REVIEW ARTICLE

Declassifying Mobility Anita Aminoshariae, DDS, MS,*

Scott A. Mackey, DDS, MS,†

Classification Leena Palomo, DDS, MSD,‡ and

James C. Kulild, DDS, MS*

ABSTRACT
SIGNIFICANCE
Introduction: Tooth mobility is often discussed among dental health care providers
according to a numerical scale (ie, 1, 2, or 3) without a clear understanding of the definition of The results of this review
each category. Thus, a comprehensive review to examine and discuss the various suggested that the original
classifications is needed. The aim of this comprehensive review was to discuss the main Miller index classification has
clinical classifications of tooth mobility. Methods: The authors conducted electronic been modified to some extent,
searches in MEDLINE, Scopus, and PubMed. Additionally, the authors manually searched the and clinicians might find this
textbooks, gray literature, and bibliographies of all relevant articles. Results: The most index to be the most effective
commonly referenced clinical index for mobility was the Miller index; yet, many other mobility and accurate when
classifications exist as well as modifications of those indexes. The literature has been very determining tooth mobility.
inconsistent and at times inaccurate when classifying mobility; using various stages of mobility
using grades, classes, and scores interchangeably and not defining the meaning of the actual
numerical scores/terminologies are common problems. Conclusions: In order to avoid
ambiguity and provide clarity regarding the impact of degrees of mobility when used clinically,
this review comprehensively discusses different classifications and definitions of tooth mobility
with attention to the importance of using them consistently and accurately. There is a need to
standardize 1 classification for mobility. (J Endod 2020;46:1539–1544.)

Tooth mobility is commonly assessed as part of a comprehensive dental examination1–11. Dr Grossman

had the insight to include mobility as part of an endodontic diagnosis and treatment plan1, but due
diligence has not been paid to accurately record the various stages of mobility in endodontics2,7–11. The
nomenclature for mobility categorization and/or the definition of each category can easily be
misunderstood and miscommunicated between dental team members. The American Association of
Endodontists’ Glossary of Endodontic Terms9 defines mobility as follows: “Movement of tooth in its
socket resulting from an applied force, usually measured on an increasing scale of 1–3 or measured by
the amount of horizontal and/or vertical mobility in millimeters.” The determination of an increasing scale
remains elusive and vague using this the American Association of Endodontist’s glossary; yet, mobility
remains a critical criterion in the documentation of a tooth and predicting the outcome of an
endodontically treated tooth1,8,10. A common and popular endodontic textbook defined mobility as
“directly proportional to the integrity of the attachment apparatus or to the extent of inflammation in the
periodontal ligament7.” The authors did not describe any specific classification but stated the following:
“The teeth should be evaluated on the basis of how mobile they are relative to the adjacent and
contralateral teeth7.” Similarly, another group of authors8 (described mobility as a “test partially
determining both the status of the periodontal ligament and the prognosis” (pg.79). The authors
discussed teeth with extreme mobility with a potentially altered prognosis but did not define what From the Departments of *Endodontics
“extreme mobility” indicated. However, it is critical not only to record mobility during the examination but and ‡Periodontics, Case Western Reserve
also to accurately document this clinical finding during the follow-up appointments. Additionally, mobility University, School of Dental Medicine,
Cleveland, Ohio; and †Northeast Ohio VA
should be recorded during the management of dental trauma2,8,11. The American Association of
Healthcare System, Louis Stokes
Endodontists’ Treatment of Traumatic Dental Injuries referred to documenting “increased mobility,” but it Cleveland VA Medical Center, Cleveland,
would remain unclear how to record this “increased mobility”11. Thus, clear, concise, and complete Ohio
communication among dental health care providers concerning the degree of tooth mobility is of critical Address requests for reprints to Dr Anita
importance. Aminoshariae, American Board of
Tooth mobility may have significant clinical implications in the final treatment plan chosen. Tooth Endodontics, 10900 Euclid Avenue, Rm
mobility has been associated with greater attachment loss after various modes of therapy and phases of 239C, Cleveland, OH 44106.
E-mail address: Axa53@case.edu
treatment. Tooth mobility was related to clinical attachment loss in patients re-examined for periodontal 0099-2399/$ - see front matter
attachment loss after 28 years12. Teeth with increased mobility had significantly more attachment loss
Copyright © 2020 American Association
during the maintenance phase13. Mobile teeth that were treated with regenerative therapy did not of Endodontists.
respond as favorably as nonmobile teeth14. Thus, tooth mobility may play a role in determining the https://doi.org/10.1016/
strategic value of a tooth and contribute to the treatment recommendation offered to the patient10. j.joen.2020.07.030

