CLASSIFICATION OF PERIODONTAL DISEASES

Contents Introduction History Dominant Paradigms in the historical

development of classification systems Classification systems Conclusion References

Introduction Systematic arrangement into classes or

groups based on perceived common characteristics.

A means of giving order to a group of disconnected facts.

Need for classification Provides a framework for scientifically

studying Etiology Pathogenesis Treatment

To assess the prognosis, outcome and determine the treatment plan.

Advancing age and leads to progressive loosening and loss of teeth.

Very aggressive type that occurs in younger patients.

History Giralamo Cardono

Fauchard (1723) – ‘Scurvy’ of the gums

Early 19th century – Riggs Disease (John W Riggs 1811-1885)

1st to differentiate periodontal diseases

Gottlieb, 1920s Schmutz-Pyorrhoe Alveolar atrophy or Diffuse atrophy Paradental-Pyorrhoe Occlusal trauma Alveolar atrophy or Diffuse atrophy :

Accumulation of deposits, inflammation, shallow pockets, and resorption of the alveolar crest.

Non inflammatory disease - loosening of teeth,elongation,and wandering of teeth ,no dental deposits. Pockets are formed only in later stages

Paradental-Pyorrhoe:

Occlusal trauma :

Irregularly distributed pockets - shallow to extremely deep. May start as Schmutz-Pyorrhoe or as diffuse atrophy.

Physical overload which results in resorption of the alveolar bone and loosening of teeth.

McCall & Box : Periodontitis - those inflammatory diseases in which all three components of the periodontium

Periodontitis Simplex periodontitis Complex periodontitis

Dominant paradigms in the historical development of classification systems

1870–1920 The clinical features of the diseases

1920–1970 The concepts of classical pathology

1970–present Infectious etiology of the diseases

Clinical characteristics paradigm (1870-1920)

Local factors Black (1894), WD Miller (1890), Patterson (1885), Riggs(1882)

Systemic disturbances Peirce (1892), GA Mills (1881), LL Dunbar (1894)

Both local and systemic factors WD Miller (1890), Patterson (1885)

Classification of periodontal diseases

following the “Clinical characteristics”

paradigm

C.G. Davis (1879) Gingival recession with minimal or no inflammation.

Periodontal destruction secondary to ‘lime deposits’. Mechanical pressure → alveolar bone resorption

because of lack of nutrition.

Riggs’ Disease ‘... loss of alveolus without loss of gum.’ The

perceived problem was a ‘necrosed alveolus’ or death of the periodontal membrane.

G.V. Black (1886) Constitutional gingivitis A painful form of gingivitis Simple gingivitis Calcic inflammation of the peridental

membrane Phagedenic pericementitis (phagedenic =

spreading ulcer or necrosis) ‘Phagedenic pericementitis’ ‘Chronic

suppurative pericementitis’

Drawbacks/ Limitations: Little or no scientific evidence was used No accepted terminology or classification

system was adopted

Pyorrhea alveolaris

Phagedenic pericementitis

Calcic inflammation

of the peridental membrane

Riggs’ disease

Chronic suppurative

pericementitis

Classical pathology paradigm (1920-1970)

 Gottlieb and Orban

All disease categories labeled as ‘dystrophic’, ‘atrophic’, or ‘degenerative.

Inflammatory Non- inflammatory

(degenerative/dystrophic)

Classification of periodontal diseases

following the “Classical pathology”

paradigm

INFLAMMATION1. Gingivitis (little or no pocket formation; can include

ulcerative form – Vincent’s) A. Local (calculus, food impaction, irritating

restorations, drug action etc) B. Systemic (Pregnancy, Diabetes, Other Endocrine

Dysfunctions, Tuberculosis, Syphilis, Nutritional Disturbances, Drug Action, Allergy, Hereditary, Idiopathic. Etc)

2. Periodontitis

A. Simplex– bone loss, pockets, abscesses can form, cases have calculus

B. Complex – etiologic factors similar to periodontitis, cases have little, if any calculus.

ORBAN 1942

DEGENERATION1. Periodontosis (attacks young girls and older men; often caries

immunity) A. Systemic disturbances (Diabetes, Endocrine dysfunctions, Blood

dyscrasias, Nutritional disturbance, Nervous disorders, infectious diseases)

B. Hereditary C. Idiopathic

2. Atrophy Periodontal atrophy (Recession. No inflammation no pockets;

osteoporosis) (Local trauma, Presenile, Senile, Disuse, Following inflammation,

Idiopathic)

3. Hypertrophy Gingival hypertrophy (Chronic irritation, Drug action, Idiopathic)

4. Traumatism (Periodontal traumatism, Occlusal trauma)

World workshop in Periodontics

(1966) •Periodontosis as a distinct disease entity ???????

