Classification of Periodontal diseases, types, history, advantages, drawbacks, advancements

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
Essentialistic or Nominalistic disease classification
Future challenges in the classification of
periodontal diseases
Conclusion
References

3. The classification of periodontal diseases has come a long way
over the past hundred years.
Periodontitis is a complex disease of the tooth supporting
structures resulting in inflammation in supporting tooth
structures resulting in progressive attachment loss and bone loss
that has no geographic , ethnic or age barriers.
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. DESIRABLE CHARACTERISTICS OF A
CLASSIFICATION SYSTEM

6. NEED FOR
CLASSIFICATION

7.  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

8. Recognition and treatment of periodontal disease can be traced back to
antiquity.
Recognition and treatment of periodontal disease can be traced back to
antiquity.
5000 YEARS AGO – ANCIENT EGYPTIAN AND CHINESES WRITINGS5000 YEARS AGO – ANCIENT EGYPTIAN AND CHINESES WRITINGS
IN 10TH
CENTURY – ABU I QUASIM
ALBUCASIS OF CORDOVA SPAIN
IN 10TH
CENTURY – ABU I QUASIM
ALBUCASIS OF CORDOVA SPAIN

13. IN 17TH
CENTURY – VON LEEUWENHOEK
19TH CENTURY - THE GERM THEORY OF DISEASE OF
PASTEUR, KOCH AND LISTER
19TH CENTURY - THE GERM THEORY OF DISEASE OF
PASTEUR, KOCH AND LISTER
ADOLPH WITZEL (1847–1906)ADOLPH WITZEL (1847–1906)
FIRST TRUE ORAL MICROBIOLOGIST WAS
WD MILLER (1853–1907)
JOHN W RIGGS (1811–1885)
IN 1771 – JOHN HUNTER – NATURAL HISTORY OF HUMAN
TEETH
IN 1778 – A PRACTICAL TREATISE ON THE DISEASES OF TEETH

14. RIGGS Disease:RIGGS Disease: Loss of alveoli without loss OfLoss of alveoli without loss Of
gums.gums.
Death of periodontal membraneDeath of periodontal membrane
Deprives the alveoli of nutritionDeprives the alveoli of nutrition
Death of alveolar boneDeath of alveolar bone

15. A LONG-STANDING DILEMMA

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

17. CLINICAL FEATURES OF THE DISEASE
1870-1920

18. Davis CG in 1879 classified three different forms of destructive
periodontal diseases.
C.G DAVIS,1879

19. Shortcomings of this C.G. Davis classification -
1. No emphasis was given on age of onset of diseases and
rate of progression.
2. Inadequate or unclear classification criteria.
3. Little or no scientific evidence was used to support the
opinions of the clinicians of that time.
4. Periodontitis which can be due to systemic diseases is
not considered.

20. First: margins of the gums showed inflammatory action &
bleeding at slightest touch of the brush.
Second: inflammation extends over the thinner alveolar
border causing absorption of bone & gum tissue, forming
small pockets filled with pus.
Third: thicker portions of the process are involved
absorbing it most rapidly.
Fourth: the disease has swept away all of the alveoli &
much of the gum.
John M. Riggs (1875)

23. Shortcomings of G.V. Black classification -
1. Little or no scientific evidence was used to support the
opinions of the clinicians of that time.
2. Inappropriate emphasis on age of onset of diseases and
rates of progression of this diseases.
3. Inadequate or unclear classification criteria.
4. Periodontitis which can be due to systemic diseases is
not considered.

24. PYORRHOEA ALVEOLARIS (MOST COMMON).
• RIGGS DISEASE
• CALCIC INFLAMMATION OF PERIDENTAL MEMBRANE.
• PHAGEDENIC PERICEMENTITIS.
• CHRONIC SUPPURATIVE PERICEMENTITIS.
In the latter part of 19th
century, periodontitis
underwent numerous modifications in names:
The point of these historical examples is to emphasize that little or no scientific evidence
was used to support the opinions of the clinicians of the time.
What caused the periodontal disease, how they should be classified, and the terminology
used to describe them, seem to have approached the number of clinicians who treated
the patients with these diseases.
Hence it is not surprising then, that no generally accepted terminology or classification
system for periodontal diseases was not adopted during this era.

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

26. CLASSICAL PATHOLOGY PARADIGM
(1920–1970).
As the field of periodontology began to mature scientifically in
the first half of the 20th century, many clinical scholars in both
Europe and North America began to develop, and argue about,
nomenclature and classification systems for periodontal diseases.
What emerged from this debate was the concept that there were at
least two forms of destructive periodontal disease Inflammatory
and Non-inflammatory (‘degenerative’ or ‘dystrophic’).
This conclusion was primarily based on the over-interpretation of
histopathological studies from a group of investigators led by
Gottlieb and Orban.

