Staging and grading of periodontitis: Framework and

proposal of a new classification and case definition

MAURIZIO S. TONETTI, HENRY GREENWELL, KENNETH S. KORNMAN
Periodontitis
microbially-associated, host-mediated inflammation
that results in loss of periodontal attachment

leads to activation of host response - proteinases

• loss of marginal PDL fibers

• apical migration of the junctional epithelium
• apical spread of the bacterial biofilm along the root surface
 - loss of attachment due to the action of
inflammatory mediators
- Alveolar bone loss

Periodontitis Clinical presentation differs based on:

◦ age of patient
◦ lesion number, distribution, severity, and
location within the dental arch
◦ amount of oral biofilm
1999 classification system
1. Necrotizing periodontitis
2. Chronic periodontitis
3. Aggressive periodontitis
4. Periodontitis as a manifestation of systemic diseases
 Highlighted the need to distinguish between the
more common forms of periodontitis: Chronic and
Aggressive
Aggressive types had specific criteria to be
qualified as such
1999 cases of periodontitis that would not satisfy the
“aggressive” phenotype definition would be
classification classified as “chronic” → more manageable cases
system chronic and aggressive periodontitis were
differentiated to identify and focus on the more
problematic cases
◦ greater severity earlier in life
◦ higher risk of progression
◦ need of specific treatment approaches
Problems in clinical application
▪differences between chronic and aggressive periodontitis were not
so clear
▪overlap between the diagnostic categories
▪difficult for clinicians to apply the classification system
▪clinicians, educators, researchers and epidemiologists have voiced
concern about their ability to correctly differentiate between
aggressive and chronic periodontitis cases
 There is no specific pathophysiology that
Current differentiates aggressive and chronic
periodontitis or provides guidance for different
positions – 2017 interventions.
Classification
System There is little evidence that aggressive and
chronic periodontitis are different diseases.
 There are multiple factors that influence clinically observable
Current disease outcomes at the individual level for both aggressive
positions – and chronic phenotypes.

2017
Classification Rates of periodontitis progression are consistent across all
observed populations throughout the world.
System
 Specific segments of the population exhibit different levels of
Current disease progression.
positions – A classification system based only on disease severity fails to
capture important dimensions of an individual's disease
2017 ◦ complexity that influences approach to therapy
Classification ◦ risk factors that influence likely outcomes
System ◦ level of knowledge and training required for managing the
individual case
Current positions –
2017 Classification
System
Assimi S et al. Acute
necrotizing periodontitis: A
case report Austin J Dent.
2016; 3(3): 1041.
Necrotizing periodontitis is a separate disease
entity
distinct pathophysiology characterized by
prominent bacterial invasion and ulceration of
epithelium
◦ rapid and full thickness destruction of the
marginal soft tissue resulting in characteristic
soft and hard tissue defects
◦ prominent symptoms
◦ rapid resolution in response to specific
antimicrobial treatment
 periodontal manifestation of the systemic
Current positions – disease - periodontitis observed with systemic
2017 Classification diseases that severely impair host response →
primary diagnosis should be the systemic
System disease
Despite substantial research on aggressive periodontitis since the
1999 workshop,there is currently insufficient evidence to consider
aggressive and chronic periodontitis as two pathophysiologically
distinct diseases.
Phenotypic variances among different populations
• a small segment of the adult population expresses severe generalized periodontitis
• most express mild to moderate periodontitis
• variance in clinical severity of periodontitis is attributable to genetics
Phenotypic variances among different populations
• future research advances: disease-specific mechanisms in the context of the multifactorial
biological interactions involved in specific phenotypes
• may be valuable in guiding better management of complex cases
• may lead to novel approaches that enhance periodontitis prevention, control, and regeneration
• multi-dimensional profiles that combine biological and clinical parameters are emerging
• better define phenotypes and may guide deeper understanding of the mechanisms that lead
to differences in phenotypes
Clinical application
• There is clinical value in individualizing the diagnosis and the case definition of a periodontitis
patient
• take into account:
• multifactorial etiology to improve prognosis
• account for complexity and risk
• provide an appropriate level of care for the individual
Integrating Current
Knowledge to
Advance Classification
of Periodontitis
 microbially-associated, host-mediated inflammation that
Clinical results in loss of periodontal attachment