JOE  Volume 46, Number 11, November 2020 Declassifying Mobility Classification 1539
 It should be noted that various types of
teeth have different physiological ranges of
mobility in various individuals15. Because teeth
are suspended within the alveolar socket via the
periodontal ligament, there is a degree of
physiological mobility that is expected; up to 0.2
mm of mobility is considered to be
physiological16. As such, mobility can be
defined as physiological or pathologic15,17. Two
factors may contribute to excessive tooth
mobility:
(1) widening of the periodontal ligament
(caused by occlusal trauma, pathology,
or infection) and
(2) loss in the height of the periodontal
supporting tissues4. However, many
factors might contribute to an
excessively mobile tooth including
acute trauma, inflammatory changes in
the supporting periodontal apparatus,
infection, occlusal trauma disharmony,
parafunctional habits, hormonal
imbalances, periodontal disease, and/
or periapical disease5,6. Although
mobility is an important consideration in
the decision guide of endodontically
treated teeth18, it is weighed against
other predisposing factors such as the
ferrule effect, endodontic treatment,
and periodontal status. Tooth mobility is
1 parameter of the periodontal status19.
Some of these other parameters may
be more critical than others20,21. A
comprehensive search on the subject of
tooth mobility revealed that there are
many classifications when discussing
this topic19. Thus, the degree of mobility
can be falsely relayed among clinicians
and may even result in inadvertent
confusion when treatment planning.
In order to have a common
understanding among clinicians regarding the
degree of tooth mobility, a comprehensive
review of different indexes of mobility is
warranted to arrive at common, shared, and
factually accurate descriptive narratives. Thus,
the aim of this comprehensive review was to
discuss the main classifications of tooth
mobility.
MATERIALS AND METHODS
The authors conducted electronic searches in
MEDLINE, Scopus, and PubMed. Additionally,
the authors manually searched the textbooks,
gray literature and bibliographies of all relevant
articles.
Miller Index
Arguably, the Miller index22 was the most
commonly used reference in the clinical
1540 Aminoshariae et al.
classification for tooth mobility3,13,23–43.
Mobility is detected by using an instrument (eg,
a mirror handle) on either side of the tooth and
applying a controlled force. Using this index,
mobility can be scored. The tooth is held firmly
between 2 instruments and moved back and
forth. Mobility is scored on a scale of 0–3 as
follows:
 0: no detectable movement when force
was applied
 1: greater than normal movement
(physiological)
 2: no greater than 1 mm in buccolingual
direction
 3: movement of more than 1 mm in a
buccolingual direction and depressible
This classification measures tooth
mobility in a linear quantity and has been
criticized for failing to address the cause and/or
causes for mobility26,27. A close examination of
Miller’s classification also shows that there are
many different scores and applications using
this same terminology or a modification of
it19,27–29.
Modification of the Miller Index
This classification is similar to the one
described by Miller with half scores added to
the measurements19. Thus, the scores are 0,
1
/2, 1, 11/2, 2, 21/2, and 3.
Wasserman Method
This method uses a scoring system from 1–
530. A tooth that can be vertically displaced is
given a score for its measured mobility plus 1.
The scoring system is as follows:
 1: normal tooth mobility
 2: slight mobility, less than 3/4 mm of
movement buccolingually
 3: moderate mobility, up to 2 mm of
movement buccolingually
 4: severe mobility more than 2 mm
 5: severe mobility more than 2 mm and
depressible
This index presented limitations in that 3
of the 5 possible scores are reserved for highly
mobile teeth19.
Glickman Classification
This classification of mobility categorizes teeth
into 2 grades: physiological or pathologic
(Glickman), but the pathologic mobility is
further classified as follows31:
 Grade 1: slightly more than physiological
 Grade 2: moderately more than
physiological
 Grade 3: severe mobility buccolingually
and/or mesiodistally combined with vertical
displacement
This classification was criticized for its
limited clinical usefulness because there were
other reasons to cause pathologic mobility19.
Lovdal Classification
This classification is graded from 0–3 as
follows:
 0: normal mobility
 1: teeth somewhat more mobile than
normal
 2: teeth showing conspicuous mobility in a
transversal but not in an axial direction
 3: teeth mobility in an axial as well as a
transversal direction
This classification32 was criticized for
having less objective criteria than the Glickman
and Miller indexes19.
Prichard Classification
This classification is graded from 1–3 as
follows33:
 1: slight mobility
 2: moderate mobility
 3: extensive mobility in the lateral or
mesiodistal direction combined with vertical
displacement
Grant, Stern, and Everett
Classification
This classification is graded on a scale of 0–3
as follows34:
 0: no perceptible movement
 1
/2: barely perceptible movement
 1
/2–21/2: increasing degrees of mobility
 3: depressible in the socket
Nyman, Lindhe, and Lundgren
Classification
This classification appears to apply to fixed
partial dentures35. They are classified as
follows:
 Mobility degree 0: horizontal mobility of the
bridge of less than 0.2 mm
 Mobility degree 1: horizontal mobility of the
bridge of 0.2 to 1 mm
 Mobility degree 2: horizontal mobility of the
bridge of 1–2 mm
Ramfjord Classification/Fleszar
Classification
The authors36,37created a new classification
because they alleged that the Miller index was
discriminating in research application because
it was difficult to reproduce and discriminating
in accuracy25. The classification is as follows:
JOE  Volume 46, Number 11, November 2020
  M0: physiologic mobility, firm tooth
 M1: slightly increased mobility
 M2: definite to considerable increase in
mobility but no impairment of function
 M3: extreme mobility; a "loose" tooth that
would be uncomfortable in function
Armitage Classification
In this classification38 mobility is classified as
follows:
 Class I: the tooth can be moved less than 1
mm or more in a buccolingual or
mesiodistal direction