27. Gottlieb, in particular, had a significant influence on the field
when he postulated that certain forms of destructive periodontal
disease were due to degenerative changes in the periodontium.
He believed that he had discovered histological evidence of an
impairment in the continuous deposition of cementum (i.e.
‘cementopathia’). This cemental defect was presumably initiated
by the degeneration of the principal fibers of the periodontal
ligament that eventually resulted in detachment of connective
tissue from the tooth followed by resorption of adjacent bone.
(J Periodontol 1946:17:7-23)

28. Almost all classifications published from 1920-1970 had
 Dystrophic
 Atrophic
 Degenerative categories

29. Gottlieb (1920 )
 Considered to be the first author who clearly distinguished and
classified various forms of periodontal diseases:
1. Schmutz-Pyorrhoe: was thought to be the result of the
accumulation of deposits on the teeth and was characterized by
inflammation, shallow pockets, and resorption of the alveolar
crest.
2. Alveolar atrophy or diffuse atrophy: was described as a
noninflammatory disease exhibiting loosening of teeth,
elongation, and wandering of teeth in individuals who were
generally free of carious lesions and dental deposits. In this
disease, manifesting pockets are formed only in later stages.

30. Gottlieb (1920 )-
3. Paradental-Pyorrhoe: was characterized by irregularly distributed
pockets varying from shallow to extremely deep. This form of
disease may have started as Schmutz-Pyorrhoe or as diffuse
atrophy.
4. Occlusal trauma: a form of physical overload which was believed
to result in resorption of the alveolar bone and loosening of
teeth.
 Shortcomings of Gottlieb,s classification -
1. Microbiological bases were not given much importance.
2. Unclear classification criteria.

31. KANTOROWICZ 1924
Dystrophic diseases with little inflammation
 PRE-SENILE ATROPHY.
 DYSTROPHY FROM OCCLUSAL TRAUMA.
 DYSTROPHY FROM LACK OF OCCLUSION.
 DIFFUSE ATROPHY.

32. SIMONTON 1927
GOTTLEIB 1928
CHEMOBACTERIAL –
Parodontitis
SYSTEMIC
Parodontitis
Diffuse atrophy
Inflammatory.
SCHMUTZ
PYORRHEA
( poor oral hygiene)
Degenerative
or atrophic.
Diffuse
alveolar
atrophy
(systemic or
metabolic
causes).
Paradental
pyorrhea.

33. BECK 1929,1931
PARADENTITIS
- SIMPLE
- SECONDARY
PARADENTOSIS
- PRESENILE ATROPHY.
- PARADENTOSIS DUE TO TRAUMA.
- PARADENTOSIS DUE TO LACK OF OCCLUSION.
- DIFFUSE ALVEOLAR ATROPHY
- PARADENTOSIS SECONDARY TO PARADENTITIS.

34. 8th
INTERNATIONAL DENTAL
CONGRESS 1931
 PURE GINGIVITIS
 PREPARADENTAL GINGIVITIS
 INFLAMMATORY PARADENTOSIS
 DYSTROPHIC PARADENTOSIS
 PRESENILE ATROPHY
 SENILE ATROPHY

35. ROY(1933-1935)
ALVEOLARPYORRHEA:
Characterized by precocious senile alveolar
resorption due to upset in general constitution of
the individual.
PYORRHEA WITH POCKETS
- common
- hyperemic gingivitis exists
- ischemia

36. PYORRHEA WITHOUT POCKETS
type with absence of local causes : no gingivitis
juvenile atrophy : adolescent disease
type with tooth movement due to laxity of
paradentium :osteoporosis
deformatory pyorrhea

37. HAUPL and LANG 1928,1940
 (A) PARADENTITIS:
 MARGINAL PARADENTITIS : etiology being mechanical, thermal, chemical,
infectious factors, functional disturbances, tooth malformation, systemic disturbances
 SUPERFICIAL MARGINAL PARADENTITIS: epithelial changes being
progressive, formation of pocket , connective tissue changes , changes in paradental
bone.
 MARGINAL PARADENTITIS PROFUNDA
 APICAL PARADENTITIS
 (B) PARADENTOSIS:
PARADENTOSIS DUE TO TRAUMA
PARADENTOSIS DUE TO LACK OF OCCLUSION
DIFFUSE ALVEOLAR ATROPHY
PARADENTOSIS SECONDARY TO PARADENTITIS
 (C) PARADENTOMA

38. THOMA and GOLDMAN 1939
(A) INFLAMMATORY CONDITIONS:
- GINGIVITIS : marginal , hypertrophic,ulcerative and may be of local or systemic
origin
- MARGINAL PARADONTITIS : due to poor oral hygiene
B) DEGENERATIVE CONDITIONS:
- PARADONTOSIS
- ATROPHY : 1. gingival recession (faulty tooth brushing)
2. presenile atrophy (normal physiologic process, recession of gingiva
and resorption of alveolar crest)
3. disuse atrophy (decreased/lack of functions of jaws)
4. atrophy due to abnormal occlusal trauma
C) SYNDROME OF PARADONTITIS AND PARADONTOSIS