World workshop in Periodontics

(1977)

•No scientific basis for retaining the concept : non-inflammatory or degenerative forms of destructive periodontal disease.

Periodontosis - Infection

Juvenile periodontitis

Infection/ host response Paradigm (1970- present)

Robert Koch (1876) - The germ theory of disease

W.D. Miller - Early proponent of the infectious nature of periodontal diseases

Pyorrhea alveolaris: Predisposing circumstances Local irritation Bacteria (not specific, but various)

Systemic conditions

Reluctance to accept Degenerative nature of periodontal

diseases (i.e. domination of the ‘Classical Pathology’ paradigm).

Microbiological studies

Harald Löe (1965-1968) - classical ‘experimental gingivitis’

Infection/Host Response Paradigm - Dominant

paradigm

Classification of periodontal diseases

following the “Infection / Host

response” paradigm

GINGIVITIS Chronic Marginal Gingivitis

Acute Necrotizing Ulcerative Gingivitis (ANUG)

PERIODONTITIS Juvenile Periodontitis Rapidly Progressive Periodontitis Adult Type Periodontitis

PAGE AND SHROEDER 1982

Suzuki, 1988 Modification of Page & Schroeder 1982

3 plausible hypothesis for the

pathogenesis of the disease: Direct tissue destruction by bacteria &

metabolic products Immune hyper-responsiveness Immune deficiencies involving neutrophil

function (chemotaxis and phagocytosis)

Adult Periodontitis > 35 yrs

Rapidly Progressing Periodontitis Type A 14 - 26 yrs

Type B >26 yrs

Post juvenile Periodontitis 26 – 35 yrs

Juvenile Periodontitis 12 – 26 yrs

Prepubertal Periodontitis < 14 yrs

SUZUKI 1988

Modifications : Subdivisions to rapidly progressive

periodontitis Post- juvenile periodontitis

Advantages : Short and Easy

Shortcomings : Does not include all criteria and conditions

like gingival conditions

I. Adult Periodontitis

II. Early Onset Periodontitis A. Prepubertal Periodontitis 1. Generalised 2. Localised B. Juvenile Periodontitis 1. Generalised 2. Localised C. Rapidly Progressive Periodontitis

III. Periodontitis Associated With Systemic Diseases Downs syndrome, Diabetes, Papillon-Lefevre syndrome,

HIV, others

IV. Necrotising Ulcerative Periodontitis

V. Refractory Periodontitis

WORLD WORKSHOP IN CLINICAL PERIODONTITIS, 1989

Merits: Inclusion of ‘Periodontitis Associated with

Systemic Disease’

Inclusion of ‘Refractory periodontitis’

Critical evaluation Depended heavily on the age of the affected

patients Baab DA(1986), Page RC (1983) and the rates of progression Page RC (1983).

The dividing line between adult and early onset categories -35 years.

‘Rapidly Progressive’ and ‘pre-pubertal periodontitis’ - not a single entity

Periodontitis

Overlap exists among different diagnostic categories and cases did not clearly fit into any single category’

Considerable ‘heterogeneity’ existed within the Refractory Periodontitis

KS Kornman (1996) Loe (1993) Choi J-I (1990), Lee et al(1995),

Magnusson(1991)

I. Periodontitis In Adults

II. Periodontitis In Juveniles Localized Form Generalized Form

III. Periodontitis With Systemic Involvement Primary Neutrophil Involvement Disorders Secondary/Associated Neutrophil

Impairment Other Systemic Diseases

IV. Miscellaneous Conditions

GENCO, 1990

Shortcomings: Onset, duration of diseases not considered Gingival diseases not considered

I. Gingivitis Gingivitis, Plaque Bacterial Non - Aggravated Systemically Aggravated Related To Sex Hormones Related To Drugs Related To Systemic Diseases Necrotising Ulcerative Gingivitis Systemic Determinants Unknown Related To HIV Gingivitis, Non-Plaque Associated With Skin Disease Allergic Infectious