definition of detected as clinical attachment loss (CAL) by circumferential

assessment of the erupted dentition with a standardized
periodontitis periodontal probe with reference to the cementoenamel
junction (CEJ)
Important considerations
1. Some clinical conditions other than periodontitis present with clinical attachment loss.
2. Periodontitis definitions based on marginal radiographic bone loss suffer from severe
limitations.
◦ they are not specific enough and miss detection of mild to moderate periodontitis
◦ should be limited to the stages of mixed dentition and tooth eruption when clinical attachment level
measurement with reference to the CEJ are impractical
◦ In such cases periodontitis assessments based on marginal radiographic bone loss may use bitewing
radiographs taken for caries detection.
Objectives of a periodontitis case definition system
A case definition system should facilitate the identification, treatment and prevention of
periodontitis in individual patients.
Given current knowledge, a periodontitis case definition system should include three
components:
1. Identification of a patient as a periodontitis case,
2. Identification of the specific form of periodontitis
3. Description of the clinical presentation and other elements that affect clinical management,
prognosis, and potentially broader influences on both oral and systemic health.
 thedentalsurgery.co.uk

Definition of a patient as a periodontitis case

Guidelines
✓periodontal inflammation, measured as bleeding on
probing (BoP), is an important clinical parameter to
assess treatment outcomes and residual disease risk
post-treatment
✓BoP does NOT change the initial case definition as
defined by CAL or change the classification of
periodontitis severity
 Periodontitis case
Interdental CAL at ≥2 non-adjacent teeth OR
Buccal or oral CAL ≥3 mm with pocketing >3 mm at ≥2 teeth
CAL is due to non-periodontal causes such as:
◦ gingival recession of traumatic origin
◦ cervical dental caries
◦ CAL on the distal aspect of a second molar and associated with
malposition or extraction of a third molar
◦ endodontic lesion
◦ vertical root fracture

dentalcare.com
 Key to
periodontitis
case definition
“detectable” interdental
CAL
the clinician should be able to
specifically identify areas of
attachment loss during
periodontal probing or direct
visual detection of the interdental
CEJ during examination ncbi.nim.nih.gov

measurement errors and local

factors should be taken into
account
“detectable” interdental
attachment loss may represent
different magnitudes of CAL based
on:
skills of the operator
local conditions that may facilitate
or impair detection of the CEJ -
position of the gingival margin with
respect to the CEJ; the presence of
calculus or restorative margins
case definition does NOT specify a
threshold of detectable CAL - to
avoid misclassification of initial
periodontitis cases as gingivitis
to increase specificity of the nature.com
definition - detection of CAL at two
non-adjacent teeth is required
Specific CAL thresholds are needed
for epidemiological surveys
Three forms of periodontitis
1. Necrotizing periodontitis
2. Periodontitis as a direct manifestation of systemic diseases
3. Periodontitis
 Differential
diagnosis –
Necrotizing
periodontitis
based on history and the specific
signs and symptoms of necrotizing
periodontitis

history of pain, presence of

Assimi S et al. Acute
ulceration of the gingival margin necrotizing periodontitis: A
case report Austin J Dent.
and/or fibrin deposits at sites with 2016; 3(3): 1041.
characteristically decapitated
gingival papillae, and, in some
cases, exposure of the marginal
alveolar bone
 Periodontitis as a manifestation
of systemic disease
follow the classification of the primary disease

presence or absence of an uncommon systemic disease that

definitively alters the host immune response

AIBarrak, Z.M., Alqarni, A.S., Chalisserry, E.P. et al. Papillon–Lefèvre syndrome: a series of five cases among siblings. J
Med Case Reports 10, 260 (2016). https://doi.org/10.1186/s13256-016-1051-z
 do not have the local characteristics of necrotizing
periodontitis or the systemic characteristics of a rare
immune disorder with a secondary manifestation of
Periodontitis comes with a range of phenotypes
different approaches to clinical management
different complexities
Stage I Periodontitis

the borderline between gingivitis and periodontitis

• early stages of attachment loss

response to persistence of gingival inflammation and biofilm dysbiosis

if CAL occurs at a relatively early age, these patients may have

heightened susceptibility to disease onset
Stage II Periodontitis
established periodontitis