39. ROBINSON 1935
Clincial types of paradentosis:

40. WESKI 1937
PARADENTITIS
(GINGIVITIS)
I.Hypertrophic
II.Simple
III.Ulcerative
PARADENTOSIS
I.Partial atrophic (true form)
II.Total atrophic (alveolar atrophy)
PARADENTOMA
I.Localized
II.Epulis
III.Generalized
IV.Elephantiasis gingivae

41. BOX, MCCALL 1940
GINGIVITIS
acute
chronic
PERIODONTITIS
acute
chronic
 (The term was used 1st
time)
PERIODONTITIS SIMPLEX (exogenous factors)
PERIODONTITIS COMPLEX (endogenous factors)

42. ORBANS; 1942
1. INFLAMMATORY CONDITIONS
GINGIVITIS
i.Localized to free margin of the gingiva
ii.Swelling, shallow pockets
iii.Acute or chronic, according to the
duration
iv.Ulcerative- purulent according to the
symptoms
v.Local or systemic, according to the
etiology
PERIODONTITIS
Inflammation extends to deeper tissues,
may be deep pockets, suppuration,
abscess formation varying degree of
alveolar resorption.
i. Simplex: following gingivitis
ii. Complex: following periodontosis

43. ATROPHIC CONDITIONS
Periodontal atrophy – bone recession
Precocious aging- disuse, loss of
normal function
Trauma- toothbrush ,orthodontia
GINGIVOSIS: systemic
aetiology, involving degeneration
of connective tissue
2. DEGENERATIVE CONDITIONS
PERIODONTOSIS:
Degeneration of the collagenous
fibers of the periodontal
membrane. Irregular bone
resorption.
•Early – no inflammation
•Late: deep periodontal
pockets with periodontitis

44. 3.PERIODONTALTRAUMATISM
I.Pressure necrosis and its
consequence
II.Primary – overstress, bruxism
III.Secondary- loss of supporting
tissues
3.PERIODONTALTRAUMATISM
I.Pressure necrosis and its
consequence
II.Primary – overstress, bruxism
III.Secondary- loss of supporting
tissues
4. GINGIVAL HYPERPLASIA
i.Overgrowth of gingiva in varying
degrees
ii.Infections-pyogenic granuloma
iii.Endocrine dysfunction-
pregnancy
iv.Drugs- dilatin
v.Idiopathic
4. GINGIVAL HYPERPLASIA
i.Overgrowth of gingiva in varying
degrees
ii.Infections-pyogenic granuloma
iii.Endocrine dysfunction-
pregnancy
iv.Drugs- dilatin
v.Idiopathic

45. Shortcomings of ORBAN, 1942 classification -
1. Degeneration is not an appropriate word to be used, rather it
should be called Inflammatory diseases.
2. Microbiological bases were not given much importance.

46. FISH 1944
• GINGIVITIS
i. Acute ulcerative
ii. Sub-acute marginal
iii.Chronic marginal
iv. Traumatic
• PYORRHEA
i. Pyorrhea complex (gradual deepening of sulcus)
ii. Pyorrhea profunda (deep pocket, pus formation, tooth mobility)
iii. Senile alveolar resorption.
• NEOPLASIA
i. Odontoclastoma
ii. Cementoma
iii. Fibrous epulis

47. HINE and HINE 1944
(A) INFLAMMATORY :
 GINGIVITIS
local: calculus, faulty restorations, poor contact areas, drugs
Systemic: nutritional deficiencies, blood dyscariasis
 PERIODONTITIS SIMPLEX – similar to gingivitis but more severe
irritation
 SPECIFIC ENTITIES – tuberculosis, syphilis, radiation
(B) ATROPHY or DEGENERATION :
 gingivitis
 trauma
 senile
 disuse
 idiopathic

48. (C) PERIODONTITIS COMPLEX
Periodontosis : systemic disturbances, degeneration of connective tissue
fibres in periodontal membrane, bone resorption
(D) HYPERTROPHY:
 trauma
 senile
 idiopathic

49. HELD 1949
TRUE PARADONTOPATHIA:
 gingivitis,
 paradontolysis,
 paradontitis,
 periodontal atrophy
SYMPTOMATIC PARADONTOPATHIA :
avitaminosis,
blood dyscarasias
ENLARGEMENT CONDITIONS:
 epulis,
 elephantiasis gingivae
NEOPLASIA :
 odontoclastoma,
 cementoma,
 fibrous epulis

50. MILLER 1950
GINGIVITIS: ACUTE, SUBACUTE, CHRONIC, EXUDATIVE, HYPERPLASTIC,
NECROTIZING, DIETARY, INDOLENT, ENDOCRINOPATHIC, ALLERGIC,
HEMOPATHIC
PERIODONTAL ABSCESS:
PARODONTA : PERICEMENTAL/GINGIVAL
PERIAPICAL
• ALVEOLOCLASIA:
BONE RESORPTION
NUTRITIONAL DEFICIENCY
ENDOCRINOPATHIC
• PERICEMENTOCLASIA : POCKET FORMATION
• ULATROPHIC: ISCHEMIA,
AFUNCTIONAL
TRAUMATIC
CALCIC