RANNEY, 1993

II. Periodontitis Adult Periodontitis Non-Aggravated Systemically Aggravated

Neutropenia, Leukemias, Lazy Leukocyte Syndrome, AIDS, Diabetes Mellitus

Early Onset Periodontitis Localised Early Onset Periodontitis Neutrophil Abnormality

Generalised Early Onset Periodontitis Neutrophil Abnormality, Immunodeficient

Early Onset Periodontitis Related To Systemic DiseaseLAD, Papillon-Lefevre Syndrome,Chediak Higashi

Syndrome, AIDS, Diabetes Mellitus Type I, Trisomy 21,

Early Onset Periodontitis, Systemic Determinants Unknown

Necrotising Ulcerative PeriodontitisSystemic Determinants UnknownRelated To HIVRelated To Nutrition

Periodontal Abscess

Modifications: Elimination of the ‘Refractory Periodontitis’

category - heterogeneous group

Elimination of the ‘Periodontitis Associated with Systemic Disease’ category

Shortcomings: Lenghty

AMERICAN ACADEMY OF PERIODONTOLOGY, 1999

GINGIVAL DISEASES Dental plaque induced Non plaque induced

CHRONIC PERIODONTITIS Localised Generalised

AGGRESSIVE PERIODONTITIS Localised Generalised PERIODONTITIS AS MANIFESTATION SYSTEMIC DISEASES Associated with hematological disorders Associated with genetic disorders Not otherwise specified 

NECROTIZING PERIODONTAL DISEASES Necrotizing Ulcerative gingivitis Necrotizing Ulcerative periodontitis ABSCESSES OF THE PERIODONTIUM Gingival abscess Periodontal abscess Periocoronal abscess PERIODONTITIS ASSOCIATED WITH ENDODONTIC LESIONS Endodontic –periodontal lesion Periodontal – endodontic lesion Combined lesion DEVELOPMENTAL OR ACQUIRED DEFORMITIES OR CONDITIONS Localized tooth related Mucogingival deformities around teeth Mucogingival deformities in edentulous area Occlusal trauma

GINGIVAL DISEASES Dental plaque induced gingival diseases:

1) Gingivitis associated with plaque only: Without local contributing factors With local contributing factors

2) Gingival diseases modified by systemic factorsPuberty associated gingivitisMenstrual cycle associated gingivitisPregnancy associated gingivitisDiabetes mellitus associated gingivitis

3) Associated with blood dyscrasiasLeukemia associated gingivitisOthers

4) Gingival diseases modified by medicationsDrug influenced gingival enlargementsDrug induced gingivitis

5) Gingival diseases modified by malnutrition

Non-Plaque-Induced Gingival Lesions

1. Gingival diseases of

bacterial origin• Neisseria

gonorrhea-associated lesions

• Treponema pallidum-associated lesions

• Streptococcal species-associated lesions

• Other

2. Gingival diseases of viral

origin• Primary

herpetic gingivostomatitis

• Recurrent oral herpes

• Varicella-zoster infection

• Other

3. Gingival diseases of

fungal origin• Candida-

species infections

• Histoplasmosis

• Other

4. Gingival lesions of genetic origina. Hereditary gingival fibromatosisb. Other

5. Gingival manifestations of systemic conditions A) Mucocutaneous disorders i) Lichen planus

ii) Pemphigoidiii) Pemphigus vulgarisiv) Erythema multiforme v) Lupus erythematosusvi) Drug inducedvii) Other

B) Allergic reactions

Dental restorative materials

• Mercury• Nickel• Acrylic• Other

Reactions attributable to

• Toothpastes/Dentifrices

• Mouthrinses/Mouthwashes

• Chewing gum additives

• Foods and additives• Others

6. Traumatic lesions

7. Foreign body reactions

8. Not otherwise specified (NOS)

Physical injury

Chemical injury

Thermal injury

CHRONIC PERIODONTITIS Localised Generalised

Clinical features and characteristics of Chronic Periodontitis are:

Most prevalent in adults

Amount of destruction is consistent with the presence of local factors

Subgingival calculus is a frequent finding

Variable microbial pattern

Slow to moderate rate of progression

Sub classifications:

Extent

Localised (<30%)

Generalised

(>30%)

Severity Slight

(1-2mm)

Moderate(3-4 mm)

Severe (≥ 5mm)

Can be modified by :

Local factors

Environmental factors (smoking,

stress)

Systemic factors

(diabetes mellitus, HIV)

AGGRESSIVE PERIODONTITIS

Localised Generalised

Common features of localized and generalized forms of Aggressive Periodontitis are: Patients are otherwise clinically healthy

Rapid attachment loss and bone destruction

Familial aggregation.