 Class II: the tooth can be moved 1 mm or
more in a buccolingual or mesiodistal
direction but does not exhibit abnormal
mobility in an occlusoapical direction
 Class III: the tooth can be moved 1 mm or
more in both the buccolingual or
mesiodistal and occlusoapical directions
Carranza Classification
In the Carranza classification39, teeth are
graded as follows:
 Normal: not mobile
 Grade 1: slightly more than normal
 Grade 2: moderately more than normal
 Grade 3: severe mobility faciolingually and/
or mesiodistally combined with vertical
displacement
Miller-McEntire Classification
In the Miller-McEntire classification40, teeth are
classified as follows:
 Class I: the tooth is mobile but does not
affect the prognosis.
 Class II: the tooth is mobile, and the level of
the mobility is affecting the prognosis.
 Class III: the tooth is mobile and prognosis
is hopeless, but it may be treated under
certain circumstances and maintained.
Table 1 provides a summary of
descriptions of the mobility indexes.
DISCUSSION
This review focused on different
terminologies and classifications used for
pathologic tooth mobility. For a proper
diagnosis, treatment, and prognosis of a
diseased tooth, clinicians need to have a
common language and understanding of the
different classifications. Conflicting issues
with various classifications suggested that,
perhaps, clarity was lacking.
JOE  Volume 46, Number 11, November 2020
Mobility classifications have been
described only by periodontists these last 7–9
decades (Table 1). There is a dearth of
information about the stages of mobility
throughout the endodontic literature, the
American Association of Endodontists’
glossary, and various endodontic
textbooks1,2,7–11,18, and, when stated, it
remains elusive as to what the various scores
actually indicate. The American Association of
Endodontists’ glossary describes 3 scales of
mobility without an explicit definition of the
characteristics of each level or a defining
mobility classification system. As shown in
Table 1, class II in 1 classification indicates
mobility of 2 mm and more, whereas in a
different classification it might indicate less
than 1 mm. That is a significant difference and
worthy of accurate documentation. Simply
stated, class II is not equal and equivalent to
another class II mobility. Naming the
classification must be part of an endodontic or
periodontic clinical requirement; otherwise, the
documentation would suffer from
inconsistency. Even though, Dr Grossman in
19501 included mobility as part of a
comprehensive endodontic evaluation, the
numerical scales, in the endodontic literature,
have been scarcely defined2,7–11,18, adding to
more inconsistency and ambiguity. Ideally, a
joint effort from both the American Association
of Endodontists and the American Academy of
Periodontology should be made to standardize
mobility classification.
There have been various attempts to
mechanize the process of assessing tooth
mobility to produce an objective
measurement15,17,41–43. Although a worthy
goal, standardization of mobility
measurements using a device has not been
widely used outside of the research arena
because of the complexity involved and the
time required to operate19. The clinician is left
with the simple, yet somewhat crude and
subjective, determination of mobility using the
handles of instruments and/or fingers to apply
a force to the tooth.
The American Academy of
Periodontology has 2 documents that mention
tooth mobility, neither of which references a
particular mobility index but simply states that
mobility should be evaluated as part of a
periodontal examination44,45.
However, the American Board of
Periodontology uses a specific criterion, the
Miller index46, on periodontal chartings
given to candidates challenging the oral
board examination46. The choice of the
Miller index for the board examination is not
an endorsement of that index; it is likely
chosen for the purposes of using an index
that is commonly referred to in the literature
and familiar to candidates taking the
examination.
Interestingly, Laster et al19 compared
the assignment of the Miller index to teeth
whose mobility was also assessed objectively
using the periodontometer. They found that
when modifying the Miller index to include
half-step increments, the index gave highly
accurate determinations of mobility
compared with the periodontometer when
assessing mobility on an average basis and
that there was a high positive correlation
between the periodontists’ assessment of
clinical tooth mobility and the measurements
of the periodontometer. However,
periodontists, when assigning Miller mobility
on a tooth-by-tooth basis, introduced
significant error and inconsistency in the
clinical evaluation. The determination of tooth
mobility to this day remains much more of an
art than a science.
Having a consensus regarding tooth
mobility is important because it relates to an
accurate diagnosis, treatment planning, and
prognosis among clinicians10,11. There is no
ambiguity with normal or physiological mobility
because it does not add any additional risks.
Increased tooth mobility as an important
parameter in decision making, influencing the
treatment, prognosis, severity, and
progression of periodontal disease, has been
the subject of interest by many authors with
different outcomes and not always in
accordance with pre-existing conditions12,47–
50
. These authors reported different outcomes
when increased tooth mobility was considered
as a factor influencing the severity and the rate
of progression of periodontal disease.
However, the authors agreed that, in the
absence of adequate hygiene and the
presence of inflammatory processes and
endodontic disease, mobility was a critical
contributing factor8,50,51, but by itself
pathologic mobility was not always associated
with poorer prognosis17.
When disclosing and formulating risks,
benefits, treatments, and options to patients, it
would be incumbent on our profession to be
clear concerning mobility classification and
terminology. This would ensure that proper
diagnosis and treatment options could be
rendered and discussed with the patient. In
order to avoid confusion regarding the impact
of degrees of mobility, this review has
comprehensively discussed different
classifications and definitions of mobility with
Declassifying Mobility Classification 1541
TABLE 1 - Historical Mobility Indexes