51. AMERICAN ACADEMY OF PERIODONTOLOGY (AAP)
1957
1.INFLAMMATION
• Gingivitis
• Periodontitis
• Primary (simplex)
• Secondary( complex)
2. DYSTROPHY
I.Occlusal traumatism
II.Periodontal disuse atrophy
3.GINGIVOSIS
4.PERIODONTOSIS
2. DYSTROPHY
I.Occlusal traumatism
II.Periodontal disuse atrophy
3.GINGIVOSIS
4.PERIODONTOSIS

52. CARRANZA AND CARRANZA, 1959

53. The first generally acknowledged classification of periodontal disease
appeared in 1966 in Ann Arbor (Michigan, USA) during the first Workshop,
at which the disease was classified into :-
“Gingivitis” and “Periodontitis”.

54. MCPHEE AND COWLEY, 1969

55. 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.

56. INFECTION/ HOST RESPONSE PARADIGMS
(1970–present)
Soon after the 1876 publication of Robert Koch in which he
provided experimental proof of the germ theory of disease, some
dentists began to suggest that periodontal diseases might be caused
by bacteria.
W.D. Miller, in particular, was an early proponent of the infectious
nature of periodontal diseases.

57. Miller also recognized that certain systemic conditions (e.g.
diabetes, pregnancy) could modify the course of disease.
Although he spent most of his life studying the oral microflora
associated with caries and periodontal disease, his work had very
little impact on convincing his contemporaries that periodontal
diseases were infections.
He was, however, an early advocate of the ‘Infection/Host
Response Paradigm’ that would come to dominate the field nearly
a hundred years later.

58. According to Miller’s opinion three factors are to be taken into
consideration in every case of pyorrhea alveolaris:
(1) predisposing circumstances
(2) local irritation
(3) bacteria.
(Miller WD, The Micro-organisms of the Human Mouth .
Philadelphia: The S.S White Dental Mfg.Co,1890:328-334)
In addition, microbiological studies revealed that the periodontal
microflora was exceedingly complex and no clear group of
microorganisms could be causally linked to the diseases.
 It was not until the classical ‘experimental gingivitis’ studies
published by Harald Löe and his colleagues from 1965 to 1968 that
the Infection/Host Response Paradigm began to move in the
direction of becoming the dominant paradigm.

59. PRICHARD 1972
A) DISEASES AFFECTING THE SURFACE OR GINGIVA:
1. Inflammation without surface destruction-
 Marginal gingivitis
 Generalized diffuse gingivitis
 Gingival enlargement
2. Inflammation with surface destruction
I. NUGs
II. Herpetic gingivostomatitis
III. Desquamative gingivitis : Oral ulcers
B) DISEASES THAT AFFECT THE DEEPER STRUCTURES
Chronic destructive periodontal disease or periodontitis
a. Periodontal abscess
b. Periodontal traumatism : Primary traumatism , Secondary traumatism

60. AAP 1977
 JUVENILE PERIODONTITIS
CHRONIC MARGINAL PERIODONTITIS
SCHLUGER, YUODELIS AND PAGE, 1977
GINGIVITIS
I.Plaque associated gingivitis
II.Acute ulcerative necrotizing
gingivitis
III.Hormonal gingivitis
IV.Drug induced gingivitis MARGINAL
PERIODONTITIS
Adult type
Juvenile type

61. GRANT et al, 1979
1.INFLAMMATORY
Gingivitis
Periodontitis
Juvenile periodontitis .
2.TRAUMATIC/DEGENERATIV
E
 Periodontal trauma
 Gingival recession
 Alveolar atrophy
3.SYSTEMIC/GENETIC/IMM
UNOLOGIC
• Hereditary gingival
fibromatosis
• Chediak-Higashi syndrome
• Down syndrome
• Hypophosphotasia
• Cyclic neutropenia
• Lazy leukocyte syndrome
• Diabetes mellitus
• Juvenile periodontitis
• Hyperkeratosis palmar
plantaris

62. RAMJFORD AND ASH,1979
• GINGIVITIS
1. Simplex
2. Complex (Gingival hyperplasia, Necrotizing lesions, Traumatic)
• GINGIVAL ATROPHY OR RECESSION
1. Systemic factors
2. Local factors
• TRAUMA FROM OCCLUSION
• PERIODONTITIS
1. Simplex
2. Complex
3. Juvenile

63. Shortcomings of this classification -
1. No emphasis on age of onset of diseases and rate of progression.
2. Very unclear classification criteria.
3. Periodontitis which can be due to systemic diseases is not
considered.

64. PAGE AND SCHROEDER, 1982

65. Shortcomings of this classification –
1 .Absence of a gingival diseases component .
2. Periodontitis which can be due to systemic diseases is not
considered .