Amount of microbial deposits inconsistent with disease severity

Common characteristics, but not universal: Diseased sites infected with A.a

Abnormalities in phagocyte function

Hyper-responsive macrophages producing elevated levels of PGE2 and IL-1β

Self-arresting disease progression

Sub classifications

Localised • Circumpubertal

onset• Robust serum

antibody response• Localised proximal

attachment loss on at least two permanent teeth, one of which is first molar

Generalised • Usually , < 30

years• Poor serum

antibody response• Generalised

proximal attachment loss affecting at least three teeth other than first molar and incisor

PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASE

Hematologic • Neutopenias • Leukemias• Others

Genetic • Cyclic

neutropenia• Down syndrome• LAD syndrome• Chediak –

Higashi Syndrome

• Papillon- lefevre syndrome

NECROTIZING PERIODONTAL DISEASE

Necrotizing ulcerative gingivitis (NUG) Necrotizing ulcerative periodontitis (NUP)

Necrotizing ulcerative gingivitis

NUGBacterial etiology?

Necrotic lesion

Pre disposing factors

(stress, smoking, immunosuppresi

on)

Contributing factor

Malnutrition

Necrotizing ulcerative periodontitis NUP + HIV : 20.8 times more likely to have

CD4+ cell counts below 200 cells/mm3

Probability of death within 24 months : 72.9%

ABSCESSES OF THE PERIODONTIUM

Gingival abscess Periodontal abscess Pericoronal abscess

• A localized purulent infection that involves the marginal gingiva or interdental papilla.

• Trauma, Foreign body impaction etc

Gingival

•A localized purulent infection located contiguous to the periodontal pocket that leads to destruction of periodontal ligament and alveolar bone

•Moderate to deep pockets, Incomplete calculus removal etc

Periodontal

•A localized purulent infection within the tissue surrounding the crown of a partially erupted tooth.

• Retention of debris, plaque etc beneath the operculum

Pericoronal

PERIODONTITIS ASSOCIATED WITH ENDODONTIC LESION

Endodontic – Periodontal Lesion Periodontal – Endodontic Lesion Combined Lesion

Endodontic – Periodontal L esion

Periapical lesion Accessory canals

Periodontal ligament PDL / Furcation

Clinical attachment and

bone loss

Pulpal infection

PERIODONTITIS ASSOCIATED WITH ENDODONTIC LESION

Endodontic – Periodontal Lesion Periodontal – Endodontic Lesion Combined Lesion

DEVELOPMENTAL OR ACQUIRED DEFORMITIES OR CONDITIONS

Localized tooth related Mucogingival deformities around teeth Mucogingival deformities in edentulous

area Occlusal trauma

Localized tooth related factors

1)Tooth anatomic factors2)Dental restorations/appliances3)Root fractures 4)Cervical root resorption and cemental tears

• Cervical enamel projections and enamel pearls

• Palatogingival grooves, proximal root groove

•Open contacts

Tooth anatomic factors

•Impingement of biologic width•Rough surfacesDental

restorations

•Apical migration of plaque along fracture lineRoot

fractures

B) Mucogingival deformities and conditions around teeth

1) Gingival/soft tissue recession

2) Lack of keratinized gingiva

3) Decreased vestibular depth

4) Aberrant frenum / muscle position

5) Gingival excessa. Pseudopocketb. Inconsistent gingival marginc. Excessive gingival displayd. Gingival enlargement

6) Abnormal color

Mucogingival deformities and conditions on edentulous ridges

1) Vertical and/or horizontal ridge deficiency2) Lack of gingival/keratinized tissue3) Gingival/soft tissue enlargement4) Aberrant frenum/muscle position5) Decreased vestibular depth6) Abnormal color

Occlusal trauma 1) Primary occlusal trauma 2) Secondary occlusal trauma

1989 1999

1. Addition of a Section on "Gingival Diseases“

Clinical expression of gingivitis can be substantially modified by: 1) systemic factors 2) medications, and 3) malnutrition

Non-plaque induced gingival lesions includes a wide range of disorders that affect the gingiva.