management is relatively simple

• standard treatment principles

• regular personal and professional bacterial removal and monitoring

careful evaluation of the stage II patient's response to standard

treatment principles is essential
• case grade plus treatment response may guide more intensive management for
specific patients
Stage III Periodontitis
significant damage to the attachment apparatus
• tooth loss may occur without treatment
• deep periodontal lesions that extend to the middle portion of the root
• deep intrabony defects, furcation involvement, history of periodontal
tooth loss/exfoliation, and presence of localized ridge defects
management is complicated

masticatory function is preserved

• does not require complex rehabilitation of function
Stage IV Periodontitis
considerable damage to the periodontal support
• deep periodontal lesions that extend to the apical portion of the root
and/or history of multiple tooth loss
• tooth hypermobility due to secondary occlusal trauma
• posterior bite collapse and drifting
loss of masticatory function
• significant tooth loss - dentition is at risk of being lost

requires stabilization

restoration of masticatory function

 irrespective of the stage at diagnosis:
periodontitis may progress with different rates in individuals
may respond less predictably to treatment in some patients

Grade of may or may not influence general health or systemic disease

Periodontitis critical for precision management

risk assessment tools and risk factors have been associated
with tooth loss
it is possible to estimate risk of periodontitis progression and
tooth loss
 cigarette smoking and diabetes
◦ affect the rate of progression of periodontitis
◦ may increase the conversion from one stage to the next
Risk factors
Emerging risk factors: obesity, specific genetic factors,
physical activity, or nutrition
◦ may one day contribute to assessment
 allows rate of progression to be considered based on
evidence
Direct evidence - longitudinal observation available for
Grading of example in the form of older diagnostic quality radiographs
periodontitis Indirect evidence - assessment of bone loss at the worst
affected tooth in the dentition as a function of age (%
radiographic bone loss divided by the age of the subject
grade can modified by the presence of risk factors
 assume a moderate rate of progression (grade B)
look for direct and indirect measures of actual progression in
the past

Grading of risk factor can modify the estimate of the patient's future
course of disease
periodontitis risk factor, should therefore shift the grade score to a higher
value
For example: stage II grade B becomes grade C in the
presence of poorly controlled Type II diabetes mellitus
How to determine the stage (CAL)
1. Look for the greatest interdental CAL (CEJ to base of the pocket) from the
patient and classify accordingly.
a. 1-2 mm: Stage I
b. 3-4 mm: Stage II
c. ≥5 mm: Stage III or IV
How to determine the stage (RBL)
1. Estimate the percent bone loss = 40% to 50%
Stage III or IV
2. Compute for the percent bone loss
1. Measure radiographic bone loss
a. Measure the radiographic bone level from the CEJ to the alveolar bone crest (RBL).
b. Measure the radiographic root length from the CEJ to the root apex (RRL).
c. Compute for percentage bone loss using the formula:
RBL – 2 X 100
RRL – 2

*2 is subtracted from RBL and RRL because the average distance of the alveolar bone to
the CEJ in a normal periodontium is 2mm, therefore 2mm level of bone apical to the CEJ is NOT
bone loss.

Example: 50 year old patient

: number of teeth with CAL = 20
: total number of teeth = 30 RBL=
RBL = 12 mm
7 mm
12-2 X 100
7 – 2__ X 100
26-2
15 – 2
RRL=
RBL =26
RRL 15mmmm
105_XX100
100 = 38%
2413 = 41.7% 12mm
7mm and and15mm
26mm are are sample
sample measurements
measurements only
only forsample
for this this patient.
sampleMeasurements
case. Measurements
should be
Stage III or IV should be taken
taken from actualfrom actual radiographs.
radiographs.
How to determine the extent or distribution
1. Number of teeth involved (with CAL) / Total number of teeth examined
2. Localized is < 30% Generalized is ≥ 30%
3. Molar-Incisor pattern
How to determine the grade
1. Direct evidence (from the table)
2. Compute using the formula % bone loss/age of the patient

Example: age of patient is 50 y/o

% bone loss is 42%
Grade = 42/50
= 0.84
= Grade B → adjust if grade modifiers are present (see table)