence of bone loss ≥ 2mm over 5 years
      Indirect evidence of progression % bone loss/age < 0.25 0.25–1.0 > 1.0
      Case phenotype VHeavy biofilm deposits with low levels of destruction Destruction commensurate with biofilm deposits Destruction exceeds expectation given biofilm deposits; specific clinical patterns suggestive of periods of rapid progression and/or early onset disease (e.g., molar/incisor pattern; lack of expected response to standard bacterial control therapies)
      Grade modifiers Risk factors Smoking Non-smoker Smoker < 10 cigarettes/day Smoker ≥ 10 cigarettes/day
      Diabetes Normoglycemic/no diagnosis of diabetes HbA1c < 7.0% bin patients with periodontitis HbA1c ≥ 7,0% in patients with periodontitis
      Table 2: Periodontitis grade: CAL = clinical attachment loss 8
The third subgroup "Periodontal manifestations in systemic diseases and developmental and acquired conditions" summarizes systemic diseases whose oral manifestation may be periodontitis. This includes genetic disorders, such as Papillon Lefèvre syndrome. Also a poorly controlled diabetes mellitus may have a bad influence on the course of periodontitis 2. In addition, all other states are described that adversely affect the periodontium.

Periodontal manifestations of systemic diseases and developmental and acquired conditions

  1. Systemic diseases or conditions affection the periodontal supporting tissues15
  2. Other periodontal conditions8, 13
    1. Periodontal abscesses
    2. Endontic-Periodontal lesions
  3. Mucogingival deformities and conditions around teeth16
    1. Gingival phenotype
    2. Gingival/soft tissue recessions
    3. Lack of gingiva
    4. Decreased vestibular depth
    5. Aberrant frenum/muscle position
    6. Gingival excess
    7. Abnormal color
    8. Condition of the exposed root surface
  4. Traumatic occlusal forces17
    1. Primary occlusal trauma
    2. Secondary occlusal trauma
    3. Orthodontic forces
  5. Prostheses and tooth-related factors that modify or predispose to plaque-influenced gingival diseases/periodontitis18
    1. Localized tooth-related factors
    2. Localized dental prostheses-related factors
The fourth subgroup "Peri-implant Diseases and Conditions" describes all peri-implant states from health to diseases of implant surrounding tissues. Peri-implant health is characterized by the absence of inflammation and bleeding on probing 2. This health status may exist with normal and also reduced bone support 2, 19, 20.

Peri-implant diseases and conditions

  1. Peri-implant health21
  2. Peri-implant mucositis22
  3. Peri-implantitis23
  4. Peri-implant soft and hard tissue deficiencies24


sources

  • 1) Armitage GC. Development of a classification system of periodontal diseases and conditions. Ann Periodontol. 1999;4:1-6
  • 2) Caton JG, Armitage G, Berglundh T, Chapple ILC, Jepsen S, Kornman KS, Mealey BL, Papapanou PN, Sanz M, Tonetti MS. A new classification scheme for periodontal and peri-imlant diseases and conditions-Introduction and key changes from 1999 classification. J Clin Periodontol. 2018;45:45(Suppl 20);S1-S8
  • 3) Lang NP, Bartold PM. Periodontal health. J Clin Periodontol. 2018;45(Suppl 20):S230-S236
  • 4) Trombelli F, Farina R, Silva CO, Tatakis DN. Plaque-induced gingivitis: Case definition and diagnostic considerations. J Clin Periodontol. 2018;45(Suppl 20):S44-S66
  • 5) Chapple ILC, Mealey BL, et al. Periodontal health and gingival diseases and conditions on an intact and 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
  • 6) Murakami S, Mealey BL, Mariotti A, Chapple ILC. Dental plaque-induced gingival conditions. J Clin Periodontol. 2018;45(Suppl 20):S17-S27
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  • 8) Papapanou PN, Sanz M et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-imlant Diseases and Conditions. J Clin Periodontol. 2018;45(Suppl 20):S162-S170
  • 9) Needleman I, Garcia R, Gkranias N, et al. Mean annual attachment bone level and tooth loss: A systematic review. J Clin Periodontol. 2018;45(Suppl 20):S112-S129
  • 10) Fine DH, Patil AG, Loos BG. Classification and diagnosis of aggressive periodontitis. J Clin Periodontol. 2018;45(Suppl 20):S95-S111
  • 11) Billings M, Holtfreter B, Papapanou PN, Mitnik GL, Kocher T, Dye BA. Age-dependent distribution of periodontitis in two countries: findings from NHANES 2009 to 2014 and SHIP-TREND 2008 to 2012. J Clin Periodontol. 2018;45(Suppl 20):S130-S148
  • 12) 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
  • 13) Herrera D, Retamal-Valdes B, Alonso B, Feres M. Acute periodontal lesions (periodontal abscesses and necrotizing periodontal diseases) and endo-periodontal lesions. J Clin Periodontol. 2018;45(Suppl 20):S78-S94
  • 14) Jepsen S, Caton JG, et al. Periodontal manifestations of systemic diseases and developmental and acquired conditions: consensus report of work group 3 on the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol. 2018;45(Suppl 20):S219-S229
  • 15) Albandar JM, Susin C, Hughes FJ. Manifestations of systemic diseases and conditions that affect the periodontal attachment apparatus: case definitions and diagnostic considerations. J Clin Periodontol. 208;45(Suppl 20):S171-S189
  • 16) Cortellini P, Bissada NF. Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations. J Clin Periodontol. 2018;45(Suppl 20):S199-S206
  • 17) Fan J, Caton JG. Occlusal trauma and excessive occlusal forces: Narrative review, case definitions, and diagnostic considerations. J Clin Periodontol. 2018;45(Suppl 20):S207-S218 18) Ercoli C, Caton JG. Dental prostheses and tooth-related factors. J Clin Periodontol. 2018;45(Suppl 20):S207-S218
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  • 19) Berglundh T, Armitage G, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions. J Clin Periodontol. 2018;45(Suppl 20):S286-S291
  • 20) Renvert S, Persson GR, Pirih FQ, Camargo PM. Peri-implant health, peri-implant mucositis and peri-implantitis: case definitions and diagnostic considerations. J Clin Periodontol. 2018;45(Suppl 20):S278-S285
  • 21) Araujo MG, Lindhe J. Peri-implant health. J Clin Periodontol. 2018;45(Suppl 20):S36-S36
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