2. Replacement of "Adult Periodontitis" With "Chronic Periodontitis“

The age-dependent nature – diagnostic dilemma

A nonspecific term : "Chronic Periodontitis" – more accurate

Substitute terminologyPeriodontitis-Common

Form

Type II Periodontiti

s

Chronic Periodontiti

s

3. Replacement of "Early-Onset Periodontitis" With "Aggressive Periodontitis"

Wise to discard classification terminologies that were age-dependent or required knowledge of rates of progression

4. Elimination of a Separate Disease Category for “Refractory Periodontitis”

"Refractory Periodontitis" – not a single disease entity.

Small percentage of cases of all forms of periodontitis might be non responsive to treatment.

The "refractory" designation - applied to all forms of periodontitis in the new classification system (e.g., refractory chronic periodontitis, refractory aggressive periodontitis, etc.

5. Clarification of the Designation “Periodontitis as a Manifestation of Systemic Diseases”

Retained in the new classification since it is clear that destructive periodontal disease can be a manifestation of certain systemic diseases.

It should be noted that diabetes mellitus is not on this list.

6. Replacement of “Necrotizing Ulcerative Periodontitis” With “Necrotizing Periodontal Diseases”

Both clinical conditions under the single category of "Necrotizing Periodontal Diseases."

Inclusion of "Necrotizing Periodontal Diseases" as a separate category is that both NUG and NUP might be manifestations of underlying systemic problems such as HIV infection.

7. Addition of a Category on "Periodontal

Abscess”

8. Addition of a Category on "Periodontic-Endodontic Lesions”

9. Addition of a Category on "Developmental or Acquired Deformities and Conditions”

MERITS: A gingivitis or gingival disease category Heterogeneous disease categories of

prepubertal, refractory and rapidly progressive periodontitis eliminated.

Criteria of age and rate of progression removed

The reasons for these changes - not arbitrary, but based on available data and understanding of the nature of periodontal infections

Critical evaluation Complex classification as numerous disease

categories are listed

Diabetes associated gingivitis and not Diabetes associated periodontitis

Developmental/ acquired deformities – Inappropriate to include it

Removal of localized juvenile periodontitis – retrograde step, most well defined of all periodontal diseases and with a large body of research

Term ‘chronic’ as a replacement for ‘adult’ – inappropriate

Not based on the microbiological features or genetic factors that control the clinical expression of these diseases

Chronic Periodontitis’ - polymicrobial and polygenic, are altered by important environmental and host-modifying conditions.

Hence, possible to subclassify the multiple forms of ‘Chronic Periodontitis’ into discrete microorganism/host genetic polymorphism groups

Extent Severity Age

Clinical characteris

tics

VAN DER VELDEN, 2005

Parameters are set in the following order: extent, severity, clinical characteristics and age

Examples for diagnoses are: Generalized severe refractory post

adolescent periodontitis, Localized minor prepubertal periodontitis, Localized severe adult periodontitis.

Demerits Refractory periodontitis

Modification by Systemic factors

Gingival diseases

Conclusion Classification systems for periodontal

diseases have evolved based on the understanding of the nature of these diseases

Although classification systems for periodontal diseases currently in use are based on, the Infection/Host Response paradigm, some features of the older paradigms are still valid and have been retained.

The new system is not perfect and will need to be modified

References Gary C. Armitage, Classifying periodontal

diseases – a long standing dilemma., Periodontology 2000, Vol. 30, 2002, 9–23

Gary C. Armitage, Periodontal diagnosis and classification of periodontal diseases. Periodontology 2000, Vol 34, 2004, 9-21

Gary C. Armitage, Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1-6.

Ubele Van Der Velden, Purpose and problems of periodontal disease classification. Periodontology 2000, Vol. 39, 2005, 13–21

Newman, Takei, Klokkevold, Carranza. 10th edition. Carranza’s Clinical Periodontology. W. B. Saunders Company.

Angelo Mariotti. Dental Plaque-Induced Gingival Diseases. Ann Periodontol 1999;4:7-17.

Thank you!