66. WEATHERFORD CLASSIFICATION -1987
Uses elements from the classification of Prichard (1972) & Page and
Schroeder(1982) and combines the rate of destruction with age of patient.
I. DISEASES AFFECTING THE SURFACE OF GINGIVA
A. Inflammation without destruction.
Marginal gingivitis
Generalized diffuse gingivitis
Gingival enlargement
I. DISEASES AFFECTING THE SURFACE OF GINGIVA
A. Inflammation without destruction.
Marginal gingivitis
Generalized diffuse gingivitis
Gingival enlargement
B. Inflammation With Surface Destruction
- NUG
- Herpetic gingivostomatitis
- Desquamative gingivitis
- Oral ulcers
II. DISEASES AFFECTING THE DEEPER STRUCTURES
Early onset periodontitis
I. Prepubertal – loc / gen
II. Juvenile periodontitis
III. Rapidly progressing periodontitis
IV. Post-pubertal periodontitis
V. Adult type, Rapidly progressing type
B. Inflammation With Surface Destruction
- NUG
- Herpetic gingivostomatitis
- Desquamative gingivitis
- Oral ulcers
II. DISEASES AFFECTING THE DEEPER STRUCTURES
Early onset periodontitis
I. Prepubertal – loc / gen
II. Juvenile periodontitis
III. Rapidly progressing periodontitis
IV. Post-pubertal periodontitis
V. Adult type, Rapidly progressing type

67. B. PERIODONTAL TRAUMATISM
Primary traumatism
Secondary traumatism
B. PERIODONTAL ABSCESS
MERITS
 Clearly differentiates gingivitis, gingival enlargement, NUG, periodontitis & so on.
 Useful in teaching.
DEMERITS
Age-dependent criteria.
Rate of bone destruction
DEMERITS
Age-dependent criteria.
Rate of bone destruction

68. AAP 1986
(A)JUVENILE PERIODONTITIS - PREBUBERTAL:
(1) Localized juvenile periodontitis
(2) Generalized juvenile periodontitis
(B) ADULT PERIODONTITIS
(C) NECROTIZING ULCERATIVE GINGIVO-
PERIODONTITIS
(D) REFRACTORY PERIODONTITIS

69. Shortcomings of (AAP) 1986 classification –
1. Absence of a gingival diseases component .
2. Periodontitis which can be due to systemic diseases has not
been considered .
3. Periodontal abscess and periodontic-endodontic lesions were
not included.
4. Extensive overlap among the categories.
5. Age dependent classification of periodontitis appears invalid.

70. SUZUKI, 1988

71. Shortcomings of this classification –
1. Absence of gingival diseases component .
2. Periodontitis which can be due to systemic diseases is not
considered .
3. Term adult periodontitis created a diagnostic dilemma for
clinicians, needed to be replaced with term chronic.
4. Extensive overlap among the categories.
5. Periodontal abscess and periodontic-endodontic lesions were
not included.

72. GRANT, STEM AND LISTGARTEN, 1988
1.BACTERIALLY INDUCED
DISEASES
- Gingivitis
- Periodontitis
Adult Type
Post Juvenile
Early Onset (Localized
& Generalized)
- Acute necrotizing
ulcerative gingivitis
- Acute abscess
- Pericoronitis
2.FUNCTIONALLY INDUCED
DISEASES
-- traumatic occlusion
- disuse atrophy
3. TRAUMA
- habits
accidentaccident

73. At the Workshop of the American Academy of Periodontology (AAP) held in
1989 in Princeton (California, USA) for the first time a detailed classification
was presented of periodontal diseases and conditions. (CATON J)

74. Shortcomings of this classification –
1. Habits and Accidents cannot be considered as
periodontal diseases .
2. Inadequate classification criteria.
3. Term adult periodontitis created a diagnostic dilemma
for clinicians.
4. Extensive overlap among the categories.
5. Periodontic-endodontic lesions were not included.
6. Subclassification of gingivitis was not given importance.

75. WORLD WORKSHOP IN CLINICAL PERIODONTICS,
1989, PRINCETOWN (CALIFORNIA, USA)
1. ADULT PERIODONTITIS:
Age of onset > 35 years,
Slow rate of disease progression,
No defects in host defenses.
2. EARLY ONSET PERIODONTITIS:
Age of onset < 35 years, Rapid rate of disease
progression, Defects in host defenses.
• Pre-pubertal ( Generalized & Localized
• Juvenile (Generalized & Localized)
• Rapidly Progressive
3. PERIODONTITIS ASSOCIATED
WITH SYSTEMIC DISORDERS
(Down’s syndrome, Papillon lefevre
syndrome, AIDS, Diabetes type 1, Other
diseases)
4. NECROTISING ULCERATIVE
PERIODONTITIS
5. REFRACTORY PERIODONTITIS

76. Advantage:
Patients could be placed into age based categories & easy method.
Unfortunately, the 1989 classification had many shortcomings including:
1) Considerable overlap in disease categories.
2) Absence of a gingival disease component.
3) Inappropriate emphasis on age of onset of disease and
rates of progression.
4) Inadequate or unclear classification criteria.