Index 0 1 2 3 4 5
Miller No mobility Greater than ,1 mm in .1 mm in NA NA
physiologic buccolingual buccolingual
direction direction and
depressible
Wassermann NA Normal ,3/4 mm 3
/4 mm , 2 .2 .2 mm
mobility mm mm and
depressible
Glickman NA Slightly more Moderately Severe mobility NA NA
than more than in any direction
physiological physiological and
depressible
Lovdal Normal Greater than Conspicuous Mobile in axial NA NA
mobility normal transverse and transverse
mobility directions
Prichard NA Slight Moderate Extensive NA NA
mobility mobility mobility with
depressibility
Grant* No mobility Increasing Increasing Depressible NA NA
mobility mobility
Nyman Mobility 0.2–1 mm 1–2 mm NA NA
,0.2 mm
Ramfjord Physiological Slight Definite Extreme NA NA
mobility increased mobility,
mobility, no uncomfortable
impingement in function
on function
Fleszar Physiological Slight Definite Extreme NA NA
mobility increased mobility,
mobility, no uncomfortable
impingement in function
on function
Armitage NA ,1 mm .1 mm but .1 mm and NA NA
mobility not depressible
depressible
Carranza NA Slightly Moderately Severe mobility NA NA
greater than greater than and
normal normal depressible
Miller- NA Mobile but Mobile and Mobile with NA NA
McEntire does not affects hopeless
affect prognosis prognosis
prognosis

NA, not applicable.

*Scale in half increments from 0–3.

attention to the importance of using them
consistently and accurately.
CONCLUSION
The purpose of this review was to clarify the
enigma in the various classifications cited in the
periodontal literature. The authors noted that
many of these systems depended on the
individual examiners and were subjective. The
results of this review suggested that the ACKNOWLEDGMENTS
original Miller index classification has been
The authors deny any conflicts of interest
modified to some extent, and clinicians might
related to this study. The content is solely
find this index to be the most effective and
the responsibility of the authors and does
accurate when determining tooth mobility. A
not necessarily represent the official views
universal classification to standardize mobility
of the United States Department of
by joint efforts of the American Association of
Veterans Affairs, or the United States
Periodontology and the American Association
Government.
of Endodontists would be warranted.

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1544 Aminoshariae et al. JOE  Volume 46, Number 11, November 2020