Classification of Periodontal Disease

Classification of Periodontal Disease

• Periodontitis is a spectrum disorder, requiring consideration of several factors.
• Key learning outcomes include assessing and managing periodontal and soft tissue health, considering risk factors and lifestyles. Monitoring and recording changes in periodontal health is also important.
• Clinical characteristics paradigm (1870-1920): No information on pathogenesis, dependent on clinical appearance/patient reports.
• Classical pathology paradigm (1920-1970): Inflammatory/non-inflammatory, some influence of bacteria, observation of some degenerative changes.
• Infection/host response paradigm (1970-present): No simple bacteria infections, now complex multifactorial, involving subgingival microbiota and environmental factors.

Intended Learning Outcomes

• Students will list a brief history of periodontal classification.
• Students will explain the rationale behind the need for classification systems.
• Students will describe the rationale for each component of the 2017 periodontal classification system.
• Students will use the BSP flowchart to aid diagnosis and produce a diagnosis based on the 2017 classification.

Chronology of Classification Systems

• Various researchers and organizations have contributed to the history of classifications. Examples include Kantorowicz (1924), McCall and Box (1925), Simonton (1927), Haupl and Lang (1927), Gottlieb (1928), Becks (1929), and many more.
• These classifications have evolved over time.

Previous Classifications

• World Workshop in Clinical Periodontics (1989) included early-onset periodontitis, prepubertal periodontitis (localized/generalized), juvenile periodontitis (localized/generalized), adult periodontitis, necrotising ulcerative periodontitis, refractory periodontitis, and periodontitis associated with systemic diseases.
• World Workshop in Clinical Periodontics (1993) focused on adult periodontitis (beginning at the fourth decade of life,) early-onset periodontitis (before the fourth decade, rapid progression, altered host response), and necrotising periodontitis (tissue necrosis with attachment and bone loss).

American Academy of Periodontology (1999)

• Developed to address issues with previous classifications, primarily the 1989 classification.
• Included gingival diseases (plaque and non-plaque induced), modification by systemic factors, medications, and malnutrition.
• Renamed "adult periodontitis" to "chronic periodontitis", "early-onset periodontitis" to "aggressive periodontitis", and removed "refractory periodontitis".
• Classified periodontitis as a manifestation of systemic diseases and included categories for periodontal abscesses, periodontic-endodontic lesions, and developmental/acquired deformities and conditions.

Why Classify Periodontal Disease?

• A classification system is needed to improve diagnostics and treatment.

Periodontal Diagnosis with 2017 Classification System

• The 2017 classification system is designed for clinical practice implementation.
• It includes periodontal health, gingival diseases, and associated conditions as well as peri-implant diseases and conditions.
• Recommendations of the British Society of Periodontology (BSP) are described for the implementation of the 2017 classification of periodontal diseases and conditions in British dental practices.
• A diagnostic pathway is illustrated for patients with dental biofilm-induced periodontitis using the Basic Periodontal Examination (BPE) and grading/staging of periodontitis.

Gingivitis

• Plaque-induced gingivitis is exacerbated by systemic conditions.
• Gingival diseases are classified.

Necrotizing Diseases

• Microbially-associated, host-mediated inflammation resulting in periodontal attachment loss.

Periodontitis Definition

• Microbially-associated, host-mediated inflammation resulting in loss of periodontal attachment.

Extent/Distribution

• Localised (up to 30% of teeth)
• Generalised (more than 30% of teeth)
• Molar/incisor pattern

Staging

• Based on the percentage of bone loss relative to the root length.
• The worst case scenario is considered.

Staging Process

• Stages of periodontitis (early/mild, moderate, severe, very severe) are defined based on interproximal bone loss.

Healthy Periodontium

• Images of healthy periodontium and periodontitis cases are included for visual reference.

Tooth Loss

• Tooth loss is assigned to Stage IV if it results from advanced periodontal bone loss.

Grading

• Grading considers the worst bone loss, susceptibility of the patient, and patient age.

Current Disease Status

• Stage and grading incorporate historic disease as bone loss is irreversible.
• Periodontal treatment history needs to be considered.
• Patients may have received past periodontal treatment.

Current Disease Status (Assessment)

• Stable, in Remission, or Unstable periodontal status assessments are based on bleeding on probing (BOP) and probing pocket depth (PPD).

Classification to Diagnosis

• Classification relates to stage and grade of periodontitis.
• Diagnosis is informed by current health/disease status to enable prognosis and therapeutic strategy.

Lifestyle Factors

• Lifestyle factors such as smoking, diabetes, etc. are identified as risk factors for periodontal disease.

Risk Factor Assessment

• Smoking and sub-optimally controlled diabetes are provided as examples of modifiable risk factors.

Diagnostic Statement

• The diagnostic statement includes the extent, stage, grade, stability, and risk factors of periodontitis to improve personalized periodontal treatment strategies.