77. Shortcomings of 1989 classification
1. Overlapping occurred among categories, and cases existed
that did not clearly fit into any single category. For
example,if children with generalized prepubertal periodontitis
have defects in leukocyte adherence, could that justify their
inclusion in the category “periodontitis”as a manifestation of
systemic disease or generalized prepubertal periodontitis?
2. Clear distinction between generalized juvenile periodontitis
and RPP in all cases is not yet possible since these and other
forms of early onset periodontitis can be found in the same
family.

78. 3. Inappropriate emphasis on age of onset of disease and rates of
progression. Using the patient’s age as the major classification
criterion has important limitations since clinical conditions with the
same underlying etiology and susceptibility may be classified
differently on the basis of the patient’s age only.
4. Inadequate or unclear classification criteria. For example, how
does one classify the type of periodontal disease in a 21-year- old
patient with the classical incisor-first molar pattern of localized
juvenile periodontitis (LJP)? Since the patient is not a
juvenile,should the age of the patient be ignored and the disease
classified as LJP anyway?

79. GENCO 1990
1. PERIODONTITIS IN ADULTS
2. PERIODONTITIS IN JUVENILE
Localised form
Generalised form
3. PERIODONTITIS WITH SYSTEMIC INVOLVEMENT
Primary neutrophil disorders
Secondary or associated neutrophil impairement
Other systemic diseases
4. MISCELLANEOUS CONDITIONS

80. Shortcomings of GENCO , 1990 classification -
1. Absence of gingival diseases component.
2. Inappropriate emphasis on age of onset of diseases.
3. Very unclear classification criteria.
4. Diseases under category of miscellaneous conditions adds to
more confusion.

81. RANNEY 1993
GINGIVITIS
1.GINGIVITIS, PLAQUE BACTERIAL
Non-aggravated
Systemically aggravated by sex hormones, drugs , systemic disease
2. NUGs
Systemic determinants unknown
Related to HIV
3.GINGIVITIS, NON-PLAQUE ASSOCIATED with skin disease;
allergic; infectious
PERIODONTITIS
1. ADULT-PERIDONTITIS
Non-aggravated
Systemically aggravated (neutropenias, leukemias, lazy leukocyte
syndrome, AIDS, Crohn’s disease, diabetes mellitus, Addison’s
disease)

82. 2.EARLY-ONSET PERIODONTITIS
a. Localized early-onset periodontitis
Neutrophil abnormality
b. Generalized early-onset periodontitis
Neutrophil abnormality- immuno-deficient
c. EARLY-ONSET PERIODONTITIS RELATED TO SYSTEMIC DISEASE
•Leukocyte adhesion deficiency,
•hypophosphatasia,
•Papillon -Lefevre syndrome,
•neutropenias,
•leukemia's,
•Chediak-Higashi syndrome,
•AIDS,
•diabetes mellitus type,
•trisomy 21,
•histiocytosis X,
•Ehlers- Danlos syndrome (Type VIII)
d. EARLY-ONSET PERIODONTITIS, SYSTEMIC DETERMINANTS UNKNOWN

83. 3.NUP
• Systemic determinants unknown
• Related to HIV
• Related to nutrition
4.PERIODONTAL ABSCESS
ACCEPTS OCCLUSAL TRAUMA AS A
PHYSIOLOGICAL ADAPTATION RATHER
THAN A DISEASE.
ACCEPTS OCCLUSAL TRAUMA AS A
PHYSIOLOGICAL ADAPTATION RATHER
THAN A DISEASE.

84. Shortcomings of this classification-
1. Trauma from occlusion factor was not considered.
2. Sub-categorization was inadequately done.
3. Periodontic-endodontic lesions were not included.
4. Term adult periodontitis created a diagnostic dilemma for
clinicians, needed to be replaced with term chronic.
5. Mucogingival deformities factor and conditions in dentulous
and in edentulous were not considered.
6. Overlapping of disease category.

85. SO AGAIN A CLASSIFICATION SYSTEM WAS
PROPOSED IN 1993 BY EUROPEAN WORKSHOP IN
PERIODONTOLOGY.
(ATTSTROM & VANDER VELDEN)
• ADULT PERIODONTITIS
• EARLY ONSET PERIODONTITIS
• NECROTISING PERIODONTITIS
• But the 1993 European classification lacked the detail necessary for adequate
characterization of the broad spectrum of periodontal diseases encountered
in clinical practice.
• The need for a revised classification system for periodontal diseases was
emphasized during the 1996 World Workshop in Periodontics.

86. • On October 30-November 2, 1999, the INTERNATIONAL WORKSHOP FOR
A CLASSIFICATION OF PERIODONTAL DISEASES AND CONDITIONS
was held in OAK BROOK (ILLINOIS, USA) and a new classification was
agreed upon.
Gingival category was added.
The heterogeneous categories of PREPUBERTAL, REFRACTORY AND
RAPIDLY PROGRESSING PERIODONTITIS were eliminated as distinct
categories.
‘Refractory’ designation remains in the new classification but not as a single
entity because conceptually talking, all forms of periodontitis can be
unresponsive to treatment.
Criteria of age and rate of progression were removed.

87. Data from ARMITAGE GC, Ann
Periodontol 1999
THE FOLLOWING CLASSIFICATION OF PERIODONTAL
DISEASES WAS PROPOSED:
1. Gingival diseases (G)
2. Chronic periodontitis (CP)
3. Aggressive periodontitis (AP)
4. Periodontitis as a manifestation of systemic diseases (PS)
5. Necrotizing periodontal diseases (NP)
6. Periodontal abscesses
7. Periodontitis with endodontic lesion
8. Developed and acquired deformations and conditions.

88. 1. GINGIVAL DISEASES
DENTAL PLAQUE INDUCED GINGIVAL DISEASES.
1. GINGIVITIS EXCLUSIVELY CAUSED BY PLAQUE :
A. With no local modifying factors
B. With local modifying factors .
2. GINGIVAL DISEASES MODIFIED BY SYSTEMIC FACTORS:
A. Associated with hormonal influences :
1) Puberty associated Gingivitis.
2) Menstrual cycle associated Gingivitis.
3) Pregnancy associated
a) gingivitis
b) Pyogenic granuloma
4) Diabetes mellitus associated gingivitis
B. Associated with blood disease
1) Gingivitis associated with leukemia
2) Other diseases
CLASSIFICATION OF PERIODONTAL DISEASES &
CONDITIONS 1999

89. 3. GINGIVAL DISEASES MODIFIED BY MEDICATIONS
1. Drug influenced Gingival diseases.
2. Drug induced gingival enlargements.
3. Drug induced gingivitis.
a) Gingivitis associated with oral contraceptives.
b) Other medications.
4. GINGIVAL DISEASES MODIFIED BY MALNUTRITION
a. Gingivitis due to lack of vitamin C
b. Others

90. NON PLAQUE INDUCED GINGIVAL DISEASES.
1. GINGIVAL DISEASES OF SPECIFIC BACTERIAL AETIOLOGY
A. Lesions associated with Neisseria gonorrhoeae
B. Lesions associated with Treponema pallidum
C. Lesions associated with Streptococci
D. Others
2. GINGIVAL DISEASES OF VIRAL AETIOLOGY
A. infection with the herpes virus
1) Primary herpetic gingivostomatitis
2) Recurring oral herpes
3) Varicella zoster infection
B. Others
3. GINGIVAL DISEASES OF FUNGAL AETIOLOGY
A. Infection with candida: generalised gingival candidiasis
B. Linear gingival erythema
C. Histoplasmosis
D. Others

91. 4. GINGIVAL DISEASES OF GENETIC AETIOLOGY
A. Inherited fibromatosis of the gingiva
B. Others
5. GINGIVAL MANIFESTATIONS OF SYSTEMIC CONDITIONS
A. MUCOCUTANEOUS LESIONS
1) lichen planus
2) pemphigoid
3) pemphigus vulgaris
4) erythema multiformis
5) lupus erythematosus
6) caused by medications
7) others

92. B. ALLERGIC REACTIONS
1) Material in restorative dentistry
A) Mercury
B) nickel
C) acrylic
D) others
2) Reaction to:
A) Toothpaste
B) Mouthwashes
C) Additives in chewing gum
D) Foods and additives
3) Others
6. TRAUMATIC LESIONS (FACTITIOUS, IATROGENIC,
ACCIDENTS)
A. CHEMICAL
B. PHYSICAL
C. THERMAL
7. REACTION TO FOREIGN BODIES
8. NOT OTHERWISE SPECIFIED

93. CRITICAL ANALYSIS
Important feature of this section is acknowledgement that clinical expressions of gingivitis
can be substantially modified by:
Systemic factors such as perturbations in endocrine systems
Medications
Malnutrition
Important feature of this section is acknowledgement that clinical expressions of gingivitis
can be substantially modified by:
Systemic factors such as perturbations in endocrine systems
Medications
Malnutrition
I) Addition of a section on ‘gingival diseasesI) Addition of a section on ‘gingival diseases
The section on non plaque induced gingival lesions includes a wide range of
disorder that affect the gingiva. Many of these are encountered in clinical
practice.

94. II) REPLACEMENT OF ADULT PERIODONTITIS
WITH CHRONIC PERIODONTITIS
Epidemiologic data and clinical
experiences suggest that form of
periodontitis commonly found in adults
can also be seen in the adolescents.
Clearly the age related nature of the adult
periodontitis designation created problems.
So chronic periodontitis was a more appropriate
term used to characterize the constellation of the
destructive disease.
• Earlier disease was thought to be slowly progressive, however some patients
experience short periods of rapid progression.
Therefore workshop participants concluded that rates of the disease progression should
not be used to exclude the people from receiving the diagnosis of chronic periodontitis.

95. III) REPLACEMENT OF THE EARLY ONSET PERIODONTITIS
WITH AGGRESSIVE PERIODONTITIS

96. It is now known that most of the patients having
diagnosis of generalized pre-pubertal
periodontits actually had one of the variety of
systemic conditions that interfere with
resistance of bacterial infections.
They are now included under heading
“periodontitis as manifestation of the
systemic diseases.”
1989 classification contained
category termed ‘prepubertal
periodontits’ which had localized
and generalized forms.

97. IV) ELIMINATION OF A SEPARATE DISEASE
CATEGORY FOR REFRACTORY PERIODONTITIS.
In 1989 classification, a separate disease category was devoted to refractory
periodontitis. This heterogenous group of periodontal disease refers to instances in
which there is a continuing progression of periodontitis inspite of the excellent
patient compliance and the provision of periodontal therapy that succeeds in most
patients.
However refractory periodontitis is NOT a single entity and
therefore it was concluded that rather than a single disease
category the “refractory“ designation can be kept as a
separate group in the new classification .
However refractory periodontitis is NOT a single entity and
therefore it was concluded that rather than a single disease
category the “refractory“ designation can be kept as a
separate group in the new classification .

98. V) REPLACEMENT OF THE NECROTIZING
ULCERATIVE PERIODONTITIS WITH NECROTIZING
PERIODONTAL DISEASE

99. VI) ADDITION OF THE CATEGORY OF THE PERIODONTAL ABSCESS
VII) ADDITION OF A CATEGORY ON “PERIODONTIC-ENDODONTIC
LESIONS”
VIII) ADDITION OF A CATEGORY ON “DEVELOPMENTAL OR
ACQUIRED DEFORMITIES AND CONDITIONS”

100. ESSENTIALISTIC OR NOMINALISTIC
DISEASE CLASSIFICATION
At present, the best option is to classify the periodontitis in an exhaustive
but also exclusive way and use a terminology for the various classes of
the disease which makes it easy to understand the case.
This is the nominalistic concept of classification . Vander Velden in 2000
suggested a classification based on four dimensions, i.e. extent, severity,
age, and clinical characteristics.
The following is a presentation of the original classification with a few
additions:

101. VANDER VELDEN, 2000

103.  THE CLASSIFICATION IS established IN THE FOLLOWING
WAY:
 First, the severity category is determined for each tooth;
 Next, the extent category is determined by counting the number of teeth with
the most severe condition;
 Diagnosis on the basis of clinical characteristics is added if applicable
 Diagnosis on the basis of age.
IN THE NOMENCLATURE, THE PARAMETERS FOR THE CLASSIFICATION ARE SET IN THE
FOLLOWING ORDER:
 1.extent
 2. severity
 3. clinical characteristics
 4. age.
 Examples for diagnoses are:
 localized minor pre-pubertal periodontitis,
 localized severe juvenile periodontitis,
 semi-generalized minor juvenile periodontitis
 generalized severe refractory post-adolescent periodontitis
 localized severe adult periodontitis
One could make the diagnosis even more detailed by including two levels of extent and
severity when appropriate, e.g. localized severe, semi-generalized moderate adult
periodontitis.

104. 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

105. Guidelines for determining severity of periodontitis
GINGIVITIS OR MILD
PERIODONTITIS???

106. Chronic versus aggressive periodontitis

107. CHRONIC
OR
AGGRESSIVE
.continuous model
.random model
.asynchronous model
LOCALIZED versus GENERALIZED PERIODONTITIS
• WHERE WE WERE……… tooth sites involved
• According to task force report
WHERE WE ARE SUPPOSED TO BE ……….
NO. OF TEETH INVOLVED

108. FUTURE CHALLENGES IN THE
CLASSIFICATION OF PERIODONTAL
DISEASES
Now that we have entered the post-genomic era, classification
systems based on the microbiological features of periodontal
diseases or on the genetic factors would seem logical as these factors
dominate the expression of the disease. Sub-classifications of
diseases are problematic as these infections are poly-microbial and
polygenic .
 Also environmental and host-modifying conditions (e.g. oral
hygiene, smoking, emotional stress, diabetes) reshape the clinical
expression of these diseases

109. It is conceivable that with much more information and the
application of sophisticated multivariate analyses, it may
eventually be possible to sub-classify the multiple forms of
‘Chronic Periodontitis’ into discrete microorganism/host genetic
polymorphism groups.
It will be necessary to address head on the nagging question,
‘When are important host-modifying factors (e.g. smoking,
diabetes), should or should’nt be a principal part of the disease
classification?’
That is, in an evidence-based classification should there be a
‘smoking-induced periodontitis’ or a ‘diabetic periodontitis?’
When do modifying factors become an essential classification
characteristic of the disease?

110. CONCLUSION

111. REFERENCES
1. Clinical periodontology. Newman, Takei, Klokkevold, Carranza. 10th
edition. P 100-109
2. Clinical periodontology. Carranza, Newman. 8th
edition. P 58-61
3. Clinical periodontology. Carranza. 6th
edition. 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